Identifying older drivers at risk of traffic violations by using a driving simulator: a 3-year longitudinal study.

OBJECTIVES: This prospective longitudinal study aims to determine which simulated driving tasks of a personal computer (PC)-based driving simulator can be used to identify problematic older drivers, using their 3-year driver violation points record as the outcome measure. METHODS: A total of 129 urban community-dwelling older drivers volunteered to participate in the study. Using a driving simulator, specific driving tasks were devised to test the performance of older drivers. Their officially recorded driver violation points were retrieved immediately after the simulated driving assessment and thereafter for the following 2 years. Self-reported driving records were also collected during the same period. Hierarchical Poisson regression analysis, adjusting for gender, age, and driving exposure (hours of driving per week), was then undertaken to determine those driving tasks that affected the frequency of traffic violations. RESULTS: All participants incurred at least one driver violation point during the 3-year period. The simulated driving tasks found to be significantly associated with the incidence of traffic violations were working memory and use of indicator. CONCLUSIONS: This longitudinal study demonstrated that the driving simulator was able to identify unsafe older drivers at risk of traffic violations if appropriate simulated driving tasks were used. Such a screening tool should be adopted prior to administering a more detailed but expensive road test.     

Occupational therapy assessment of open-road driving performance: validity of directed and self-directed navigational instructional components.

OBJECTIVE: The purpose of this study was to validate an assessment tool used by occupational therapists to evaluate on-road driving performance. METHODS: The driving assessment was conducted over a 15-km route that consisted of a range of traffic situations and contained both directed and self-directed navigational instruction. The driving performance of four groups of drivers of different ages and visual characteristics was assessed independently by an occupational therapist and driving instructor using a range of scoring criteria. RESULTS: The occupational therapist scores were significantly affected by the drivers' age and visual characteristics (directed navigation, F(3,133) = 6.05, p = 0.001; self-directed navigation, F(3,133) = 5.04, p < 0.002), and these group differences were greater for self-directed navigational instruction. The occupational therapist scores were highly correlated with the driving instructor's global driver safety rating (r = 0.76, p < 0.001). DISCUSSION: The driving assessment instrument was a valid measure of on-road driving performance relative to an independent global driving safety evaluation. The instrument provided detailed information regarding driving performance and highlighted areas of difficulty, particularly when drivers followed self-navigational instruction.     

Driving skills in elderly persons with stroke: comparison of two new assessment options

OBJECTIVE: To compare the effectiveness of two methods of assessing off-road driving skills that claim to predict on-road driving fitness of persons with stroke. METHOD: Fifty-six persons with stroke (age 44 to 82 yrs; mean, 60.2 yrs) completed the 2 off-road driving assessments along with standard clinical and on-road driving tests. MAIN OUTCOME MEASURES: Linear stepwise regression on 4 variables of the Dynavision Performance Assessment Battery (DPAB), the Cognitive Behavioral Driver's Inventory (CBDI) variable (composite score), and the variables of age, gender, and lesion side. RESULTS: A 4-minute endurance subtest from the DPAB was superior to the CBDI in predicting success/failure in the on-road driving test (75%). However, success on both the 4-minute endurance subtest from the DPAB and the CBDI tests significantly improved the prediction of on-road success. If participants passed the CBDI and the endurance test from the DPAB, they also passed the on-road assessment. CONCLUSION: Driving fitness of elderly persons with stroke can be assessed with reasonable accuracy using off-road tests, minimizing the expense and risk associated with on-road assessments in this population.     

Usefulness of the driveABLE cognitive assessment in predicting the driving risk factor of stroke patients

[Purpose] This study examined the usefulness of the DriveABLE cognitive assessment tool (DCAT) in predicting the driving risk factor of stroke patients, and compared the cognitive and driving functions of two groups discriminated by DCAT. [Subjects and Methods] A total of forty-two stroke patients with a driver’s license participated in this study. Two participants with communication problems were excluded. DCAT was used to evaluate the risk potential to the driver, and the subjects were classified into two groups according to the probability of driving risk estimated by the DCAT evaluation. The safe driver group (SDG) and unsafe driver group (USDG) underwent a driving simulator and cognitive function assessments. [Results] The results of the SDG and USDG were compared. The SDG showed higher cognitive function than the USDG. In addition, the SDG showed higher ability than the USDG in most of the tests associated with the driving function (pedal reaction time, average reaction time, centerline crossing, road edge excursion, off-road accidents, collisions). [Conclusion] DCAT is a useful tool for predicting the risk of driving. In addition, it can predict the driving ability of stroke patients related to the cognitive function. Nevertheless, a multi-faceted study of associated with driving and cognitive functions for safe driving will be needed.Key words: DriveABLE cognitive assessment, Driving, Stroke     

Development and assessment of a neuropsychological battery to aid in predicting driving performance

PURPOSE: This study was conducted to select a neuropsychological battery that correlated with driving simulator skills, thus enabling practitioners to provide information to older patients and their families about driving risks. METHODS: The study was conducted in two phases. In Phase 1, a survey inquiring as to the kinds of neuropsychological tests currently used to screen patients for driving was sent to 292 licensed neuropsychologists. Of these 292 surveys, 125 (43%) were returned. We used the responses to develop a battery of nine tests, including eight neuropsychological tests and one other cognitive measure: (1) the Seashore Rhythm Test, (2) Logical Memory (Immediate [I] and Delayed [II]) of the Wechsler Memory Scale-Revised (WMS-R), (3) WMS-R Visual Reproduction (Immediate [I] and Delayed [II]), (4) Trails A and B, (5) Digit Span, (6) Digit Symbol, (7) Block Design, (8) Visual Form Discrimination, and (9) a Zoo Map Test. The complete battery included 12 measures. In Phase 2, 22 licensed drivers were recruited ranging in age from 67 to 91 years (14 males and 8 females). The Mini-Mental Status Exam (MMSE) was administered to all subjects. Scores on this test served as a criterion cutoff for placement into a group of subjects with suspected dementia (Group 1, MMSE score below 25) or a group of control subjects (Group 2, with a MMSE score of 25 or above). None of the patients had any gross motor difficulties. Following screening, subjects were administered the neuropsychological battery, a driving simulator test, and a Driving Habits Interview. RESULTS: Data revealed a significant difference between the performance of Groups 1 and 2 on the driving simulator test in two distinct areas, staying within one's lane boundaries and speed. The suspected dementia subjects had significantly more lane boundary crossings than the control subjects and drove at significantly slower speeds. Ten neuropsychological measures correlated with driving simulator performance. The number of lane boundary crossings correlated with the greatest number of neuropsychological tests, with more lane boundary crossings correlated with poorer performance on the neuropsychological tests. In particular, Trails A, Trails B, and Logical Memory (Immediate) correlated with the largest number of driving measures. CONCLUSION: Preliminary findings show that commonly used neuropsychological tests correlated with driving simulator skills as measured with a driving simulator. Because the driving simulator has been shown to be correlated with actual on-road driving, one may hypothesize that these neuropsychological tests may be predictive of on-road driving. This research is important in defining an appropriate battery to screen for driving skills in patients with known or suspected dementia.     

Visual testing for readiness to drive after stroke: a multicenter study

OBJECTIVE: The purpose of this study was to determine the ability of a visual-perception assessment tool, the Motor-Free Visual Perception Test, to predict on-road driving outcome in subjects with stroke. DESIGN: This was a retrospective study of 269 individuals with stroke who completed visual-perception testing and an on-road driving evaluation. Driving evaluators from six evaluation sites in Canada and the United States participated. Visual-perception was assessed using the Motor-Free Visual Perception Test. Scores range from 0 to 36, with a higher score indicating better visual perception. A structured on-road driving evaluation was performed to determine fitness to drive. Based on driving behaviors, a pass or fail outcome was determined by the examiner. RESULTS: The results indicated that, using a score on the Motor-Free Visual Perception Test of < or =30 to indicate poor visual-perception and >30 to indicate good visual perception, the positive predictive value of the Motor-Free Visual Perception Test in identifying those who would fail the on-road test was 60.9% (n = 67/110). The corresponding negative predictive value was 64.2% (n = 102/159). Univariate logistic regression analyses revealed that older age, low Motor-Free Visual Perception Test scores and a right hemisphere lesion contributed significantly to identifying those who failed the on-road test. CONCLUSIONS: The predictive validity of the Motor-Free Visual Perception Test is not sufficiently high to warrant its use as the sole screening tool in identifying those who are unfit to undergo an on-road evaluation.     

P-drive: assessment of driving performance after stroke.

OBJECTIVE: To investigate aspects of validity and stability of Performance Analysis of Driving Ability (P-Drive), for people with stroke when used in a driving simulator. DESIGN: A cross-sectional observational study. SUBJECTS: The study included a consecutive series of 101 participants with stroke referred for evaluation or selected from a stroke registry. METHODS: P-Drive was used to observe driving performance in order to assess driving ability. P-Drive comprises 20 items assessing the quality of the participant's driving performance. Aspects of validity and reliability in P-Drive were evaluated using Rasch statistics. RESULTS: The items (95%) and participants (97%) demonstrated acceptable goodness-of-fit and met statistical expectations according to the Rasch model. The results support internal scale validity and person response validity. P-Drive could separate the participants with different driving abilities and the standard errors were within reasonable criteria for drivers with a moderate-to-low ability to drive. CONCLUSION: The findings from this study indicated that P-Drive is an assessment tool with properties of internal scale validity, person response validity, and which also contains aspects of reliability in relation to precision of the estimates and separation. P-Drive seems to be a valid and stable assessment tool for assessing the driving ability in a simulator of people with stroke.     

Critical review and analysis of the impact of the physical infrastructure on the driving ability, performance, and safety of older adults.

Literature on the impact of physical infrastructure on older adult safe driving performance was reviewed in 2005 as part of the American Occupational Therapy Association's Evidence-Based Literature Review Project. Existing guidelines for driving environments, related to changes in visual, cognitive, and psychomotor abilities associated with the aging process (as published in the Highway Design Handbook for Older Drivers and Pedestrians, Federal Highway Administration, 2001), are exhaustive, but the authors made no attempt to critically assess the strength of the study design or level of evidence. In laboratory studies since 1999, the interventions lacked applicability to real-life driving environments. Further investigation of the effectiveness of best practice interventions and how the driving environment can better accommodate the needs of older drivers is needed. Occupational therapy interventions that focus on the occupation of driving and compensation and education strategies that allow older adults to drive safely as long as possible are included.     

Opioids and driving ability

INTRODUCTION: Clinical observations of patients under oral opioid treatment suggest that the initially appearing central side effects such as sedation, dizziness or drowsiness decrease after a few weeks of treatment. However, it is still unclear whether long-term treatment with opioids impairs complex psychomotor functions such as driving a car. METHODS: Twenty patients on stable dosages of oral opioids were examined using a driving simulator. The patients were regular car drivers and not older than 70 years. Additionally, every patient had to complete a questionnaire for mental condition and vigilance and the "d II" letter cancellation task. Control groups tested in the same way were: patients before an elective operation after taking benzodiazepines for sedation, volunteers after alcohol consumption (0.80 per thousand ), physicians on call with less than 4 h of sleep and healthy volunteers without any medication. RESULTS: Some of the patients treated with opioids reacted as fast as medication-free volunteers. There were no significant differences between the reaction times of older patients (>50 years) receiving opioids in comparison to the group of older healthy volunteers. The same result was obtained in the letter cancellation task. No differences could be seen between medication-free volunteers and patients receiving opioids with regard to tasks of visual or motor control skills. The volunteers under influence of alcohol and the patients under benzodiazepines had a considerable decrease in performance. CONCLUSIONS: Long-term therapy with opioids does not inevitably impair complex skills, but the decision to permit driving a car can only be made in the individual case. PRACTICAL RECOMMENDATIONS: At the beginning of therapy with opioids the physician has to fulfil his duty to inform the patient of any possible dangers of treatment. From the medical point of view, driving must be prohibited until a stable opioid dosage is reached. Any changes in dosage (increase, reduction), change of the opioid and poor general condition independent of the opioid therapy must result in prohibition of car driving. Continuous control of the therapy with documentation is a duty of the physician. The written documentation should include the patients' physical and mental condition, side effects and the therapeutic result. From the medical point of view, driving can be possible when dosage treatment and general condition remain stable. In any case, the doctor has to remind the patient of the responsibility of critical self-examination. In doubt, special performance investigation should be taken into consideration.     

Occupational Therapy Practice as it Relates to Drivers with Dementia

ABSTRACT

Background: Occupational therapy has taken a leading role in the screening, assessment, and retraining of potentially unsafe older drivers. This investigation examined the attitudes, knowledge, and practices of occupational therapists (OTs) concerning drivers with dementia. Methods: A questionnaire that obtained perspectives about and experiences with drivers with dementia was mailed to licensed OTs from North Carolina and South Carolina. Results: The sample was comprised of 180 OTs. Therapists who had a strong perceived role regarding driver rehabilitation and intervention, believed that it was an important topic to address, and were knowledgeable about driving-related issues were more likely to address the issue with clients and their family. Conclusions: The growing concern about the safety of older drivers with dementia supports the importance of OTs addressing the driving needs of their clients. We recommend increasing the number of trained OT driving specialists as well as emphasizing dementia-related continuing education training for OT generalists.     

Supporting Safety in the Older Adult Driver: A Public Health Nursing Opportunity

The effective operation of a motor vehicle encompasses a wide range of cognitive processes that can decline due to age‐related changes in neuroanatomical structures and cognitive functionality. The increasing number of older adult drivers in our rapidly aging population heightens the public safety concern of unsafe driving associated with these changes. Nurses caring for older adults in public health settings are well positioned to make a difference in the management of older patients who may be at risk of endangering themselves or others on the roadways. In this article, information is provided for increasing nurses’ awareness of the cognitive factors inhibiting effective driving, recognizing older adults who may be at risk for unsafe driving, and facilitating a patient/family to seek a driving evaluation.     

Vision, attention, and self-reported driving behaviors in community-dwelling stroke survivors

OBJECTIVE: To elucidate the relationships among vision, attention, driving status, and self-reported driving behaviors in community-dwelling stroke survivors. DESIGN: A cross-sectional design to compare stroke survivors to older adults without stroke on visual measures, attentional measures, and self-reported driving behaviors. SETTING: Rehabilitation center at a university hospital. PARTICIPANTS: Fifty stroke survivors and 105 older adults without neurologic or visual impairment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Visual acuity, contrast sensitivity, peripheral vision, useful field of view (UFOV), Behavioral Inattention Test, and a driving habits questionnaire. RESULTS: Stroke survivors had impaired contrast sensitivity, peripheral vision, and UFOV compared with older adults in good visual and neurologic health. Driving stroke survivors typically had less attentional impairment than nondrivers. Stroke survivors who returned to driving reported difficulty in challenging driving conditions, drove less, and relied more on other people for transportation than older adults without stroke. CONCLUSIONS: These results suggest that vision and attention, both of which are important for driving, are often impaired in stroke survivors. The severity of these deficits could be an influence on driving status and driving behavior. Stroke survivors who return to driving strategically limit their driving exposure and rely on others for transportation, which suggests that they may deliberately self-regulate their driving behavior.     

Driving evaluation practices of clinicians working in the United States and Canada.

OBJECTIVE: To determine off-road and on-road driving evaluation practices of clinicians in the United States and Canada who assess individuals with disabilities for fitness to drive. PARTICIPANTS: Participants were 114 clinician attendees at the 2003 annual Association of Driver Educators for the Disabled with driving assessment experience ranging from 1 month to 25 years. MEASURES: Information was elicited regarding the clinician, clientele, referral practices, and off-road and on-road driving evaluation practices and retraining practices using a self-administered questionnaire. RESULTS: Participants were largely occupational therapists (68%) who worked in 42 different states and provinces. The most prevalent clientele were persons with traumatic brain injury (97%) and stroke (96%). Testing times greater than 60 min were common for both the off-road (61%) and on-road (49%) evaluations. Commonly performed off-road assessments included the Brake Reaction Timer; Trail Making Test, Parts A and B; and the Motor Free Visual Perception Test, used by 73%, 72%, and 66%, respectively; comprehensive computer-based driving evaluation was rare. Sixty-one percent indicated that all clients underwent on-road evaluation regardless of the off-road results. Finally, 78% used a standard driving route, whereas 24% used a scoring system to evaluate on-road driving. CONCLUSION: Driving assessment in Canada and the United States is multidimensional and time-intensive. Although the domains being assessed are similar across clincians, specific off-road and on-road assessment practices vary greatly. The majority use nonstandardized on-road assessments.     

International Older Driver Consensus Conference on Assessment,Remediation and Counseling for Transportation Alternatives: Summary and Recommendations

SUMMARY

On December 1 and 2, 2003, 63 international experts on older driver issues met to examine three critical issues related to the safe mobility of older drivers. Conference participants addressed standards and protocols for screening and evaluating the skills of older drivers. For drivers judged to lack the necessary skills to drive safely, participants addressed methods of remediation that could enable older persons with limited cognitive or physical abilities to continue to drive. For those persons whose skills are judged inadequate for safe driving, conference participants addressed the question as to how best to counsel individuals and their caregivers on practical alternatives to driving.

Consensus was achieved as to the current methods for best assessing and screening drivers, remediation techniques, and providing advice and counsel for those persons and the caregivers as to appropriate actions for those no longer able to drive safely.     

直观教学法在驾驶人员心肺复苏技能培训中应用效果观察

目的：探讨对驾驶人员进行心肺复苏技能培训的方法及意义。方法：2006年12月-2007年3月分5批对158名来自不同行业的驾驶人员进行心肺复苏技能培训,每批4课时。培训前先对学员急救知识掌握情况进行问卷调查,再通过播放视图、幻灯片、视频等各种多媒体手段、培训者动作示范、引导学员利用自身身体触摸进行自我和相互练习、模拟人上操作训练等各种直观教学方法,对驾驶人员进行心肺复苏技能培训。结果：培训后心肺复苏技能理论知识合格率为100%,模拟操作考核合格率第1次为91%,第2次为100%。结论：直观教学法适用于驾驶人员心肺复苏技能培训,学校培训是普及心肺复苏技能的重要途径。     

Driving performance in patients with mild to moderate glaucomatous clinical vision changes

The purpose of this study was to determine the relationship between clinical measures of visual function and driving-related skills in patients with glaucoma who had good visual acuity in at least one eye and mild to moderate visual field loss. METHODS: Twenty-five patients with glaucoma and twenty-nine age-equivalent normally sighted control subjects were included in the study. We tested each patient on an interactive driving simulator and collected vision data, including Lighthouse visual acuity, Goldmann and Humphrey visual fields, and Pelli-Robson contrast sensitivity. Information about real-world accident history for the previous 5-year period was obtained. RESULTS: The glaucoma patients did not have significantly more simulator or real-world accidents than the normally sighted group. There were no significant differences between the groups in performance on seven of the eight simulator indexes that were measured. Of the clinical visual function measures, only lower contrast sensitivity in the eye with better contrast sensitivity correlated with driving skills, including slower speeds (r(24) = 0.58, p < or = 0.01), more lane boundary crossings (r(24) = -0.54, p < or = 0.01), and longer braking response times (r(24) = -0.60, p < or = 0.01) for the patient group. CONCLUSION: Reduced contrast sensitivity may be important in indicating the level of driving skills for individuals with glaucoma, who have normal or near-normal visual acuity and mild to moderate visual field loss.     

Screening At-Risk Older Drivers: A Cross-Program Analysis of Canadian Occupational Therapy Curricula

ABSTRACT

Aims: As individuals grow older they are more likely to experience health-related changes that affect driving. Concerns for both older drivers and public safety necessitate rigorous and valid occupational therapy screening processes for evaluating fitness to drive. This paper focuses on the current level of clinical training for addressing the issue of medical fitness to drive in Canada. Methods: A survey was sent to all 14 university occupational therapy programs to determine the level of training offered for screening medically at-risk older drivers. Data were analyzed using NVivo 8 and several themes emerged. Results: Types of training and learning resources to address this issue varies considerably across programs. Faculty reported graduating students have sufficient competency to perform brief office-based screening but not a comprehensive evaluation. Conclusions: Standardization of curriculum across occupational therapy programs on this topic is needed as well as development of training opportunities for advanced levels of competency.     

Driving performance and workload assessment of drivers with tetraplegia: an adaptation evaluation framework

The purpose of this study was to establish a baseline for further research on adaptation evaluation for drivers with disabilities. Driving performance and workload for 26 drivers with spinal cord injuries (tetraplegia) was studied and compared to a matched group of able-bodied drivers in a driving simulator. Drivers with tetraplegia used two types of hand-operated controls for accelerating and braking. Able- bodied drivers drove with standard pedals. The drivers with tetraplegia performed the driving task equally as well as the control group but had a slightly longer reaction time (10%). Workload assessment revealed that drivers with tetraplegia experienced a significantly greater time pressure and spent more effort than did the able-bodied drivers. They were also more tired from braking and accelerating. The drivers with tetraplegia using separate levers had greater standard deviation in lateral lane position (7 cm), while those using a combined lever were more tired from braking and accelerating. Observed differences could be interpreted as indicators of insufficient adaptation.     

Investigating the driving performance of drivers with and without autism spectrum disorders under complex driving conditions

Purpose: The aim of this study was to investigate the driving performance of drivers with autism spectrum disorders under complex driving conditions.

Method: Seventeen drivers with autism spectrum disorders and 18 typically developed drivers participated in a driving simulator trial. Prior to the assessment, participants completed the Driving Behaviour Questionnaire and measurements of cognitive and visual-motor ability. The driving simulation involved driving in an urban area with dense traffic and unpredictable events.

Results: In comparison with the typically developed group, drivers with autism spectrum disorders reported significantly more lapses in driving, committed more mistakes on the driving simulator, and were slower to react in challenging situations, such as driving through intersections with abrupt changes in traffic lights. However, they were also less likely to tailgate other vehicles, as measured by time-to-collision between vehicles, on the driving simulator.

Conclusions: The performances of licensed drivers with autism spectrum disorders appeared to be safer in respect to car-following distance but were poorer in their response to challenging traffic situations. Driver education for individuals with autism spectrum disorders should focus on quick identification of hazards, prompt execution of responses, and effective allocation of attention to reduce lapses in driving.

• Implications for rehabilitation

• Drivers with autism spectrum disorders reported significantly more lapses during driving.

• Drivers with autism spectrum disorders were observed to be poorer in traffic scenarios requiring critical response.

• Driver education for individuals with autism spectrum disorders should focus on managing anxiety and effective attention allocation while driving.

• Driving simulators can be used as a safe means for training critical response to challenging traffic scenarios.

     

Car driving in schizophrenia: can visual memory and organization make a difference?

Abstract

Purpose: Driving is a meaningful occupation which is ascribed to functional independence in schizophrenia. Although it is estimated that individuals with schizophrenia have two times more traffic accidents, little research has been done in this field. Present research explores differences in mental status, visual working memory and visual organization between drivers and non-drivers with schizophrenia in comparison to healthy drivers. Methods: There were three groups in the study: 20 drivers with schizophrenia, 20 non-driving individuals with schizophrenia and 20 drivers without schizophrenia (DWS). Visual perception was measured with Rey-Osterrieth Complex Figure test and a general cognitive status with Mini-Mental State Examination. Results: The general cognitive status predicted actual driving situation in people with schizophrenia. No statistically significant differences were found between driving and non-driving persons with schizophrenia on any of the visual parameters tested, although these abilities were significantly lower than those of DWS. Conclusion: The research demonstrates that impairment of visual abilities does not prevent people with schizophrenia from driving and emphasizes the importance of general cognitive status for complex and multidimensional everyday tasks. The findings support the need for further investigation in the field of car driving for this population – a move that will considerably contribute to the participation and well-being.

• Implication for Rehabilitation

• Unique approach for driving evaluation in schizophrenia should be designed since direct applications of knowledge and practice acquired from other populations are not reliable.

• This research demonstrates that visual perception deficits in schizophrenia do not prevent clients from driving, and general cognitive status appeared to be a valid determinant for actual driving.

• We recommended usage of a general test of cognition such as Mini-Mental State Examination, or conjunction number of cognitive factors such as executive functions (e.g. Trail Making Test) and attention (e.g. Continuous Performance Test) in addition to spatial-visual ability tests (e.g. Rey-Osterrieth Complex Figure test) for considering driving status in schizophrenia.