Automobile driving performance of brain-injured patients with visual field defects

The purpose of this study was to examine whether patients with visual field defects resulting from cerebral injury are handicapped in their driving ability, because visual field loss as assessed in standard perimetry is often the basis for withdrawal of a person's driving license. Driving performance was tested on a driving simulator to obtain standardized results and for safety reasons. The visual field was assessed both with standard automated perimetry and computer-based, high-resolution, qualitative perimetry. We investigated nine patients with purely cerebral field defects (mostly homonymous binocular defects) who had no further neuropsychological or ophthalmological deficits. Their performance (driving speed, reaction time, and driving error rate) was compared with that of a control group of ten subjects. We found no differences in any of the tested parameters between the visually impaired subjects and the normal participants. This suggests that individuals with visual field defects, including those who suffer from homonymous hemianopia, may perform as adequately as normal individuals in realistic driving scenarios. The perimetrically assessed visual field may, thus, be of limited value for the prediction of driving safety, and we conclude that patients who have field defects should not summarily be denied a driving license.     

Leisure-time activities of patients with ICDs: findings of a survey with respect to sports activity, high altitude stays, and driving patterns

Background: Physicians who are caring for patients with implantable cardioverter-defibrillators (ICDs) are regularly confronted with questions concerning daily activities. This study evaluates the habits of ICD patients with respect to sports activities, stays at high-altitude, and driving patterns.
Methods: A survey was performed in 387 patients with ICDs who were followed at two hospitals in Switzerland. The special-designed questionnaire addressed lifestyle practices concerning sports activity, high-altitude visits, and driving motor vehicles.
Results: Fifty-nine percent of ICD patients participated in some kind of sports activity; an ICD shock was experienced in 14% of these patients. Fifty-six percent of the patients reported a stay at high altitudes at least 2,000 m above the sea level; 11% of them stayed regularly above 2,500 m; 4% of these patients experienced an ICD shock during high altitude stay. Seventy-nine percent of the patients drove a motor vehicle; 2% of them experienced an ICD shock during driving, but none of them reported loss of consciousness or a traffic accident.
Conclusion: It is accepted that ICD patients disqualify for competitive sports. However, the patients may be encouraged to continue leisure-time physical activities at low-to-moderate intensity. Staying at high altitudes and driving motor vehicles are very rarely associated with ICD shocks. Therefore, these activities that are likely to contribute to a better quality of life should not be discouraged in most ICD recipients in the absence of other medical reasons.     

Driving over 65: proceed with caution

The issue of driving in the elderly population will continue to be relevant for public discourse. Because the termination of driving may be seen as an end of independence, it is important to appreciate that it has both emotional and pragmatic consequence. Senescence includes a host of physiological changes that may influence one's driving ability. Yet, aging alone does not infer poor driving ability. Health care providers should encourage and support the development of accurate methods of evaluation for older drivers and discuss adaptive strategies with older drivers in an effort to maintain their independence while promoting public safety.     

Driving mishaps and hypoglycaemia: risk and prevention

Driving is a complex, multi-task activity that can be affected by cognitive impairment resulting from episodes of severe hypoglycaemia. Intensive insulin therapy increases the likelihood of severe hypoglycaemia but there have been few studies examining effects on driving skills. A survey carried out recently indicated that patients with type 1 diabetes had twice the incidence of driving accidents than their non-diabetic spouses or patients with type 2 diabetes. The motor accidents were associated with more frequent low blood glucose while driving and less frequent self-monitoring. In driving simulation tests it was found that driving has an intrinsic metabolic demand that can contribute to hypoglycaemia. Driving performance began to deteriorate at around 3.6 mmol/l but drivers frequently did not recognise and failed to treat the hypoglycaemia. Those who did self-treat had more driving relevant symptoms and less neuroglycopenia quantified by EEG alpha-theta differences. Patients should be recommended not to begin driving if blood glucose is below 4.5 mmol/l and should not continue to drive if they suspect that blood glucose has fallen below 4 mmol/l while driving. If hypoglycaemia is suspected patients should immediately pull off the road, measure blood glucose if possible, treat themselves as necessary and not resume driving until glucose and cognitive-motor function return to normal. The problems of driving and hypoglycaemia should be discussed with patients with diabetes and behavioural interventions instigated. To this end, Blood Glucose Awareness Training (BGAT) and Hypoglycaemia Anticipation, Awareness and Treatment Training (HAATT) have been developed and shown to markedly reduce incidence of driving mishaps.     

Driving strategies used by older adults with macular degeneration: assessing the risks.

Older adults with macular degeneration use multiple driving strategies. A secondary analysis focused on driving strategies was conducted on data from two studies that had explored the experience of visual impairment in older adults diagnosed with macular degeneration. Findings revealed 24 driving strategies. Twelve categories emerged, reflecting two themes: (1) strategies used while performing the task of driving and (2) strategies used to continue driving. By understanding these strategies, nurses can assess the conditions under which these older adults drive and the risks taken. Findings guide nurses to counsel and educate older adults regarding driving.     

Rehabilitation is a way of thinking,not a way of doing

There is strong evidence that the processes used by rehabilitation services are effective at reducing mortality and morbidity, yet purchasers still feel that there is insufficient evidence to warrant buying rehabilitation. Why? Evidence in support of many individual treatments is either weak or absent, but it is important not to conflate evidence about the process with evidence about specific actions. The absence of evidence concerning specific interventions should not be interpreted as meaning that rehabilitation is ineffective, and should certainly not be used as an excuse not to purchase rehabilitation. The evidence strongly suggests that the whole system works and until we have further evidence, the system should be bought as a whole. Further research into specific interventions should continue, but in addition there should be more research attention paid to the rehabilitation process itself.     

Re-framing the representation of women in advertisements for hormone replacement therapy

This article examines and presents examples of contemporary advertising within the medical and health professions that continue the process and organisation of knowledge about women and their reproductive bodies. It draws on feminist and poststructural perspectives to inform a critical evaluation of the visual representations of menopausal women and hormone replacement therapy. These representations work to construct certain definitions of the feminine that sustain and support existing contradictory cultural meanings and values about menopause. I argue that the images continue to misrepresent and define what forms of femininity and sexual gender are desirable and acceptable for menopausal women. The article addresses the problems of gender discrimination and bias within the advertising industry, and illustrates the ways in which readers of visual texts may be influenced by stereotypic assumptions concerning a woman's lived experience of menopause. It illustrates how specific symbolic images directed towards men and women for hormone replacement therapy, testosterone deficiency and sexual dysfunction influence the viewer's decision making and action responses.     

Evaluation of fitness to drive. The physician's role in assessing elderly or demented patients

The role of physicians in deciding whether a patient should continue to drive is purely advisory. However, physicians have a moral and, in some states, a legal obligation to report patients who are no longer fit to drive. The most authoritative test to predict safe driving in the elderly is an on-road evaluation conducted by the state driver's licensing authority, which has ultimate responsibility for deciding a patient's fitness to drive. Patients with mild dementia are generally considered safe drivers, although specialized testing, such as an on-road test, may be indicated. Those with moderate dementia can be further evaluated by the on-road test, since psychological testing to distinguish moderate from mild dementia is imprecise. Severe dementia is generally considered a contraindication to driving. When a patient is deemed unfit to drive, the physician can provide counseling and support to help ease the transition away from driving.     

Older adult drivers with cognitive impairment

As the number of drivers with cognitive impairment increases, family physicians are more likely to become involved in decisions about cessation of driving privileges in older patients. Physicians who care for cognitively impaired older adults should routinely ask about driving status. In patients who continue to drive, physicians should assess pertinent cognitive domains, determine the severity and etiology of the dementia, and screen for risky driving behaviors. Cognitive impairment detected by office-based tests may indicate that the patient is at risk of a motor vehicle crash. Referral for performance-based road testing may further clarify risk and assist in making driving recommendations. Physicians should assist families in the difficult process of driving cessation, including providing information about Web sites and other resources and clarifying the appropriate state regulations. Some states require reporting of specific medical conditions to their departments of motor vehicles.     

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.

     

Establishing the credibility of qualitative research findings: the plot thickens

Qualitative research is increasingly recognized and valued and its unique place in nursing research is highlighted by many. Despite this, some nurse researchers continue to raise epistemological issues about the problems of objectivity and the validity of qualitative research findings. This paper explores the issues relating to the representativeness or credibility of qualitative research findings. It therefore critiques the existing distinct philosophical and methodological positions concerning the trustworthiness of qualitative research findings, which are described as follows: quantitative studies should be judged using the same criteria and terminology as quantitative studies; it is impossible, in a meaningful way, for any criteria to be used to judge qualitative studies; qualitative studies should be judged using criteria that are developed for and fit the qualitative paradigm; and the credibility of qualitative research findings could be established by testing out the emerging theory by means of conducting a deductive quantitative study. The authors conclude by providing some guidelines for establishing the credibility of qualitative research findings.     

Mobility scooter driving ability in visually impaired individuals

Purpose: To investigate how well visually impaired individuals can learn to use mobility scooters and which parts of the driving task deserve special attention.

Materials and methods: A mobility scooter driving skill test was developed to compare driving skills (e.g. reverse driving, turning) between 48 visually impaired (very low visual acuity?=?14, low visual acuity?=?10, peripheral field defects?=?11, multiple visual impairments?=?13) and 37 normal-sighted controls without any prior experience with mobility scooters. Performance on this test was rated on a three-point scale. Furthermore, the number of extra repetitions on the different elements were noted.

Results: Results showed that visually impaired participants were able to gain sufficient driving skills to be able to use mobility scooters. Participants with visual field defects combined with low visual acuity showed most problems learning different skills and needed more training. Reverse driving and stopping seemed to be most difficult.

Conclusions: The present findings suggest that visually impaired individuals are able to learn to drive mobility scooters. Mobility scooter allocators should be aware that these individuals might need more training on certain elements of the driving task.

• Implications for rehabilitation

• Visual impairments do not necessarily lead to an inability to acquire mobility scooter driving skills.

• Individuals with peripheral field defects (especially in combination with reduced visual acuity) need more driving ability training compared to normal-sighted people – especially to accomplish reversing.

• Individual assessment of visually impaired people is recommended, since participants in this study showed a wide variation in ability to learn driving a mobility scooter.

     

Progressive hypoglycemia's impact on driving simulation performance. Occurrence, awareness and correction

OBJECTIVE: Progressive hypoglycemia leads to cognitive-motor and driving impairments. This study evaluated the blood glucose (BG) levels at which driving was impaired, impairment was detected, and corrective action was taken by subjects, along with the mechanisms underlying these three issues. RESEARCH DESIGN AND METHODS: There were 37 adults with type 1 diabetes who drove a simulator during continuous euglycemia and progressive hypoglycemia. During testing, driving performance, EEG, and corrective behaviors (drinking a soda or discontinuing driving) were continually monitored, and BG, symptom perception, and judgement concerning impairment were assessed every 5 min. Mean +/- SD euglycemia performance was used to quantify z scores for performance in three hypoglycemic ranges (4.0-3.4, 3.3-2.8, and <2.8 mmol/l). RESULTS: During all three hypoglycemic BG ranges, driving was significantly impaired, and subjects were aware of their impaired driving. However, corrective actions did not occur until BG was <2.8 mmol/l. Driving impairment was related to increased neurogenic symptoms and increased theta-wave activity. Awareness of impaired driving was associated with neuroglycopenic symptoms. increased beta-wave activity, and awareness of hypoglycemia. High beta and low theta activity and awareness of both hypoglycemia and the need to treat low BG influenced corrective behavior. CONCLUSIONS: Driving performance is significantly disrupted at relatively mild hypoglycemia, yet subjects demonstrated a hesitation to take corrective action. The longer treatment is delayed, the greater the neuroglycopenia (increased theta), which precludes corrective behaviors. Patients should treat themselves while driving as soon as low BG and/or impaired driving is suspected and should not begin driving when their BG is in the 5.0-4.0 mmol/l range without prophylactic treatment.     

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.     

Effect of visual perception, visual function, cognition, and personality on power wheelchair use in adults

The purpose of this study was to determine to what extent visual perception, visual function, cognition, and personality traits affect power wheelchair use in adults. It also proposes to establish baseline information to help clinicians determine or predict power wheelchair driving performance and to develop service plans to address those driving skills that need improvement or compensation. Sixty-two adult power wheelchair users were recruited. Standardized instruments were used to evaluate visual perceptual skills, visual function, cognitive skills, and personality traits. The results of these evaluations were then correlated with participants' scores on a power wheelchair performance test. Strong correlations were found between power wheelchair driving performance and visual perception (p = .000), ocular motor function (p = .000 and p < or = .001), stereodepth perception (p < or = .001), and alertness to the environment (p < or = .001). No significant correlations were found between personality traits and power wheelchair driving performance. These results indicate that good visual perceptual skills, visual function, and various aspects of cognition are necessary for proficient power wheelchair use. These data will assist clinicians in identifying significant factors to consider when evaluating and training clients for power wheelchair use.     

Elderly Drivers' Perceptions of Their Driving Abilities Compared to Their Functional Visual Perception Skills and Their Actual Driving Performance

The rationale of occupational therapy is to help individuals develop and function independently within their environment. The privilege of driving affords people one aspect of independence by serving as a link for the accomplishment of other daily living tasks. Although evidence suggests an age related decline in the skills needed for safe driving, especially after age 55, the clinical predictors of driving performance are relatively unknown. This study examined the elderly drivers' perceptions of their driving abilities, compared to their clinically tested functional skills in the area of visual perception, and their actual in-care driving performance. The specific skills assessed included peripheral visual field, depth perception, color sensitivity, static visual acuity, dynamic visual acuity, and figure-ground discrimination. The comparisons were examined by the chi-square and analysis of variance (ANOVA) statistical procedures to determine whether a significant difference existed among the variables. A population sample of 115 males, 65 years and older, were selected from an outpatient clinic at the Veteran's Administration Hospital in Richmond, Virginia. Results indicated that clinically tested visual perception skills and actual in-car driving performance can be predictive based on left and right peripheral vision, and brown/green color sensitivity. This study also indicated that people generally tend to over-rate their driving abilities. It is believed that a larger sample and some testing instrument changes could yield more significant results. Limitations of this study and ideas for future research are provided.     

Validation of a driving simulator by measuring the visual attention skill of older adult drivers.

OBJECTIVE: The purpose of this study was to validate a laboratory-based driving simulator as an off-road screening tool for older adult drivers by measuring their visual attention skill, and to determine how the visual attention skill changes across time in a 45-minute simulated driving test. METHOD: One hundred and twenty-nine community-dwelling older drivers volunteered to take part in the study. A range of driving scenarios was devised and implemented in a simulator setting to assess the driving skills of the participants. Visual attention skill, an important contributing factor to motor vehicle crashes, was assessed by the participant's reaction times to a sequence of 14 visual stimuli during the primary task of sustained driving. Repeated measures of analysis of variance (ANOVA) were undertaken to determine the effects of age and gender on the visual attention skill. Trend analysis was performed to investigate how repeated exposures to the visual stimulus affected the reaction time. RESULTS: The visual attention skill of older drivers was found to decline with age (F(1,126)) = 42.52, p value = 0.002), whereas the effect of gender was not significant. Participants increased their speed of reaction times for the first half of the testing then slowed down during the second half. CONCLUSION: That visual attention skill declined with age was consistent with the literature, and validated the driving simulator as an effective screening tool for older adult drivers. With rapid advancements in computer technology, the driving simulator will likely play an important role in assisting occupational therapists with off-road assessment of older drivers.     

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.     

Management of the social consequences of seizures

People with seizures experience restrictions in many areas of life, including participation in recreational activities, social situations, employment, and driving. Health care providers and patients should be informed of the potential hazards faced by people with seizures. The patient and practitioner who know the potential risks can make rational decisions about participation in these activities. Risk assessment and participation should be individualized according to the patient's unique situation. Understanding the inherent risk of a particular activity, risk of recurrence of seizures, legal restrictions (some activities may be governed by law or specific code), seizure type, and adverse effects of medication may be useful in making decisions concerning participation in a wide variety of activities. The information in this article should be used to maximize the patient's quality of life.     

Interactive driving simulation--a new approach to diagnosis and rehabilitation of driving skills

Until recently, major methodological problems were faced in the assessment and rehabilitation of driving ability in neurological patients, concerning practical driving lessons and driving tests as well as neuropsychological tests and therapies. The use of highly-advanced driving simulators may solve parts of this problem. However, a basic requirement for effective rehabilitation is the patients' acceptance of this method. In a semi-standardized interview with 56 patients we found that the driving simulator recently installed in the Neurological Rehabilitation Centre "Godesh?he" was rated mainly positively. Also, patients experienced the simulator to be motivating, effective and informative. Hence, a very important prerequisite for successful use of driving simulators in neurological rehabilitation is given.