Assessment of older drivers in New Zealand: The current system,research and recommendations

The purpose of this article is to clarify the current New Zealand driving licensing requirements for older adults and to provide practical recommendations for those health professionals who make decisions regarding driving ability in older adults. Health professionals involved in the assessment of older drivers were asked to clarify areas where more efficient use could be made of assessment resources. A review of driving literature was performed to find specific factors associated with increased risk of negative driving outcomes in older adults. Particular attention was paid to the suitability of different types of on‐road assessment for certain patient groups, the effect of specific diseases and medications on driving safety, and the effect of cognitive impairment. A list of seven recommendations were compiled which include a focus on appropriate on‐road driving assessment referral, driver refresher courses, cognitive screening for those presenting for licence renewal and sensitive broaching of the topic of driving cessation.     

Predicting driving cessation over 5 years in older adults: psychological well-being and cognitive competence are stronger predictors than physical health

OBJECTIVES: To examine psychological, medical, and sensorimotor risk factors that predict driving cessation in older adults. DESIGN: Prospective cohort study including five waves of data collected in 1992, 1993, 1994, 1995, and 1997. SETTING: The Australian Longitudinal Study of Aging. PARTICIPANTS: One thousand four hundred sixty-six men and women aged 70 and older drawn from the electoral roll and including 753 drivers at baseline. MEASUREMENTS: Interviews, including assessments of self-rated health (indicating general well-being); medical conditions; driving status; and clinical assessments of vision, hearing, cognitive function, and grip strength, were conducted in 1992 (baseline) and 1994. Information on current driving status was obtained at baseline and four subsequent waves (1993, 1994, 1995, and 1997). Drivers and nondrivers were compared at baseline. Risk factors for driving cessation were identified using logistic regression. RESULTS: Drivers were younger and more likely to be male and had better self-rated health, vision, hearing, and cognitive performance than nondrivers at baseline. Seventeen percent of drivers in the study had vision of 6/18 or worse, and 7.3% were classified as possibly cognitively impaired. In those identified as drivers at baseline, subsequent cessation was associated with increasing age, low grip strength, poorer cognitive performance, and poorer self-rated health. CONCLUSION: Self-rated health and cognitive function were more important than medical conditions or sensory function for predicting driving cessation.     

Supporting Older Women in the Transition to Driving Cessation

This study explores how older women have their transportation needs met following driving cessation and the factors influencing the transition to driving cessation. Eleven women age 70 and older who ceased driving participated in face-to-face interviews. They often used different mobility options to continue their participation in different types of activities, and they experienced reductions in social activity participation. Location and access to public transportation, access to stable mobility options, control over mobility options, and planning for driving cessation influenced adaptation to driving cessation. The results provide direction for the development of appropriate mobility options and the development of effective programs to reduce the negative impact of driving cessation.     

Older driver safety: a report from the older drivers project

Older driver safety is a growing public health concern for which interventions are currently being sought. Statistics show that older drivers suffer a disproportionately high rate of motor vehicle fatalities compared with other adult drivers. This disproportion is due to two factors: an increased crash rate per vehicle mile driven and an increased risk of fatality in the event of a crash. Traditionally, traffic safety efforts for the older population have focused on methods to identify unsafe drivers to enforce driving cessation, but driving cessation deprives the majority of older Americans of their primary form of transportation and has been associated with an increase in depressive symptoms. In response to these concerns, the Older Drivers Project, created by the American Medical Association in partnership with the National Highway Traffic Safety Administration, describes and advocates a more acceptable approach to traffic safety. The primary objective of this approach involves helping older drivers stay on the road safely to preserve their mobility and independence. This can be accomplished through three methods: (1) optimizing the driver, (2) optimizing the driving environment, and (3) optimizing the vehicle. In this approach, driving cessation is recommended only after the safety of the driver cannot be secured through any other means.     

The On-Road Difficulties of Older Drivers and Their Relationship with Self-Reported Motor Vehicle Crashes

OBJECTIVES: To quantify the driving difficulties of older adults using a detailed assessment of driving performance and to link this with self-reported retrospective and prospective crashes.
DESIGN: Prospective cohort study.
SETTING: On-road driving assessment.
PARTICIPANTS: Two hundred sixty-seven community-living adults aged 70 to 88 randomly recruited through the electoral roll.
MEASUREMENTS: Performance on a standardized measure of driving performance.
RESULTS: Lane positioning, approach, and blind spot monitoring were the most common error types, and errors occurred most frequently in situations involving merging and maneuvering. Drivers reporting more retrospective or prospective crashes made significantly more driving errors. Driver instructor interventions during self-navigation (where the instructor had to brake or take control of the steering to avoid an accident) were significantly associated with higher retrospective and prospective crashes; every instructor intervention almost doubled prospective crash risk.
CONCLUSION: These findings suggest that on-road driving assessment provides useful information on older driver difficulties, with the self-directed component providing the most valuable information.     

Characteristics of frail older adult drivers

OBJECTIVES: To determine the prevalence of driving in older adults with mild to moderate physical frailty and to compare characteristics of current frail older adult drivers with those of former drivers in the sample. DESIGN: Retrospective study of frail older adults enrolled in randomized trials of exercise and hormone replacement therapy. SETTING: Urban, academic medical center. PARTICIPANTS: One hundred eighty-three sedentary community-dwelling men and women aged 75 and older with mild to moderate physical frailty, as defined by two of the following three criteria: modified Physical Performance Test (PPT) score between 18 and 32, peak oxygen uptake (VO2) between 10 and 18 mL/kg per minute, and self-report of difficulty or assistance with one activity of daily living (ADL) or two instrumental ADLs. Participants were classified as current or former drivers. MEASUREMENTS: Demographic characteristics, medical diagnoses, medication use, modified PPT score, and psychometric tests. RESULTS: The majority (85%) of the participants were drivers. Former drivers were more likely to be older, be female, reside in congregate independent living for the elderly, have a higher incidence of arthritis and congestive heart failure, take sedating medications, have lower total ADL scores, have lower VO2 peak scores, and have more impairment on tests of cognition and physical strength, although only age, type of residence, and grip strength were independent predictors of driving cessation in the regression analysis. CONCLUSION: Despite the presence of physical frailty, many older adults choose to continue to drive. Further studies are needed to better understand the driving behaviors of frail older adults and explore opportunities for optimizing driving abilities.     

Transportation behaviours of older adults: An investigation into car dependency in urban Australia

Aim: Increased car dependency among Australia's ageing population may result in increased social isolation and other health impacts associated with the cessation of driving. While public transport represents an alternative to car usage, patronage remains low among older cohorts. This study investigates the facilitators and barriers to public transport patronage and the nature of car dependence among older Australians. Methods: Data were gathered from a sample of 24 adults (mean age = 70 years) through a combination of quantitative (remote behavioural observation) and qualitative (interviews) investigation. Results: Findings suggest that relative convenience, affordability and health/mobility may dictate transport mode choices. The car is considered more convenient for the majority of suburban trips irrespective of the availability of public transport. Conclusion: Policy attention should focus on providing better education and information regarding driving cessation and addressing older age specific social aspects of public transport including health and mobility issues.     

Self-reported health and driving cessation in community-dwelling older drivers

BACKGROUND: Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults. METHODS: Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later. RESULTS: Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73). CONCLUSIONS: Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.     

Road Test and Naturalistic Driving Performance in Healthy and Cognitively Impaired Older Adults: Does Environment Matter?

Objectives

To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment.

Design

Cross‐sectional observational study.

Setting

Academic medical center memory disorders clinic.

Participants

One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test.

Measurements

Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor.

Results

There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition (Mini‐Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving.

Conclusion

Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study.     

The impact of executive cognitive functioning on rates of smoking cessation in the San Luis Valley Health and Aging Study

Cigarette smoking is one of the leading preventable causes of death. Previous research has shown that many common smoking cessation interventions are effective with older smokers; a few interventions have been tailored to this population. To our knowledge, however, no smoking cessation research or interventions targeted at older adults have addressed the influence of cognition on successful smoking cessation. We hypothesized that impairment of executive cognitive functioning (ECF), which is relatively prevalent among older adults, would negatively influence smoking cessation rates among older smokers. The relationship of ECF to smoking cessation was examined in a population-based sample of 1,338 community-dwelling older persons in Colorado's San Luis Valley, 204 of whom were current smokers. As predicted, current ECF did not predict early smoking behaviour, but was a significant predictor of successful smoking cessation. Older persons suffering from executive dysfunction were less likely to have quit smoking than were their cognitively intact counterparts (OR = 1.10, 95% CI 1.04-1.17, P < 0.01). Among those with normal ECF, 73.7% had quit smoking, compared with 65.1% of participants showing any level of ECF impairment. Limiting the sample to individuals who were active smokers at or after the age of 65, when executive impairment is relatively common, produced similar results. Individuals with better executive functioning were more likely to have quit smoking (OR = 1.12, 95% CI 1.02-1.23, P = 0.02).     

Longitudinal predictors of driving cessation among older adults from the ACTIVE clinical trial

We examined the physical, visual, health, and cognitive abilities of 1,656 older adults as prospective predictors of self-reported driving cessation over a 5-year period. We examined the time to driving cessation across 5 years after we controlled for days driven per week at baseline and any cognitive intervention participation. Older age, congestive heart failure, and poorer physical performance (according to the Turn 360 Test) were statistically significant risk factors for driving cessation. Slower speed of processing (according to the Digit Symbol Substitution and Useful Field of View tests) was a significant risk factor even after we took baseline driving, age, health, vision, and physical performance into consideration. Implications are that assessments of cognitive speed of processing can provide valuable information about the subsequent risk of driving cessation.     

Driving cessation and increased depressive symptoms

BACKGROUND: To understand the consequences of driving cessation in older adults, the authors evaluated depression in former drivers compared with active drivers. METHODS: Depression (as assessed using the Center for Epidemiological Studies Depression Scale), driving status, sociodemographic factors, health status, and cognitive function were evaluated for a cohort of 1953 residents of Sonoma County, California, aged 55 years and older, as part of a community-based study of aging and physical performance. The authors re-interviewed 1772 participants who were active drivers at baseline 3 years later. RESULTS: At baseline, former drivers reported higher levels of depression than did active drivers even after the authors controlled for age, sex, education, health, and marital status. In a longitudinal analysis, drivers who stopped driving during the 3-year interval (i.e., former drivers) reported higher levels of depressive symptoms than did those who remained active drivers, after the authors controlled for changes in health status and cognitive function. Increased depression for former drivers was substantially higher in men than in women. CONCLUSIONS: With increasing age, many older adults reduce and then stop driving. Increased depression may be among the consequences associated with driving reduction or cessation.     

Effect of driving training on car crashes and driving skills in older people: A systematic review and meta-analysis

The primary aim of this systematic review was to examine the efficacy of driving interventions with regard to a reduction in motor vehicle crashes and improvements in driving skills among older people. The secondary aim was to identify the optimal type (on-road or off-road) and dosage (period, sessions, and duration) of driving interventions for improving driving skills in older people. We searched MEDLINE, EMBASE, PsycINFO, and Scopus of Systematic Reviews for papers published from their inception to December 1, 2020, as well as the reference lists of the included papers. The selected studies were randomized controlled trials examining the effects of driving interventions among community-dwelling older drivers aged 65 years and over. A meta-analysis of two studies (n = 960) showed that driving interventions significantly reduced the number of motor vehicle crashes per person-years. Ten studies (n = 575) were included in the meta-analysis showing that the interventions significantly improved the driving skill scores. Driving skill scores significantly improved after on-road training, and in interventions of at least 3 h, 3 sessions, and 3 weeks. Driving interventions significantly improve driving skills and reduce motor vehicle crashes among older drivers aged 65 years and over. On-road training is more efficacious than off-road training and driving interventions of at least 3 h taking place in 3 sessions over a period of 3 weeks may be required to improve driving skills in older drivers. Geriatr Gerontol Int 2023; 23: 771–778 .     

Smoking Cessation Interventions and Older Adults

Older adults suffer a large proportion of the health consequences from smoking and can greatly benefit their health by quitting smoking. This article examines the current state of research and practice for older adults and smoking cessation interventions. For over 17 years, the health care literature has mandated that people of all ages be provided with smoking cessation interventions. However, smoking cessation interventions are offered to older adults at suboptimal rates. Nurses, especially those caring for clients in the inpatient setting, have an opportunity to provide smoking cessation interventions to older smokers. Recent research has shown that older smokers, particularly those hospitalized with cardiovascular disease, can quit at high rates when provided an intervention. Furthermore, use of nicotine replacement therapy has been shown to be safe and efficacious among older smokers with cardiovascular disease.     

Visual attention and driving behaviors among community-living older persons

BACKGROUND: Older drivers have higher rates of crashes per mile driven compared with most other drivers, and these crashes result in greater morbidity and mortality. Various aspects of cognition, particularly visual attention, have been linked with crash risk among older individuals. The current study was designed to specify those cognitive variables associated with specific on-road driving behaviors in a sample of older, nonclinic-referred individuals. METHODS: 35 community-residing active drivers aged 72 years and older (M = 80) underwent a standardized, on-road driving evaluation involving parking lot maneuvers, and urban, suburban, and highway driving. They were also administered tests of visual attention, executive function, visuospatial cognition, and memory. RESULTS: Driving score was significantly correlated with visual attention, visual memory, and executive function. Visual attention was associated with 25 of 36 driving behaviors, including those involving scanning the environment, interaction with traffic or pedestrians, and distance judgments. Executive function and visual memory were associated with fewer maneuvers, most of which were a subset of maneuvers that correlated with visual attention. CONCLUSIONS: Visual attention, a cognitive function involving search, selection, and switching, plays an important role in driving risk among older drivers. In the current study, key driving maneuvers involving interaction with other vehicles/pedestrians, such as yielding right of way and negotiating safe turns or merges, have the greatest association with visual attention. Specification of both the cognitive risk factors and their impact on problematic driving maneuvers may provide guidelines for developing targeted interventions to reduce risk among older adults.     

A Randomized Trial of a Physical Conditioning Program to Enhance the Driving Performance of Older Persons

Background As the number of older drivers increases, concern has been raised about the potential safety implications. Flexibility, coordination, and speed of movement have been associated with older drivers’ on road performance. Objective To determine whether a multicomponent physical conditioning program targeted to axial and extremity flexibility, coordination, and speed of movement could improve driving performance among older drivers. Design Randomized controlled trial with blinded assignment and end point assessment. Participants randomized to intervention underwent graduated exercises; controls received home, environment safety modules. Participants Drivers, 178, age ≥ 70 years with physical, but without substantial visual (acuity 20/40 or better) or cognitive (Mini Mental State Examination score ≥24) impairments were recruited from clinics and community sources. Measurements On-road driving performance assessed by experienced evaluators in dual-brake equipped vehicle in urban, residential, and highway traffic. Performance rated three ways: (1) 36-item scale evaluating driving maneuvers and traffic situations; (2) evaluator’s overall rating; and (3) critical errors committed. Driving performance reassessed at 3 months by evaluator blinded to treatment group. Results Least squares mean change in road test scores at 3 months compared to baseline was 2.43 points higher in intervention than control participants (P = .03). Intervention drivers committed 37% fewer critical errors (P = .08); there were no significant differences in evaluator’s overall ratings (P = .29). No injuries were reported, and complaints of pain were rare. Conclusions This safe, well-tolerated intervention maintained driving performance, while controls declined during the study period. Having interventions that can maintain or enhance driving performance may allow clinician–patient discussions about driving to adopt a more positive tone, rather than focusing on driving limitation or cessation.     

Driving cessation: what older former drivers tell us

OBJECTIVES: To understand why older drivers living in a community setting stop driving. DESIGN: A cross-sectional study within a longitudinal cohort. SETTING: A geographically defined community in southern California. PARTICIPANTS: 1,950 respondents age 55 and older who reported ever being licensed drivers. MEASUREMENTS: A mailed survey instrument of self-reported driving habits linked to prior demographic, health, and medical information. RESULTS: Of the 1,950 eligible respondents, 141 had stopped driving within the previous 5 years. Among those who stopped, mean age was 85.5 years, 65.2% were female, and the majority reported they were in very good (43.4%) or good (34.0%) health. Nearly two-thirds reported driving less than 50 miles per week prior to stopping and 12.1% reported a motor vehicle crash during the previous 5 years. The most common reasons reported for stopping were medical (41.0%) and age-related (19.4%). In bivariate analyses, age and miles driven per week were each associated with cessation (P < or = .001). Medical conditions, crashes in the previous 5 years, and gender did not reach statistical significance at the P < or = .05 level. Logistic regression results found that the number of medical conditions was inversely associated with driving cessation. CONCLUSION: The relationship between medical conditions and driving is complex; while medical conditions were the most common reason given for driving cessation, those who stopped had fewer medical conditions than current drivers. This suggests that a broader measure of general health or functional ability may play a dominant role in decisions to stop driving.     

A multidomain approach for predicting older driver safety under in-traffic road conditions

OBJECTIVES: To identify a battery of tests that predicts safe and unsafe performance on an on-road assessment of driving.
DESIGN: Prospective cohort study.
SETTING: University laboratory assessment and an on-road driving test.
PARTICIPANTS: Two hundred seventy community-living adults aged 70 to 88 recruited through the electoral roll.
MEASUREMENTS: Performance on a battery of multidisciplinary tests and on a standardized measure of on-road driving performance.
RESULTS: A combination of three tests from the vision, cognitive, and motor domains, including motion sensitivity, color choice reaction time, postural sway on a compliant foam rubber surface, and a self-reported measure of driving exposure, was able to classify participants into safe and unsafe driver groups with sensitivity of 91% and specificity of 70%.
CONCLUSION: In a sample of licensed older drivers, a short battery of tests and a self-reported measure of driving exposure were able to accurately predict driving safety.