Predicting Driving Cessation Among Cognitively Normal Older Drivers: The Role of Alzheimer Disease Biomarkers and Clinical Assessments.

BACKGROUND AND OBJECTIVES: With the aging US population and increasing incidence of Alzheimer disease (AD), understanding factors contributing to driving cessation among older adults is crucial for clinicians. Driving is integral for maintaining independence and functional mobility, but the risk factors for driving cessation, particularly in the context of normal aging and preclinical AD, are not well understood. We studied a well-characterized community cohort to examine factors associated with driving cessation. METHODS: This prospective, longitudinal observation study enrolled participants from the Knight Alzheimer Disease Research Center and The DRIVES Project. Participants were enrolled if they were aged 65 years or older, drove weekly, and were cognitively normal (Clinical Dementia Rating [CDR] = 0) at baseline. Participants underwent annual clinical, neurologic, and neuropsychological assessments, including ß-amyloid PET imaging and CSF (Aß42, total tau [t-Tau], and phosphorylated tau [p-Tau]) collection every 2-3 years. The primary outcome was time from baseline visit to driving cessation, accounting for death as a competing risk. The cumulative incidence function of driving cessation was estimated for each biomarker. The Fine and Gray subdistribution hazard model was used to examine the association between time to driving cessation and biomarkers adjusting for clinical and demographic covariates. RESULTS: Among the 283 participants included in this study, there was a mean follow-up of 5.62 years. Driving cessation (8%) was associated with older age, female sex, progression to symptomatic AD (CDR ≥0.5), and poorer performance on a preclinical Alzheimer cognitive composite (PACC) score. Aß PET imaging did not independently predict driving cessation, whereas CSF biomarkers, specifically t-Tau/Aß42 (hazard ratio [HR] 2.82, 95% CI 1.23-6.44, p = 0.014) and p-Tau/Aß42 (HR 2.91, 95% CI 1.28-6.59, p = 0.012) ratios, were independent predictors in the simple model adjusting for age, education, and sex. However, in the full model, progression to cognitive impairment based on the CDR and PACC score across each model was associated with a higher risk of driving cessation, whereas AD biomarkers were not statistically significant. DISCUSSION: Female sex, CDR progression, and neuropsychological measures of cognitive functioning obtained in the clinic were strongly associated with future driving cessation. The results emphasize the need for early planning and conversations about driving retirement in the context of cognitive decline and the immense value of clinical measures in determining functional outcomes.

Medication and Road Test Performance Among Cognitively Healthy Older Adults.

Importance: Older adults are increasingly prescribed medications that have adverse effects. Prior studies have found a higher risk of motor vehicle crashes to be associated with certain medication use. Objective: To determine whether specific medication classes were associated with performance decline as assessed by a standardized road test in a community sample of cognitively healthy older adults, to evaluate additional associations of poor road test performance with comorbid medical conditions and demographic characteristics, and to test the hypothesis that specific medication classes (ie, antidepressants, benzodiazepines, sedatives or hypnotics, anticholinergics, antihistamines, and nonsteroidal anti-inflammatory drugs or acetaminophen) would be associated with an increase in risk of impaired driving performance over time. Design, Setting, and Participants: This was a prospective cohort study of 198 cognitively healthy adults 65 years and older with a valid driver's license who were followed up annually, with rolling enrollment. Data were collected from participants in St Louis, Missouri, and neighboring Illinois who were enrolled in the Knight Alzheimer's Disease Research Center. Data were collected from August 28, 2012, to March 14, 2023, and analyzed from April 1 to 25, 2023. Participants with healthy cognition, defined as a Clinical Dementia Rating score of 0 at baseline and subsequent visits, who had available clinical, neuropsychological, road tests, and self-reported medication data were included. Exposure: Potentially driver-impairing medication use. Main Outcomes and Measures: The primary outcome measure was performance on the Washington University Road Test (pass or marginal/fail). Multivariable Cox proportional hazards models were used to evaluate associations between potentially driver-impairing medication use and road test performance. Results: Of the 198 included adults (mean [SD] baseline age, 72.6 [4.6] years; 87 female [43.9%]), 70 (35%) received a marginal/fail rating on the road test over a mean (SD) follow-up of 5.70 (2.45) years. Any use of antidepressants (adjusted hazard ratio [aHR], 2.68; 95% CI, 1.69-4.71), serotonin and norepinephrine reuptake inhibitors (aHR, 2.68; 95% CI, 1.54-4.64), sedatives or hypnotics (aHR, 2.70; 95% CI, 1.40-5.19), or nonsteroidal anti-inflammatory drugs (aHR, 2.72; 95% CI, 1.31-5.63) was associated with an increase in risk of receiving a marginal/fail rating on the road test compared with control individuals. Conversely, participants taking lipid-lowering agents had a lower risk of receiving a marginal/fail rating compared to control individuals. There were no statistically significant associations found between anticholinergic or antihistamines and poor performance. Conclusions and Relevance: In this prospective cohort study, specific medication classes were associated with an increase in risk of poor road test performance over time. Clinicians should consider this information and counsel patients accordingly when prescribing these medications.

Cortical atrophy and leukoaraiosis, imaging markers of cerebrovascular small vessel disease, are associated with driving behavior changes among cognitively normal older adults.

BACKGROUND: Cerebral small vessel disease (CSVD) as measured by cortical atrophy and white matter hyperintensities [leukoaraiosis], captured via magnetic resonance imaging (MRI) are increasing in prevalence due to the growth of the aging population and an increase in cardiovascular risk factors in the population. CSVD impacts cognitive function and mobility, but it is unclear if it affects complex, functional activities like driving. METHODS: In a cohort of 163 cognitively normal, community-dwelling older adults (age ≥ 65), we compared naturalistic driving behavior with mild/moderate leukoaraiosis, cortical atrophy, or their combined rating in a clinical composite termed, aging-related changes to those without any, over a two-and-a-half-year period. RESULTS: Older drivers with mild or moderate cortical atrophy and aging-related changes (composite) experienced a greater decrease in the number of monthly trips which was due to a decrease in the number of trips made within a one-to-five-mile diameter from their residence. Older drivers with CSVD experience a larger reduction in daily driving behaviors than drivers without CSVD, which may serve as an early neurobehavioral marker for functional decline. CONCLUSIONS: As CSVD markers, leukoaraiosis and cortical atrophy are standard MRI metrics that are widely available and can be used for screening individuals at higher risk for driving safety risk and decline in community mobility.

Driving Performance in Older Adults: Current Measures, Findings, and Implications for Roadway Safety.

BACKGROUND AND OBJECTIVES: Over 10,000 people a day turn 65 in the United States. For many older adults, driving represents an essential component of independence and is one of the most important factors in overall mobility. Recent survey studies in older adults suggest that up to 60% of older adult drivers with mild cognitive impairment, and up to 30% with dementia, continue to drive. The purpose of this review is to provide a comprehensive and detailed resource on the topics of cognition and driving for clinicians, researchers, and policymakers working on efforts related to older adult drivers. RESEARCH DESIGN AND METHODS: Publications on PubMed and Medline and discussions with experts working in geriatrics, technology, driving policy, psychology, and diverse aspects of driving performance were utilized to inform the current review. RESULTS: Research indicates that there is a complex and inverse correlation between multiple cognitive measures, driving performance, and risky driving behaviors. The fragmented nature of available peer-reviewed literature, and a reliance on correlative data, do not currently allow for the identification of the temporal and reciprocal nature of the interplay between cognition and driving endpoints. DISCUSSION AND IMPLICATIONS: There are currently no widely accepted definitions, conceptual models, or uniform set of analyses for conducting geriatric research that is focused on driving. Establishing conventions for conducting research that harmonizes the fields of geriatrics, cognition, and driving research is critical for the development of the evidence base that will inform clinical practice and road safety policy.

Cognitive and brain reserve predict decline in adverse driving behaviors among cognitively normal older adults.

Daily driving is a multi-faceted, real-world, behavioral measure of cognitive functioning requiring multiple cognitive domains working synergistically to complete this instrumental activity of daily living. As the global population of older adult continues to grow, motor vehicle crashes become more frequent among this demographic. Cognitive reserve (CR) is the brain's adaptability or functional robustness despite damage, while brain reserve (BR) refers the structural, neuroanatomical resources. This study examined whether CR and BR predicted changes in adverse driving behaviors in cognitively normal older adults. Cognitively normal older adults (Clinical Dementia Rating 0) were enrolled from longitudinal studies at the Knight Alzheimer's Disease Research Center at Washington University. Participants (n = 186) were ≥65 years of age, required to have Magnetic Resonance Imaging (MRI) data, neuropsychological testing data, and at least one full year of naturalistic driving data prior to the beginning of COVID-19 lockdown in the United States (March 2020) as measured by Driving Real World In-vehicle Evaluation System (DRIVES). Findings suggest numerous changes in driving behaviors over time were predicted by increased hippocampal and whole brain atrophy, as well as lower CR scores as proxied by the Wide Range Achievement Test 4. These changes indicate that those with lower BR and CR are more likely to reduce their driving exposure and limit trips as they age and may be more likely to avoid highways where speeding and aggressive maneuvers frequently occur.

Video feedback intervention for cognitively impaired older drivers: A randomized clinical trial.

INTRODUCTION: This clinical trial aimed to determine whether in-car video feedback about unsafe driving events (UDE) to cognitively impaired older drivers and family members leads to a reduction in such driving behaviors. METHODS: We randomized 51 cognitively impaired older drivers to receive either (1) a weekly progress report with recommendations and access to their videos, or (2) video monitoring alone without feedback over 3 months. RESULTS: UDE frequency/1000 miles was reduced by 12% in feedback (rate ratio [RR] = 0.88, 95% confidence interval [CI] = .58-1.34), while remaining constant with only monitoring (RR = 1.01, 95% CI = .68-1.51). UDE severity/1000 miles was reduced by 37% in feedback (RR = 0.63, 95% CI = .31-1.27), but increased by 40% in monitoring (RR = 1.40, 95% CI = .68-2.90). Cognitive impairment moderated intervention effects (P = .03) on UDE frequency. DISCUSSION: Results suggest the potential to improve driving safety among mild cognitively impaired older drivers using a behavior modification approach aimed at problem behaviors detected in their natural driving environment.

Physical Medicine and Rehabilitation Residency Quality Improvement and Research Curriculum: Design and Implementation.

ABSTRACT: Physical medicine and rehabilitation residency programs do not demonstrate a uniform level of training and mentorship for resident scholarly activities related in part to variable utilization of standardized curricula. The aim of this study was to design, develop, implement, and evaluate a structured Quality Improvement and Research Curriculum for a physical medicine and rehabilitation residency program in academic year 2015 using standardized methodology. A combination of five-phase project-lifecycle and six-step medical-curriculum development methodologies was used to integrate existing resources into five institutional domains: (1) Patient Safety and Quality Improvement Program; (2) Research Mentorship Program; (3) Rehab in Review; (4) Publication and Presentation Resources, and (5) Research and QI Lecture Series. Dedicated resident-faculty teams were created for individual domains and for the overall curriculum. Written materials developed included scope documents, reporting forms, and tracking tables. A dedicated webpage on the department website served as an accessible resource. A bimonthly Updates newsletter highlighted ongoing resident achievements. Program and resident outcome metrics were evaluated at the mid and end of academic year 2015. Excellent resident and good faculty participation in the curriculum was observed. Resident publication and presentation productivity improved. Time was the biggest barrier to success. Key factors for success included phased implementation, dedicated teams, scope clarity, accessible resources, personnel support, resident champions, and faculty mentorship.

The Role of Eye Tracking Technology in Assessing Older Driver Safety.

A growing body of literature is focused on the use of eye tracking (ET) technology to understand the association between objective visual parameters and higher order brain processes such as cognition. One of the settings where this principle has found practical utility is in the area of driving safety. METHODS: We reviewed the literature to identify the changes in ET parameters with older adults and neurodegenerative disease. RESULTS: This narrative review provides a brief overview of oculomotor system anatomy and physiology, defines common eye movements and tracking variables that are typically studied, explains the most common methods of eye tracking measurements during driving in simulation and in naturalistic settings, and examines the association of impairment in ET parameters with advanced age and neurodegenerative disease. CONCLUSION: ET technology is becoming less expensive, more portable, easier to use, and readily applicable in a variety of clinical settings. Older adults and especially those with neurodegenerative disease may have impairments in visual search parameters, placing them at risk for motor vehicle crashes. Advanced driver assessment systems are becoming more ubiquitous in newer cars and may significantly reduce crashes related to impaired visual search, distraction, and/or fatigue.

Feasibility and Validity of a Low-Cost Racing Simulator in Driving Assessment after Stroke.

There is a myriad of methodologies to assess driving performance after a stroke. These include psychometric tests, driving simulation, questionnaires, and/or road tests. Research-based driving simulators have emerged as a safe, convenient way to assess driving performance after a stroke. Such traditional research simulators are useful in recreating street traffic scenarios, but are often expensive, with limited physics models and graphics rendering. In contrast, racing simulators developed for motorsport professionals and enthusiasts offer high levels of realism, run on consumer-grade hardware, and can provide rich telemetric data. However, most offer limited simulation of traffic scenarios. This pilot study compares the feasibility of research simulation and racing simulation in a sample with minor stroke. We determine that the racing simulator is tolerated well in subjects with a minor stroke. There were correlations between research and racing simulator outcomes with psychometric tests associated with driving performance, such as the Trails Making Test Part A, Snellgrove Maze Task, and the Motricity Index. We found correlations between measures of driving speed on a complex research simulator scenario and racing simulator lap time and maximum tires off track. Finally, we present two models, using outcomes from either the research or racing simulator, predicting road test failure as linked to a previously published fitness-to-drive calculator that uses psychometric screening.

Validity and Reliability of the Traffic Sign Naming Test (TSNT) and Written Exam for Driving Decisions (WEDD) as Measures of Fitness to Drive Among Older Adults.

IMPORTANCE: Occupational therapists need valid and reliable tools to help determine fitness to drive of older drivers with medical conditions such as dementia. OBJECTIVE: To establish the validity and reliability of the Traffic Sign Naming Test (TSNT) and Written Exam for Driving Decisions (WEDD) as measures of fitness to drive of adults with and without dementia. DESIGN: Cross-sectional. SETTING: Washington University Medical School in St. Louis in collaboration with the Rehabilitation Institute of St. Louis. PARTICIPANTS: Older drivers diagnosed with dementia (n = 130) and without dementia (n = 34). Drivers with dementia required a physician referral indicating a medical need for a driving evaluation, a diagnosis of dementia, and an Alzheimer Detection 8 score of 2. Drivers without dementia were required to be age 55 yr or older and not meet criteria for dementia. OUTCOMES AND MEASURES: Participants completed a comprehensive driving evaluation (CDE) that included clinical measures of vision, motor, and cognition; TSNT; and WEDD. The outcome measure was performance on a standardized on-road assessment. RESULTS: The TSNT's interrater reliability was determined to be strong (κ = .80). The TSNT and WEDD demonstrated convergent validity with cognitive measures (p < .001) and discriminant validity with visual and motor measures in the CDE. The TSNT (area under the curve [AUC] = .74) and WEDD (AUC = .71) had fair ability to predict failure on a standardized on-road assessment. CONCLUSION AND RELEVANCE: TSNT and WEDD are recommended for use by occupational therapists in combination with other performance measures when determining fitness to drive or need for a CDE. WHAT THIS ARTICLE ADDS: The TSNT and WEDD can be included as screening tools (in addition to other performance measures) to assist clinicians in determining which clients need to be referred for a CDE. The TSNT and WEDD can also be included as part of a CDE to assist driving rehabilitation specialists in making final recommendations regarding fitness to drive. The scores generated from the TSNT and WEDD address driving knowledge in a way that may be more understandable to clients and more relatable to skills needed to actually drive.

Driving in the elderly in health and disease.

Driving is a complex, multifaceted instrumental activity of daily living that has an independent influence on multiple health and well-being outcomes among older adults. Therefore, the benefits of driving to the individual must be balanced, through careful assessment and diagnosis, with the potential risk to self and others posed by a medically impaired driver. The influence of dementia changes substantially during the disease progression from very mild to mild, and driving is not advised for those who have progressed to the moderate stage of Alzheimer disease. Fortunately, validated high-quality screening instruments, including modern simulators and other technology aids, can help clinicians trichotomize risk (i.e., high, moderate, or low) and determine which patients need further evaluation by a driving specialist (e.g., those in the moderate range). Moreover, a body of evidence is building regarding the efficacy of certain intervention pathways to maintain current levels of driving performance among individuals with dementia, or at least slow its decline. Even with the progression of advanced driving technologies, understanding driving ability of patients with dementia will remain a critical challenge to clinicians for the foreseeable future.

Older Adults' Expectations about Mortality, Driving Life and Years Left without Driving.

People are living and driving longer than ever before, with little preparation for transitioning to being non-drivers. We investigated driving expectations among drivers age 65 and older, including sociodemographic and driving context predictors. Cross-sectional data from 349 older drivers were explored to determine variation in how many years they expected to continue driving. General linear models examined predictors of both expectations. In this predominantly Black/African American sample, 76% of older drivers (mean age = 73 ± 5.7 years) expected a non-driving future, forecasting living an average of 5.75 ± 7.29 years after driving cessation. Regression models on years left of driving life and years left to live post-driving cessation predicted nearly half of the variance in older drivers' expectations with five significant predictors: income, current age, age expected to live to, self-limiting driving to nearby places and difficulty, visualizing being a non-driver. Many older drivers expect to stop driving before end of life.

Physician and Family Discussions about Driving Safety: Findings from the LongROAD Study.

BACKGROUND: Older adult drivers may experience decreases in driving safety with age or health status change. Discussing driving safety may help them plan for driving restriction and eventual cessation. Here, we sought to examine conversations between older adults and their family members and physicians. METHODS: In this multi-site cross-sectional analysis of baseline data from the AAA Longitudinal Research on Aging Drivers (LongROAD) cohort study, we measured the prevalence and characteristics of family and physician driving discussions. We examined associations between having driving discussions and participant characteristics using multivariate logistic regression. RESULTS: Of 2990 current drivers aged 65 to 79 years (53% female, 85.5% White), only 14.2% reported discussing driving safety with family and 5.5% had discussions with physicians. Men (adjusted OR, 1.32; 95% CI, 1.05 to 1.66) and those with Master's degrees or higher (adjusted OR, 1.65; 95% CI, 1.27 to 2.13) more often had family discussions. Those with at least a Master's degree were also more likely to speak with their physician (adjusted OR, 1.77; 95% CI, 1.17 to 2.68). CONCLUSION: Few older adults had driving safety conversations with their family or physicians. Practical and effective interventions are needed to engage family and physicians in assisting older adults with risk assessment and driving cessation planning to maintain mobility and well-being.

A Naturalistic Study of Driving Behavior in Older Adults and Preclinical Alzheimer Disease: A Pilot Study.

A clinical consequence of symptomatic Alzheimer's disease (AD) is impaired driving performance. However, decline in driving performance may begin in the preclinical stage of AD. We used a naturalistic driving methodology to examine differences in driving behavior over one year in a small sample of cognitively normal older adults with ( n = 10) and without ( n = 10) preclinical AD. As expected with a small sample size, there were no statistically significant differences between the two groups, but older adults with preclinical AD drove less often, were less likely to drive at night, and had fewer aggressive behaviors such as hard braking, speeding, and sudden acceleration. The sample size required to power a larger study to determine differences was calculated.

Planning for a Nondriving Future: Behaviors and Beliefs Among Middle-Aged and Older Drivers.

Despite the reality of older adults living many years after driving cessation, few prepare for the eventuality; empirically, planning for a nondriving future has not been directly quantified or explored. The following study quantifies 1) the extent of current drivers' planning, 2) specific planning behaviors, 3) beliefs about benefits of planning, 4) drivers' intention to plan more for future transportation needs, and 5) group differences associated with planning. In a predominantly female, black, urban sample of current drivers ages 53-92, fewer than half (42.1%) had planned at all for a nondriving future, with correspondingly low levels of planning behaviors reported. However, over 80% believed planning would help them meet their needs post-cessation and transition emotionally to being a nondriver. Most (85%) intended to plan more in the future as well, indicating further potential openness to the topic. Drivers who planned were older, drove less frequently, limited their driving to nearby places, reported less difficulty believing they would become a nondriver, and expected to continue driving three years less than non-planners. These findings suggest that drivers' perceived nearness to driving cessation impacts planning for future transportation needs, and existing perceived benefits of planning may provide leverage to motivate action.

An International Approach to Enhancing a National Guideline on Driving and Dementia.

PURPOSE OF REVIEW: The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement. METHODS: An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus. RECENT FINDINGS: The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Alzheimer Disease Biomarkers and Driving in Clinically Normal Older Adults: Role of Spatial Navigation Abilities.

PURPOSE: Older adults experience impaired driving performance, and modify their driving habits, including limiting amount and spatial extent of travel. Alzheimer disease (AD)-related pathology, as well as spatial navigation difficulties, may influence driving performance and driving behaviors in clinically normal older adults. We examined whether AD biomarkers [cerebrospinal fluid (CSF) concentrations of Aß42, tau, and ptau181] were associated with lower self-reported spatial navigation abilities, and whether navigation abilities mediated the relationship of AD biomarkers with driving performance and extent. METHODS: Clinically normal older adults (n=112; aged 65+) completed an on-road driving test, the Santa Barbara Sense of Direction scale (self-report measure of spatial navigation ability), and the Driving Habits Questionnaire for an estimate of driving extent (composite of driving exposure and driving space). All participants had a lumbar puncture to obtain CSF. RESULTS: CSF Aß42, but not tau or ptau181, was associated with self-reported navigation ability. Lower self-reported navigation was associated with reduced driving extent, but not driving errors. Self-reported navigation mediated the relationship between CSF Aß42 and driving extent. CONCLUSIONS: Findings suggest that cerebral amyloid deposition is associated with lower perceived ability to navigate the environment, which may lead older adults with AD pathology to limit their driving extent.