Predicting road test performance in adults with cognitive or visual impairment referred to a Veterans Affairs Medical Center driving clinic.

OBJECTIVES: To develop a screening battery for office-based clinicians that would assist with the prediction of impaired driving performance and deciding who should proceed to road testing in a sample of adults with cognitive or visual deficits. DESIGN: Prospective observational study. SETTING: Driving evaluation clinic at a Veterans Affairs Medical Center (VAMC) in St. Louis, Missouri. PARTICIPANTS: Seventy-seven individuals aged 23 to 91 with diagnoses of cognitive or visual impairment or both referred to an occupational therapy based driving clinic by VAMC providers because of concerns regarding driving safety. MEASUREMENTS: Predictor variables included tests of visual and cognitive functioning and activities of daily living. The major outcome was pass or fail on a standardized performance-based on-road driving test. RESULTS: Thirty percent of the referrals failed the road test. The best predictors of driving performance were the Trail-Making Test Part A and the Mazes Test from the Neuropsychological Assessment Battery. CONCLUSION: Measures of visual search, psychomotor speed, and executive functioning accurately predicted road test performance in a significant number of participants. These brief tests may assist clinicians in deciding who should proceed with a road test in a driver rehabilitation clinic or perhaps to whom it should be recommended to cease driving.

Physician input and licensing of at-risk drivers: a review of all-inclusive medical evaluation forms in the US and Canada.

This article details a systematic review of medical evaluation forms in support of licensing decisions for medically at-risk drivers. Comparisons were made between all-inclusive forms utilized by 52 State and Provincial Departments of Motor Vehicles (DMVs) in the US and Canada. Comparisons focused on length, format, content, instructional quality, medical coverage, ease of use, and other qualitative characteristics. Median page length was 2 (range 1-10), and mean word count was 1083 (494-3884). Common response options included open-ended (98%), forced choice (87%), and check box (81%). While the majority of forms (77%) required driver consent, only 24% requested information from the driver. Less than half (46%) included text on confidentiality protection. While all forms requested general medical information, just over half included specific sections for vision (54%) and cognitive/neurological conditions (56%). Most forms (81%) required that a judgment be made concerning driver safety, and half prompted for possible license restrictions. Criterion-based quality ratings were assigned on a five-point Likert scale by group consensus. One third of forms were rated as marginal or poor in comprehensiveness and utility, and just two garnered an excellent overall rating. Findings are discussed relative to current research on driver fitness and elements of a proposed model form. Best practice recommendations include a page length limitation, emphasis on in-person evaluation (i.e., as opposed to a records-only review), prompts to collect crash and other driving history information, clear instructions and stepwise format, content prompts across relevant medical categories, documentation of functional status and impairment levels, options for driving with restrictions in lieu of de-licensing, and emphasis on relative (vs. absolute) clinical judgments of overall driver safety.

Motor vehicle operation in the setting of multiple sclerosis with myelopathy: assessment, adaptive equipment, counseling, and cessation of driving.

Many individuals with multiple sclerosis are safe drivers; others self-regulate their driving or cease driving altogether because of their own safety concerns. When patients are unsafe to drive and have poor insight into their condition, they may ignore a provider's repeated communication to stop driving. Addressing this issue when a person is initially diagnosed with multiple sclerosis and continuing the discussion over time when assessing other activities of daily living may ease the process of driving cessation. Referral for a driving evaluation may be appropriate, in conjunction with referrals to a social worker for mobility counseling and to a psychologist for grief and loss issues associated with driving cessation. When repeated recommendations to stop driving are ignored, notifying the appropriate government agencies should be considered.

Test acceptability and confidence levels in older adults referred for fitness-to-drive evaluations.

In this study, we examined confidence and face validity or client acceptability of tests used in a Veterans Affairs Medical Center driving clinic. The clinic used evidence-based off-road tests and adopted the Washington University Road Test (WURT) as a performance-based on-road examination. Forty-three clients consented to participate in the study; most were male with an average age of 78.2 years (standard deviation = 12.6). In general, a trend existed toward higher client acceptability of tests adopted from the Neuropsychological Assessment Battery (Stern & White, 2003) and the WURT than of other off-road measures. Confidence decreased after administration of the psychometric test battery, yet it increased after the on-road evaluations despite a 47% failure rate in the sample. Additional study is needed on test acceptability because it may have the potential to increase understanding, compliance, or both with driving recommendations. Additional research is also needed to examine client confidence levels and their potential impact on performance during the driving evaluation process.