The Impact of Advanced Age on Driving Safety in Adults with Medical Conditions

Examining Visual Processing Reaction Time of Vision CoachTM as a Predictor for Driving Fitness

IMPORTANCE

Visual processing speed reaction time is a critical component for fitness-to-drive decisions.

OBJECTIVE

To examine Vision CoachTM reaction times of medically-at-risk drivers and healthy controls to determine the relationship with outcomes of a comprehensive driving evaluation.

DESIGN

Predictive validity design.

SETTING

University research center.

PARTICIPANTS

Of the sample (N = 419), 272 (64.9%) were healthy controls (M age = 49.4 yr, SD = 21.9, range = 21-87) with 196 (72.1%) women, and 147 (35.1%) were medically-at-risk participants (M age = 62.2 yr, SD = 15.7, range = 16-90) with 52 (35.4%) women.

OUTCOME AND MEASURES

Reaction time was measured in seconds; there was an average of three trials using the full field with 60 random appearing lights.

RESULTS

A significant difference was found between age groups for the healthy controls and the medically-at-risk participants, with no gender main effect or interactions between variables, suggesting that age-related changes and having a medical condition slowed processing speed. The receiver operating characteristic area under the curve scores for the three populations (all medically-at-risk participants, participants 16 to 64 yr old, and participants older than 65 yr) were 0.886, 0.894, and 0.783, respectively, suggesting moderate to good prediction power for fitness to drive.

CONCLUSIONS AND RELEVANCE

Vision Coach can be used as a screening tool to differentiate between drivers who will likely pass or likely fail a comprehensive driving evaluation and drivers who need further evaluation. Plain-Language Summary: With the growing number of older adults living longer and with more medical conditions, it is important for occupational therapists to have screening tools to determine fitness to drive. An on-road assessment is the gold standard for determining fitness to drive. However, the number of older adults with cognitive impairment is increasing, which can lead to a decline in processing speed while driving. As processing speed declines, it can take longer for a person to make decisions, which results in increased driving risk. Occupational therapists need a screening tool to assess processing speed, particularly for people with cognitive impairment. In this study we found that the Vision CoachTMdemonstrates good sensitivity and specificity in assessing visual processing speed reaction time as well as determining who will likely pass or fail a comprehensive driving evaluation and who should be referred for further evaluation.

Factors That Influence Returning to Driving Following Primary Total Knee Arthroplasty: A Prospective Investigation

BACKGROUND

It is unclear when a patient can return to driving after total knee arthroplasty (TKA). Currently, most surgeons simply restrict all patients from driving for 4 to 6 weeks after TKA despite variability in patient age, general health, and physical capabilities. The primary objective of this study was to create novel clinical prediction calculators to estimate the return-to-driving time following primary TKA.

METHODS

In this study, 167 patients who were undergoing a primary TKA were prospectively enrolled. Subjects received text message surveys every third day postoperatively to determine when they returned to driving. Subjects completed 8 physical performance maneuvers at their 2, 6, and 12-week postoperative clinical appointments. Additionally, subjects completed return-to-driving surveys and a structured interview. Data on demographic characteristics, operative factors, patient-reported outcomes, and patient factors were collected. Cox proportional hazard and parametric survival models were utilized to create 2 novel calculators for predicting return-to-driving time.

RESULTS

There were 156 patients (mean age, 67.7 years [range, 39 to 83 years]) who completed the study. The median return-to-driving time was 18 days (interquartile range [IQR], 12 to 27 days). Univariate analysis demonstrated that male patients returned to driving sooner (18 days) than female patients (25.3 days) (p < 0.001) and that patients who underwent left-sided surgery returned to driving sooner (20.1 days) than patients who underwent right-sided surgery (24.4 days) (p = 0.021). For preoperative factors, age, sex, laterality, and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) had an effect on return-to-driving time and therefore were included in the novel preoperative clinical prediction calculator. For postoperative factors, age, sex, laterality, preoperative KOOS, and 6 metrics from the physical performance maneuvers had an effect on return-to-driving time and therefore were included in the novel postoperative physical performance-based instrument.

CONCLUSIONS

Overall, patients undergoing primary TKA returned to driving considerably earlier than previously reported. Patient-related factors and postoperative physical performance significantly affect return-to-driving time. Using the novel preoperative clinical prediction tool, individual patients can be advised when to expect to return to driving. After surgery, the novel postoperative physical performance-based instrument can inform patients when they may be ready to return to driving.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Slowed Driving Reaction Time in Preclinical Alzheimer's Disease

Driving reaction time (DRT) is one of the most important predictors of motor vehicle crashes in older adults. Although individuals with preclinical Alzheimer's disease (AD) show subtle cognitive changes that may affect driving, their DRT to emergency events has not been investigated. We compared DRT to an emergency event between 19 drivers with preclinical AD and 21 controls in a driving simulator. All drivers engaged in a car-following task with and without distracters. After the car-following event, a crash prompted participants to brake and maneuver around the accident scene. Drivers with preclinical AD took longer to respond to the emergency event compared to controls when they were not distracted by an additional task (7.56 ± 1.46 s v 6.42 ± 1.17 s; p = .02). There were no group differences when a distraction was added to the car-following task. These pilot results have important implications on driving safety for older adults with preclinical AD when confirmed in larger on-road studies.

Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions

OBJECTIVE

This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database.

METHODS

This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group.

RESULTS

The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk.

CONCLUSIONS

The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

Patient Travel Distance to Neurologist Visits

BACKGROUND AND OBJECTIVES

The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care.

METHODS

We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel.

RESULTS

We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care.

DISCUSSION

We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Attitudes, Beliefs, and Current Practices Carried Out by Family Physicians in Spain Regarding the Prevention of Road Injuries in Older Adults: A Nationwide Cross-Sectional Study

Purpose

The activities related to the prevention of crash injuries in older adults (PCIOA) performed by Family Physicians (FPs) have been scarcely studied. Our aim was to estimate the frequency of PCIOA activities performed by FPs in Spain and its association with attitudes and beliefs regarding this health problem.

Methods

We conducted a cross-sectional study in a nationwide sample of 1888 FPs working in Primary Health Care Services, recruited from October 2016 to October 2018. Participants completed a validated, self-administered questionnaire. Study variables included three scores related to current practices (General Practices, General Advice and Health Advice), several scores related to attitudes (General, Drawbacks and Legal), demographic and workplace characteristics. To obtain the adjusted coefficients and their 95% confidence intervals, we applied mixed effects multi-level linear regression models and the likelihood-ratio test to compare multi-level and one-level models.

Results

The frequency of PCIOA activities reported by FPs in Spain was low. The General Practices Score was 0.22/1, the General Advice Score was 1.82/4, the Health Advice Score was 2.61/4, and the General Attitudes Score was 3.08/4. The importance given to road crashes in the elderly obtained 7.16/10, the role that FPs should play in the PCIOA obtained 6.73/10, and the current perceived role obtained 3.95/10. The General Attitudes Score and the importance that FPs give themselves in the PCIOA were associated with the three Current Practices Scores.

Conclusion

The frequency of activities related to the PCIOA that FPs usually carry out in Spain is far below desirable standards. The average level of attitudes and beliefs about the PCIOA of the FPs working in Spain seems adequate. The variables of the most pronounced FPs associated with the prevention of traffic accidents in older drivers were age over 50 years, female sex and foreign nationality.

Prevalence of medical factors related to aging among older car drivers: a multicenter, cross-sectional, descriptive study

Aim

An increasing number of older adults in Japan are at an increased risk of road traffic crashes. This study aimed to investigate the prevalence of potential underlying medical factors that increase the risk of road traffic crashes among older people.

Methods

This cross-sectional observational study was conducted in 11 medical institutions in Japan using self-administered questionnaires and physical examination from January to May 2021. The background and social data, data on the use of nursing care insurance, and clinical data suggestive of polypharmacy, sarcopenia, cognitive impairment, and frailty/oral frailty were obtained. The prevalence of these factors was compared between everyday and occasional drivers.

Results

Data of 127 patients were collected; their median (interquartile range) age was 73 (70–78) years. Of the total participants, 82 were men (64.6%) and 45 were women (35.4%). There were 77 everyday drivers and 50 occasional drivers. Of these, 121 (95.3%) had not applied for nursing care insurance, but the numbers of those who required help 1 and 2 were 1 (0.8%) and 3 (2.4%), respectively. Prevalence of medical factors was as follows: polypharmacy, 27.6%; sarcopenia, 8.7%; dementia, 16.4%; frailty, 15.0%; and oral frailty, 54.3%; it was not significantly different between every day and occasional drivers. Intention to return the car license was significantly higher among the occasional drivers (2.6% vs. 14.0%; odds ratio: 6.7, 95% confidence interval: 1.2–70.6, p = 0.024).

Conclusion

We uncovered the prevalence of medical factors that can be associated with road traffic crashes among Japanese older people aged ≥ 65 years in our community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03490-w.

Lifestyle Matters: Effects of Habitual Physical Activity on Driving Skills in Older Age

Research on multitasking driving has suggested age-related deterioration in driving performance. It has been shown that physical and cognitive functioning, which are related to driving performance and decline with aging, are positively associated with physical activity behavior. This study aimed to explore whether driving performance decline becomes severe with advancing age and whether physical activity behavior modifies age-related deterioration in driving performance. A total of one hundred forty-one healthy adults were categorized into three groups based on their age; old-old (74.21 ± 2.33 years), young-old (66.53 ± 1.50 years), and young adults (23.25 ± 2.82 years). Participants completed a realistic multitasking driving task. Physical activity and cardiorespiratory fitness levels were evaluated. Older groups drove more slowly and laterally than young adults, and old-old adults drove slower than young-old ones across the whole driving course. Physical activity level did not interact with the aging effect on driving performance, whereas cardiovascular fitness interacted. Higher-fitness young-old and young adults drove faster than higher-fitness old-old adults. Higher-fitness old adults drove more laterally than higher-fitness young adults. The present study demonstrated a gradual decline in driving performance in old adults, and cardiorespiratory fitness interacted with the aging effect on driving performance. Future research on the interaction of aging and physical activity behavior on driving performance in different age groups is of great value and may help deepen our knowledge.

Fitness to drive practices among non-driver trained occupational therapists in an Australian community-based rehabilitation setting

INTRODUCTION

Driving is a valued occupation given the independence and freedom it provides. Safe driving performance can be impacted by medical conditions, change in functional status and ageing processes. Occupational therapy driver assessors (OTDAs) provide invaluable driving recommendations; however, this requires specialist training for the therapist and is costly for clients. The number of OTDAs is not expected to meet the growing demand for expert services in this area, and little is known about the practices that non- OTDAs use to assist clients with returning to driving. The aims of this study were to investigate the practices of non-OTDAs in a community-based rehabilitation setting in Australia with respect to knowledge, confidence and skills in assessments, recommendations and outcomes for clients as part of the return to driving process.

METHODS

A descriptive study including medical record audits between April and September 2019 and staff surveys were completed at a large metropolitan community-based rehabilitation facility. Descriptive statistics and thematic analysis were used to summarise data.

RESULTS

A total of 102 client medical records were audited, and 13 clinician surveys were completed. Medical record audits identified that return to driving was not consistently addressed by occupational therapists. Clinician surveys outlined a lack of knowledge and confidence of return to driving processes and available assessment tools to guide this process.

CONCLUSION

All occupational therapists have an ethical obligation to address driving as an activity of daily living; however, non-OTDAs report that they are not equipped for this role. This may negatively impact on driver safety, independence and overall health and well-being of clients in community-based rehabilitation. Further research is indicated to develop evidence-based driving resources to support best practice of non-OTDAs.

Age-Related Diseases and Driving Safety

Due to demographic changes, the number of older drivers is steadily increasing. Mobility is highly relevant for leading an independent life in the elderly. It largely depends on car driving, which is a complex task requiring a multitude of cognitive and motor skills vulnerable to age- related functional deterioration. The almost inevitable effects of senescence may be potentiated by age-related diseases, such as stroke or diabetes mellitus. Respective pharmacological treatment may cause side effects, additionally affecting driving safety. The present article reviews the impact of age-related diseases and drug treatment of these conditions on driving fitness in elderly drivers. In essence, we focus on diseases of the visual and auditory systems, diseases of the central nervous system (i.e., stroke, depression, dementia and mild cognitive disorder, and Parkinson's disease), sleep disorders, as well as cardiovascular diseases, diabetes mellitus, musculoskeletal disorders, and frailty. We will outline the role of functional tests and the assessment of driving behavior (by a driving simulator or in real traffic), as well as the clinical interview including questions about frequency of (near) accidents, etc. in the evaluation of driving fitness of the elderly. We also address the impact of polypharmacy on driving fitness and end up with recommendations for physicians caring for older patients.

Reliability of P3 Event-Related Potential During Working Memory Across the Spectrum of Cognitive Aging

Event-related potentials (ERPs) offer unparalleled temporal resolution in tracing distinct electrophysiological processes related to normal and pathological cognitive aging. The stability of ERPs in older individuals with a vast range of cognitive ability has not been established. In this test-retest reliability study, 39 older individuals (age 74.10 (5.4) years; 23 (59%) women; 15 non β-amyloid elevated, 16 β-amyloid elevated, 8 cognitively impaired) with scores on the Montreal Cognitive Assessment (MOCA) ranging between 3 and 30 completed a working memory (n-back) test with three levels of difficulty at baseline and 2-week follow-up. The main aim was to evaluate stability of the ERP on grand averaged task effects for both visits in the total sample (n = 39). Secondary aims were to evaluate the effect of age, group (non β-amyloid elevated; β-amyloid elevated, cognitively impaired), cognitive status (MOCA), and task difficulty on ERP reliability. P3 peak amplitude and latency were measured in predetermined channels. P3 peak amplitude at Fz, our main outcome variable, showed excellent reliability in 0-back (intraclass correlation coefficient (ICC), 95% confidence interval = 0.82 (0.67-0.90) and 1-back (ICC = 0.87 (0.76-0.93), however, only fair reliability in 2-back (ICC = 0.53 (0.09-0.75). Reliability of P3 peak latencies was substantially lower, with ICCs ranging between 0.17 for 2-back and 0.54 for 0-back. Generalized linear mixed models showed no confounding effect of age, group, or task difficulty on stability of P3 amplitude and latency of Fz. By contrast, MOCA scores tended to negatively correlate with P3 amplitude of Fz (p = 0.07). We conclude that P3 peak amplitude, and to lesser extent P3 peak latency, provide a stable measure of electrophysiological processes in older individuals.

Cognitive dysfunction during hypoglycemia in an elderly subject without diabetes

The aim of the present study was to examine whether an elderly subject without diabetes experiences hypoglycemia during his daily life or after an oral glucose tolerance test (OGTT), and investigate whether hypoglycemic episodes affect cognitive function. The 85-year-old healthy subject, who is a sports enthusiast, showed lower than normal (< 80 mg/dl) blood glucose levels on two occasions over 6 days in the early morning. The subject also experienced hypoglycemic episodes and blood glucose levels of 65 and 74 mg/dl, respectively, during the 6-h OGTT given after a 13-h fast. Cognitive function, as assessed using a numeracy test and a driving simulator test, deteriorated during the hypoglycemic episodes but recovered 0.5 h after ingestion of a confectionary product (two pieces of Dorayaki containing 247 kcal and 51.5 g of carbohydrate each). Cognitive dysfunction caused by mild hypoglycemia can be involved in a part of traffic accidents in elderly drivers.

Cognitive prerequisites for fitness to drive: Norm values for the TMT, UFOV and NorSDSA tests

Background: Fitness-to-drive assessment is a growing area for occupational therapists. There are few off-road tests specially developed to assess fitness to drive, and several cognitive tests have no age-specific norms.Aims/objectives: The aim was to identify and describe age-related norm values for the Trail Making Test, Nordic Stroke Driver Screening Assessment and Useful Field of View test, and to study inter-correlation between test results.Materials and methods: The sample included 410 volunteers; 149 men and 261 women, mean age 52 ± 16.8 years. Commonly used off-road tests were used: TMT A and B, UFOV and NorSDSA.Results: Normative data for the specific subtests and total score for NorSDSA and UFOV are provided and presented in four age groups. Age correlated with the results for most of the subtests.Conclusions: Off-road cognitive test scores are necessary and valuable for occupational therapists in their contribution to the final decision on continued driving. In clinical practice, it can be difficult to interpret cognitive test results when working with driving assessments. Age-based norm values are suggested to be a way to provide clinicians with a benchmark against which scores can be compared.Significance: Age-based norms can guide occupational therapists working with fitness to drive.

Neuro-Cognitive Effects of Acute Tyrosine Administration on Reactive and Proactive Response Inhibition in Healthy Older Adults

The aging brain is characterized by altered dopamine signaling. The amino acid tyrosine, a catecholamine precursor, is known to improve cognitive performance in young adults, especially during high environmental demands. Tyrosine administration might also affect catecholamine transmission in the aging brain, thereby improving cognitive functioning. In healthy older adults, impairments have been demonstrated in two forms of response inhibition: reactive inhibition (outright stopping) and proactive inhibition (anticipatory response slowing) under high information load. However, no study has directly compared the effects of a catecholamine precursor on reactive and load-dependent proactive inhibition. In this study we explored the effects of tyrosine on reactive and proactive response inhibition and signal in dopaminergically innervated fronto-striatal regions. Depending on age, tyrosine might lead to beneficial or detrimental neurocognitive effects. We aimed to address these hypotheses in 24 healthy older human adults (aged 61-72 years) using fMRI in a double blind, counterbalanced, placebo-controlled, within-subject design. Across the group, tyrosine did not alter reactive or proactive inhibition behaviorally but did increase fronto-parietal proactive inhibition-related activation. When taking age into account, tyrosine affected proactive inhibition both behaviorally and neurally. Specifically, increasing age was associated with a greater detrimental effect of tyrosine compared with placebo on proactive slowing. Moreover, with increasing age, tyrosine decreased fronto-striatal and parietal proactive signal, which correlated positively with tyrosine's effects on proactive slowing. Concluding, tyrosine negatively affected proactive response slowing and associated fronto-striatal activation in an age-dependent manner, highlighting the importance of catecholamines, perhaps particularly dopamine, for proactive response inhibition in older adults.