Consensus statements for screening and assessment tools

Serial Trichotomization to Determine Fitness to Drive: Results From a Cohort of Clients Referred to a Neurology Program

IMPORTANCE

Determining cognitive fitness to drive is challenging. A previous study used serial trichotomization with five cognitive tests to determine whether drivers should continue driving, undergo further evaluation, or stop driving.

OBJECTIVE

To examine agreement between serial trichotomization and fitness-to-drive determinations made by occupational therapists.

DESIGN

Drivers referred for cognitive screens completed all tests used in the previous study. Occupational therapists provided fitness-to-drive recommendations (safe, indeterminate, or unsafe) using all clinical information available. We examined the agreement between the tests' results (using cut points from the previous study) and occupational therapists' recommendations.

SETTING

Outpatient neurology program at a chronic care and rehabilitation hospital.

PARTICIPANTS

279 clients (M age  = 66.35 yr; SD = 13.25).

OUTCOMES AND MEASURES

Tests included the Trail Making Tests A and B, the Clock Drawing Test (CDT), the Montreal Cognitive Assessment, and the Motor-Free Visual Perception Test, using a road test as the gold standard. The previous study used dual cut points with 100% sensitivity and specificity to reduce false positives and false negatives.

RESULTS

Weighted κs ranged from .03 (95% confidence interval [CI] [-.01, .08]) for the CDT to .54 (95% CI [.46, .62]) for the Trail Making Test, Part B. Although the agreement between serial trichotomization and the final recommendations was moderate (κ = .59; 95% CI [.50, .67]), serial trichotomization appeared useful for identifying unsafe drivers.

CONCLUSIONS AND RELEVANCE

These results remind us of the variability inherent in stand-alone cognitive tests, even within a serial trichotomization framework, and the importance of clinical judgement and road tests in decision making about driving. Plain-Language Summary: It can be challenging for occupational therapists to accurately determine a client's cognitive fitness to drive. Many occupational therapists lack the time, have limited training, or do not have access to comprehensive driving evaluation tools. A serial testing approach can support occupational therapists in assessing a client's cognitive fitness to drive. This study used an approach based on a series of five cognitive tests to determine whether a client should continue driving, undergo further evaluation, or stop driving. The series of tests were used to classify drivers as safe, indeterminate, or unsafe. In principle, a driver would take the second test only if the driver was classified as indeterminate on the basis of first test, and so on. By applying the tests in sequence, few drivers should remain classified as indeterminate at the end of the series of tests. This serial approach has the potential to streamline the decision-making process for occupational therapists by classifying the more extreme unsafe cases while still providing an accurate assessment of cognitive fitness to drive.

The Multiple Errands Test-Home Version and Its Association With Driving Potential: A Pilot Study

IMPORTANCE

Driving is a complex occupation requiring the interplay of high-level cognitive, physical, sensory, and behavioral skills for safe performance. Occupational therapists need to routinely address driving with adults as an occupational performance area. Further research is needed to determine whether performance-based assessment tools can support occupational therapists in screening client driving potential.

OBJECTIVE

To conduct a pilot study to determine whether the Multiple Errands Test-Home Version (MET-Home), as a performance-based assessment, either alone or in combination with other assessments, should be further investigated for use by occupational therapists to screen clients' driving potential.

DESIGN

Cross-sectional pilot study.

SETTING

Private in-clinic and community setting, including participants' homes.

PARTICIPANTS

Convenience sampling recruited 28 participants through private occupational therapy driver assessors.

OUTCOMES AND MEASURES

Participants underwent a comprehensive in-clinic and behind-the-wheel assessment, as per standard practice, and three additional cognitive tests. Data were summarized with descriptive statistics, and univariate analyses were used to examine the relationships between cognitive assessment scores and driving outcomes.

RESULTS

The MET-Home, as a stand-alone tool and in combination with other cognitive assessment scores, was not associated with driving outcomes (pass-fail). However, participant self-assessment of their MET-Home performance was associated with driving outcomes (pass-fail; p = .014).

CONCLUSIONS AND RELEVANCE

Although our findings suggest that the MET-Home is unlikely to screen for driving potential, further research of performance-based assessment tool use by occupational therapists is needed to support identification of the optimal type and timing of client referral for comprehensive assessment. Plain-Language Summary: The Multiple Errands Test-Home Version (MET-Home) is commonly completed by occupational therapists. Although this pilot study revealed that MET-Home scores were not associated with driving outcomes, performance-based assessments such as the MET-Home have the potential to guide occupational therapists when screening clients to determine when further, comprehensive assessment is indicated.

Addressing Driving in Acute Care: Perceived Relevance and Competence

Background. Recent legislation has expanded the responsibilities of occupational therapists regarding fitness to drive in the Canadian province of Ontario. To date, little is known about the practice of acute care occupational therapy with addressing driving, or how such responsibilities have affected clinical practice. Purpose. The objective of this study was to understand the relevance of driving-related knowledge areas to acute care occupational therapists and examine their self-reported competency for these areas. Method. Anonymous online surveys were administered to 41 occupational therapists working in acute care hospitals in Ontario. Findings. Therapists reported many driving-related knowledge areas are relevant to acute care practice yet consistently reported lower levels of competence for addressing such areas. Implications. Findings support the need for further competency development regarding driving-related practice in acute care. Occupational therapy curriculum and continuing education initiatives are avenues for capacity-building. Future research to identify effective competency development strategies is warranted.

Using Serial Trichotomization to Determine Fitness to Drive in Medically At-Risk Drivers

IMPORTANCE

Clinical tests that identify fit and unfit drivers with 100% sensitivity and specificity would reduce uncertainty and improve efficiency of occupational therapists performing comprehensive driving evaluations (CDEs).

OBJECTIVE

To examine whether serial trichotomization of clinical tests predicts pass-fail outcomes with 100% sensitivity and specificity in a sample of medically at-risk drivers and in drivers with and without cognitive impairment (CI) referred for a CDE.

DESIGN

Retrospective data collection and analysis of scores on the Montreal Cognitive Assessment; Trail Making Test, Part A and Part B; and the Useful Field of View® Subtests 1 to 3 and outcomes on the CDE (pass-fail or indeterminate requiring lessons and retesting). Receiver operating characteristic curves of clinical tests were performed to determine 100% sensitivity and specificity cut points in predicting CDE outcomes. Clinical tests were arranged in order from most to least predictive to identify pass-fail and indeterminate outcomes.

SETTING

A driving assessment clinic.

PARTICIPANTS

Among 142 medically at-risk drivers (M age = 69.2 yr, SD = 14.1), 66 with CI, 46 passed and 39 failed the CDE; 57 were indeterminate.

OUTCOMES AND MEASURES

On-road pass-fail outcomes.

RESULTS

Together, the six clinical tests predicted 62 pass and 49 fail outcomes in the total sample; 21 pass and 34 fail outcomes in participants with CI; and 58 pass and 14 fail outcomes in participants without CI.

CONCLUSIONS AND RELEVANCE

Serial trichotomization of clinical tests increases the accuracy of making informed decisions and reduces the number of drivers undergoing unnecessary on-road assessments. Plain-Language Summary: Clinical tests and their cut points that identify fit and unfit drivers vary substantially across settings and research studies. Serial trichotomization is one method that could help control for this variation by combining clinical test scores showing 100% sensitivity and specificity to identify pass (fit drivers) and fail outcomes (unfit drivers) and to reduce the number of drivers undergoing unnecessary on-road assessments.

The Validity of Three New Driving Simulator Scenarios: Detecting Differences in Driving Performance by Difficulty and Driver Gender and Age

OBJECTIVE

We explored the convergent and discriminant validity of three driving simulation scenarios by comparing behaviors across gender and age groups, considering what we know about on-road driving.

BACKGROUND

Driving simulators offer a number of benefits, yet their use in real-world driver assessment is rare. More evidence is needed to support their use.

METHOD

A total of 104 participants completed a series of increasingly difficult driving simulation scenarios. Linear mixed models were estimated to determine if behaviors changed with increasing difficulty and whether outcomes varied by age and gender, thereby demonstrating convergent and discriminant validity, respectively.

RESULTS

Drivers adapted velocity, steering, acceleration, and gap acceptance according to difficulty, and the degree of adaptation differed by gender and age for some outcomes. For example, in a construction zone scenario, drivers reduced their mean velocities as congestion increased; males drove an average of 2.30 km/hr faster than females, and older participants drove more slowly than young (5.26 km/hr) and middle-aged drivers (6.59 km/hr). There was also an interaction between age and difficulty; older drivers did not reduce their velocities with increased difficulty.

CONCLUSION

This study provides further support for the ability of driving simulators to elicit behaviors similar to those seen in on-road driving and to differentiate between groups, suggesting that simulators could serve a supportive role in fitness-to-drive evaluations.

APPLICATION

Simulators have the potential to support driver assessment. However, this depends on the development of valid scenarios to benchmark safe driving behavior, and thereby identify deviations from safe driving behavior. The information gained through simulation may supplement other forms of assessment and possibly eliminate the need for on-road testing in some situations.

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.

Using Serial Trichotomization with Neuropsychological Measures to Inform Clinical Decisions on Fitness-to-Drive among Older Adults with Cognitive Impairment

Decisions related to driving safety and when to cease driving are complex and costly. There is an interest in developing an off-road driving test utilizing neuropsychological tests that could help assess fitness-to-drive. Serial trichotomization has demonstrated potential as it yields 100% sensitivity and specificity in retrospective test samples. The purpose of this study was to test serial trichotomization using four common neuropsychological tests (Trail Making Test Part A and B, Clock Drawing Test, and Modified Mini-Mental State Examination). Test scores from 105 patients who were seen in a memory clinic were abstracted. After applying the model, participants were classified as unfit, fit, or requiring further testing, 38.1%, 25.8%, and 36.1%, respectively. This study provides further evidence that trichotomization can facilitate the assessment of fitness-to-drive.

Driving and Patients With Dementia

Driving is a symbol of autonomy and independence, eagerly awaited during adolescence, cherished during adulthood and reluctantly rescinded during old age. It is nevertheless an individual’s privilege, not right, especially as driving may affect other drivers and pedestrians on the road. It is therefore not only the individual patient who is at stake but essentially the entire community. In this case scenario, we describe the situation that arose when a patient with multi-infarct dementia wanted to go for a drive and his son and grandson tried to convince him that he could no longer drive. What went wrong in the caregivers/patient interaction is presented. The futility of arguing with patients who have dementia is highlighted as well as the suspiciousness it may generate. Alternate actions that can be useful to avoid/avert the situation from escalating and having a catastrophic ending are discussed. Testing/evaluating patients with dementia for fitness to drive is also reviewed and a list of select resources is included.

Transportation and Aging: An Updated Research Agenda for Advancing Safe Mobility

This article discusses what is currently known about three important topics related to older driver safety and mobility: screening and evaluation, education and training interventions, and in-vehicle technology. Progress is being made to improve the safe mobility of older adults in these key areas; however, significant research gaps remain. This article advances the state of knowledge by identifying these gaps, and proposing further research topics will improve the lives of older adults. In addition, we discuss several themes that emerged from the review, including the need for multidisciplinary, community-wide solutions; large-scale, longitudinal studies; improved education/training for both older adults themselves and the variety of stakeholders involved in older adult transportation; and programs and interventions that are flexible and responsive to individual needs and differences.

Using Serial Trichotomization With Common Cognitive Tests to Screen for Fitness to Drive

OBJECTIVE

The aim of this study was to illustrate the use of serial trichotomization with five common tests of cognition to achieve greater precision in screening for fitness to drive.

METHOD

We collected data (using the Montreal Cognitive Assessment, Motor-Free Visual Perception Test, Clock-Drawing Test, Trail Making Test Part A and B [Trails B], and an on-road driving test) from 83 people referred for a driving evaluation. We identified cutpoints for 100% sensitivity and specificity for each test; the driving test was the gold standard. Using serial trichotomization, we classified drivers as either "Pass," "Fail," or "Indeterminate."

RESULTS

Trails B had the best sensitivity and specificity (66.3% of participants correctly classified). After applying serial trichotomization, we correctly identified the driving test outcome for 78.3% of participants.

CONCLUSION

A screening strategy using serial trichotomization of multiple test results may reduce uncertainty about fitness to drive.

Older Adults with Mild Cognitive Impairments Show Less Driving Errors after a Multiple Sessions Simulator Training Program but Do Not Exhibit Long Term Retention

The driving performance of individuals with mild cognitive impairment (MCI) is suboptimal when compared to healthy older adults. It is expected that the driving will worsen with the progression of the cognitive decline and thus, whether or not these individuals should continue to drive is a matter of debate. The aim of the study was to provide support to the claim that individuals with MCI can benefit from a training program and improve their overall driving performance in a driving simulator. Fifteen older drivers with MCI participated in five training sessions in a simulator (over a 21-day period) and in a 6-month recall session. During training, they received automated auditory feedback on their performance when an error was noted about various maneuvers known to be suboptimal in MCI individuals (for instance, weaving, omitting to indicate a lane change, to verify a blind spot, or to engage in a visual search before crossing an intersection). The number of errors was compiled for eight different maneuvers for all sessions. For the initial five sessions, a gradual and significant decrease in the number of errors was observed, indicating learning and safer driving. The level of performance, however, was not maintained at the 6-month recall session. Nevertheless, the initial learning observed opens up possibilities to undertake more regular interventions to maintain driving skills and safe driving in MCI individuals.

Visual-cognitive tools used to determine fitness-to-drive may reflect normal aging

BACKGROUND

Scores on many visual-cognitive tools are proposed as indicators of fitness-to-drive. A purported feature of some tools and one believed to be important is that they are 'age-independent'. Specifically, scores are not correlated with age and poor scores represent a pathological process rather than normal aging. Yet, we know that several cognitive abilities are associated with age. One potential reason for the apparent age-independence of some tools is that focusing on older drivers leads to 'range restriction', a statistical issue that reduces the magnitude of correlations when values for one variable are restricted to a smaller range than naturally occurs. Hence, the purpose of this study was to investigate whether age is correlated with scores on visual-cognitive tests when we examine the full age range.

METHODS

We recruited 114 drivers aged 18 to 89 years (mean: 42.30 ± 26.50 years). Participants completed several visual-cognitive tools often used to examine fitness-to-drive (Trail Making Tests A and B, Attention Network Test and 'useful field of view').

RESULTS

Correlations between age and test scores for drivers 65 years and older only ranged from 0.03 to 0.48. With the whole age range, correlations ranged from 0.56 to 0.84. We also compared ordinary Pearson correlations among visual-cognitive tests scores to the corresponding partial correlations after removing the effect of age. Whereas ordinary Pearson correlations ranged from 0.40 to 0.69, partial correlations ranged from 0.01 to 0.30.

CONCLUSION

Test scores may reflect age-associated normal biological changes. These results have implications for predicting fitness-to-drive among older drivers and suggest caution in using these scores.

Clinical Assessments as Predictors of Primary On-Road Outcomes in Parkinson's Disease

Parkinson's disease (PD) is a neurodegenerative disorder that affects fitness to drive. Research that has examined clinical predictors of fitness to drive in PD, using the on-road assessment as the gold standard, has generally used a dichotomous pass/fail decision. However, on-road assessments may also result in one of two additional outcomes (pass with recommendations, or fail-remediable). Individuals within these subgroups may benefit from interventions to improve their fitness to drive abilities. This study investigated clinical predictors that could be indicative of the pass, pass with recommendations, or fail-remediable categories for drivers with PD (N = 99). Trails B, Left Finger to Nose Test, and contrast sensitivity measures were identified as significant predictors for the pass, and pass with recommendations subgroups. No significant predictors were identified for the fail-remediable subgroup. Results from this study provide a foundation for clinicians to identify drivers who can benefit from recommendations to preserve their driving abilities.