Evaluation of strategies to support implementation of a hospital walking program: protocol for a type III effectiveness-implementation hybrid trial

BACKGROUND

STRIDE is a supervised walking program designed to address the negative consequences of immobility during hospitalization for older adults. In an 8-hospital stepped wedge randomized controlled trial, STRIDE was associated with reduced odds of hospital discharge to skilled nursing facility. STRIDE has the potential to become a system-wide approach to address hospital-associated disability in Veteran's Affairs; however, critical questions remain about how best to scale and sustain the program. The overall study goal is to compare the impact of two strategies on STRIDE program penetration (primary), fidelity, and adoption implementation outcomes.

METHODS

Replicating Effective Programs will be used as a framework underlying all implementation support activities. In a parallel, cluster randomized trial, we will use stratified blocked randomization to assign hospitals (n = 32) to either foundational support, comprised of standard, low-touch activities, or enhanced support, which includes the addition of tailored, high-touch activities if hospitals do not meet STRIDE program benchmarks at 6 and 8 months following start date. All hospitals begin with foundational support for 6 months until randomization occurs. The primary outcome is implementation penetration defined as the proportion of eligible hospitalizations with ≥ 1 STRIDE walks at 10 months. Secondary outcomes are fidelity and adoption with all implementation outcomes additionally examined at 13 and 16 months. Fidelity will be assessed for STRIDE hospitalizations as the percentage of eligible hospital days with "full dose" of the program, defined as two or more documented walks or one walk for more than 5 min. Program adoption is a binary outcome defined as ≥ 5 patients with a STRIDE walk or not. Analyses will also include patient-level effectiveness outcomes (e.g., discharge to nursing home, length of stay) and staffing and labor costs. We will employ a convergent mixed-methods approach to explore and understand pre-implementation contextual factors related to differences in hospital-level adoption.

DISCUSSION

Our study results will dually inform best practices for promoting successful implementation of an evidence-based hospital-based walking program. This information may support other programs by advancing our understanding of how to apply and scale-up national implementation strategies.

TRIAL REGISTRATION

This study was registered on June 1, 2021, at ClinicalTrials.gov (identifier NCT04868656 ).

Goal Setting for Aging Adults and Care Partners: A Scoping Review

Background and Objectives

Evidence demonstrates that goal-setting and care partner support help aging adults improve their health. Less is known about how aging adults and care partners collaboratively participate in goal setting, revealing a potential gap in care delivery processes. The current review describes the scope of the literature on this topic.

Research Design and Methods

A search was conducted in several relevant databases and 1,231 articles were screened for the following inclusion criteria: (a) participants included aging adults (50+ years) and care partners, (b) goal setting was conducted, and (c) articles were in English.

Results

Common goals reported by aging adults were independence, improving or maintaining functioning, addressing symptoms, and remaining socially active. Care partners listed similar goals but also identified accessing services and supports as important. The level of care partner involvement varied across articles, with some care partners serving in a supportive role, some setting goals concurrently with the aging adult, and others setting goals on behalf of the aging adult.

Discussion and Implications

This review revealed concordant and discordant prioritization of goals within dyads. These findings illustrate the importance and potential complexity of including care partners in the goal-setting process. We also found that collaborative goal-setting and care partner-directed goals are scarce, indicating the need for additional work in this area. Collaborative goal setting aligns with person and family-centered care approaches and can contribute to better care plans that meet the needs of aging adults and their care partners.

Effectiveness of Multicomponent Exercise Interventions in Older Adults With Dementia: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Multicomponent training (MT) combines aerobic, strength, postural, and balance exercises and may be a promising intervention strategy for dementia. This meta-analysis study aims to systematize evidence concerning the effectiveness of MT in physical fitness, cognition, and functionality on activities of daily living (ADL) in older adults with dementia and to identify moderation patterns regarding training variables.

RESEARCH DESIGN AND METHODS

4 databases were systematically searched to locate potential trials through March 2019. A total of 2,312 records were identified and a final set of 17 manuscripts reviewed; of these, 6 satisfied all eligibility criteria.

RESULTS

Samples sizes ranged from 27 to 170 participants; MT programs lasted between 4 weeks and 12 months, took place from a daily basis to twice a week, and sessions ranged from 30 to 60 min. The TESTEX scale was used to analyze the methodological quality, and the funnel plots to assess the risk of bias. This meta-analysis revealed that MT interventions benefit older adults with dementia regarding ADL performance (effect size = 0.313 [0.16-0.46]; p < .01), but the evidence was not sufficiently robust to determine the effectiveness of MT on cognitive function and physical fitness, particularly, on agility.

DISCUSSION AND IMPLICATIONS

MT may be an important nonpharmacological strategy to enhance ADL functionality on older adults with dementia. Findings suggest that long-term interventions are more prevalent than high-frequency and longer duration exercise sessions. Further evidence is needed for acknowledging its benefits in specific cognitive abilities and physical fitness. This meta-analysis is registered in PROSPERO (no. CRD42020141545).

Acuity Differences Among Newly Admitted Older Residents in Rural and Urban Nursing Homes

BACKGROUND AND OBJECTIVES

Our primary objective was to assess rural-urban acuity differences among newly admitted older nursing home residents.

RESEARCH DESIGN AND METHODS

Data included the 2015 Minimum Data Set v3.0, the Area Health Resources File, the Provider of Services File, and Rural-Urban Commuting Area codes. Activities of daily living, the Cognitive Function Scale, and aggression/wandering indicators were used to assess functional, cognitive, and behavioral status, respectively. Excluding assessments for short stays (less than 90 days), assessments for 209,719 newly admitted long-stay residents aged 65 and older across 14,834 facilities in 47 states were evaluated. Difference in differences (DID) generalized linear models with state-fixed effects and clustering by facilities were used to assess the interaction effect of older age (75 plus) on rural-urban acuity differences, controlling for socioeconomic factors, admission source, and market characteristics.

RESULTS

Residents admitted to rural facilities were less functionally impaired (incidence rate ratio: 0.973-0.898) but had more cognitive (odds ratio [OR]: 1.03-1.22) and problem behaviors (OR: 1.19-1.48) than urban. Although older age was predictive of higher acuity, in DID models, the expected decline in functional status was comparable in rural and urban facilities, while the cognitive and behavioral status for older admissions was 8.0% and 8.5% lower in rural versus urban facilities, respectively.

DISCUSSION AND IMPLICATIONS

Although the higher prevalence of cognitive impairment and problem behaviors among rural admissions was attributable in part to older age, rural facilities admitted less complex individuals among older age residents than urban facilities. Findings may reflect less capacity to manage older, complex individuals in rural facilities.

Association Between Physical Performance and Cognitive Function in Older Adults Across Multiple Studies: A Pooled Analysis Study

Background and Objectives

While several studies have examined the association between cognitive and physical function, the consistency of these associations across functional contexts is unclear. The consistency of the association between cognitive and physical function performance was examined at baseline across 17 clinical studies with diverse and heterogeneous conditions such as overweight/obese, sedentary, at risk for a mobility disability, osteoarthritis, low vitamin D, or had signs of cognitive impairment.

Research Design and Methods

Data are from 1,388 adults 50 years and older who completed a cognitive and physical function assessment as part of a research study at the Wake Forest Alzheimer's Disease Research Center or the Wake Forest Older Americans Independence Center. Linear regression models were used to relate cognitive measures (Mini-Mental Status Examination, Montreal Cognitive Assessment, and the Digit Symbol Substitution Task) and physical measures (the Short Physical Performance Battery and hand grip strength) for the whole sample and treat each study as a fixed effect. All models controlled for age, sex, race, and body mass index.

Results

Overall, there was a significant association between higher scores on the Mini-Mental Status Examination (per standard deviation) and better physical function performance (Short Physical Performance Battery score b = 0.24, p < .001) and its components (gait speed, chair rise, and standing balance; ps < .05). Higher scores on the Montreal Cognitive Assessment produced similar results (Short Physical Performance Battery score b = 0.31, p ≤ .001), and higher scores on the Digit Symbol Substitution Task were also significantly associated with a better Short Physical Performance Battery score (b = 0.75, p < .001). The relationship between Digit Symbol Substitution Task and physical function performance demonstrated a stronger magnitude of association compared to the Mini-Mental Status Examination or Montreal Cognitive Assessment.

Discussion and Implications

Older adults with heterogeneous health conditions showed a consistent pattern between better cognitive function and better physical function performance with the strongest association among Digit Symbol Substitution Task scores.

Predicting Functional Dependence in Mild Cognitive Impairment: Differential Contributions of Memory and Executive Functions

BACKGROUND AND OBJECTIVES

Diagnostic criteria for mild cognitive impairment (MCI) exclude functional deficits, yet recent studies suggest that older adults with MCI can exhibit impairment in instrumental activities of daily living (IADL). To assist health care providers in detecting functional vulnerabilities that often precipitate loss of independence, we: (a) compared IADL dependence in MCI to older adults without cognitive impairment and those with dementia, (b) estimated the odds of dependence on specific IADLs in MCI, and (c) investigated the differential contributions of memory and executive functions to IADL dependence.

RESEARCH DESIGN AND METHODS

Participants were older adults (Mage = 77.58 ± 11.05) in Maryland, USA (N = 512) community and postacute rehabilitation settings. Analysis was performed on Brief Cognitive Assessment Tool (BCAT) and the Functional Activities Questionnaire (FAQ) data that assessed participants' cognitive functioning and IADL dependence, respectively.

RESULTS

61.04% of participants with MCI were dependent on one or more IADLs. MCI was associated with significantly greater odds of dependence than normal cognition on 7 of the 10 IADLs (odds ratios = 2.62-4.66). Impairment in memory and executive functions significantly predicted IADL dependence (18.52% of variance beyond demographics); executive functions were the stronger predictor, particularly for complex finances, complex cooking, and remembering events.

DISCUSSION AND IMPLICATIONS

IADL dependence can occur even in MCI. Testing suggestive of MCI should alert clinicians to further investigate the older adult's profile of cognitive and functional limitations to highlight targets for caregiver support and promote independence by "right-sizing" community or facility resources.

Aging With Long-Term Mobility Impairment: Maintaining Activities of Daily Living via Selection, Optimization, and Compensation

BACKGROUND AND OBJECTIVES

There is a growing number of adults with long-term mobility impairment aging into the older adult population. Little is known about the experiences of these individuals in maintaining activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as they face age-related changes in addition to a pre-existing mobility impairment.

RESEARCH DESIGN AND METHODS

Through in-home interviews with 21 participants (ages 52-86) with long-term mobility impairment, the present study employed a qualitative description design to explore perceptions of how and why select ADL/IADL routines (e.g., bed transfer, toileting) have changed over time. The selection, optimization, and compensation (SOC) model was used as a framework to organize participants' adaptations.

RESULTS

Among the ADL/IADL routine changes mentioned, elective selection strategies, in which a person continues to work at maintaining a task, were more frequently endorsed than loss-based selection strategies, in which a person does a task less or gets help from someone. Findings suggest that this population is actively adapting their routines to preserve their involvement in, and frequency of doing, these ADLs/IADLs. Counter to expectation, perceived age-related changes underlying activity routine changes were subtle and generally did not include sensory and cognitive declines.

DISCUSSION AND IMPLICATIONS

Findings provide insights into the difficulties adults with long-term mobility impairment experience as they age, as well as the adaptations they employ to overcome those challenges. Results highlight the need for customizable, mobility supports (e.g., assistive technologies, home modifications) that can adjust to an individual's changing abilities across the life span.

Evaluating Mobility in Advanced Dementia: A Scoping Review and Feasibility Analysis

BACKGROUND AND OBJECTIVES

Mobility decline is a symptom of advanced dementia that affects function, safety, caregiving, and quality of life. Monitoring mobility status is essential for initiating timely and targeted interventions aimed at preventing excess disability in people with dementia (PWD). The physical, cognitive, and behavioral symptoms of dementia however, present unique challenges for mobility assessment. The goals of this review were to (a) identify and describe measures of mobility used for PWD and (b) assess measures' feasibility for use in people with advanced dementia; a group whose degree of cognitive impairment results in severe functional deficits.

RESEARCH DESIGN AND METHODS

Electronic searches of Medline, Embase, CINAHL, and PsychInfo databases were conducted using keywords related to dementia, mobility, measurement, and validation. Descriptive characteristics were extracted and measures coded for mobility components. Tools were also evaluated for feasibility of use in advanced dementia and those deemed feasible, screened for psychometric strength.

RESULTS

Thirty-eight measures were included and 68% of these tools were performance-based. Elements of mobility evaluated were walking (53% of measures), postural transitions (42%), standing (40%), mobility-related behavioral/psychological symptoms (24%), transfers (10%), bed mobility (5%), and wheeled mobility (3%). 36% of studies included people with advanced dementia. Only 18% of tools received high scores for feasibility.

DISCUSSION AND IMPLICATIONS

Existing measures provide only partial information regarding mobility and few target elements that become relevant as dementia progresses. Most measures are not feasible for people with advanced dementia, and the psychometric evaluation of these measures is limited. Further research is needed to develop a comprehensive, dementia-specific, mobility assessment tool.

Gentle Physical Activity Intervention Led by Caregivers in a Medicaid Home Care Program: Do Outcomes Differ Between Family and Nonfamily Caregiving Dyads?

Background and Objectives

Caregiving dyads are fertile contexts for health promotion such as physical activity. However, previous physical activity interventions in caregiving dyads paid limited attention to care recipients’ outcomes and rarely involved paid caregivers. Home care aides (HCAs) provide nonmedical care for older family members or nonfamily clients in publicly funded home care programs in the United States. This study examined whether family and nonfamily HCA–client dyads differed in the outcomes of a 4-month gentle physical activity pilot program led by HCAs in a Medicaid home care program.

Design and Methods

A single-group prepost design was used to assess changes in clients’ function (self-reported and performance-based) and process outcomes (exercise-related social support provided by HCAs) in 18 family and 32 nonfamily HCA–client dyads. Repeated measures analysis controlled for clients’ demographic and health characteristics. Clients’ and HCAs’ motivation to continue the program beyond the intervention period was examined using quantitative and qualitative data.

Results

Client outcomes and exercise-related social support provided by HCAs improved, especially in nonfamily dyads. Both family and nonfamily dyads had high levels of motivation to continue the program, supporting the program’s sustainability for both clients and HCAs.

Discussion and Implications

Empowering HCAs to engage in health promoting activities with their clients is a promising strategy to improve the lives of caregiving dyads.

Cognitive Function as a Predictor of Major Mobility Disability in Older Adults: Results From the LIFE Study

Background and Objectives

Many cross-sectional studies have confirmed a link between gait speed and cognitive function. However, it is unknown whether cognitive function plays a role in the onset of major mobility disability (MMD) and if the effects are independent of physical function. This study examined cognitive and physical function as predictors of MMD across an average of 2.6 years of follow-up in community-dwelling older adults with compromised mobility.

Research Design and Method

Data were collected from 1,635 participants in the Lifestyle Interventions and Independence for Elders (LIFE) study ages 70–89 years free of MMD at baseline. MMD was assessed every 6 months and defined as the inability to walk 400 m in ≤15 min without assistance or sitting. Cognitive function was assessed at baseline, 18 months, and 24 months using a cognitive battery categorized into four domains: global cognitive function, processing speed, verbal memory, and executive function.

Results

Across the study duration of 2.6 years, 536 participants (32.8%) developed MMD. Cox Proportional Hazard models indicated a protective relationship for higher baseline processing speed (Hazard Ratio [HR] per standard deviation: 0.86, p = .006), executive function (HR: 0.86, p = .002), and global cognition (HR: 0.85, p = .001) on incidence of MMD adjusted for demographics, intervention, and comorbidities. Results were not significant after adjustment for gait speed. In adjusted longitudinal models, a positive change in processing speed was significantly associated with reduced risk of MMD (HR: 0.52, p < .001) while other domains were not.

Discussion and Implications

In the LIFE study, processing speed at baseline and follow-up was a significant predictor of subsequent MMD although the observed association may be explained by physical function as reflected in gait speed. More studies are needed to understand how cognitive function, alone and in combination with physical function, influences risk of MMD.

Validity of a Novel, Clinically Relevant Measure to Differentiate Functional Power and Movement Velocity and Discriminate Fall History Among Older Adults: A Pilot Investigation

Background and Objectives

Lower-body muscular power and movement velocity (MV) are associated with balance and physical function. The Tendo power analyzer (Tendo) is a portable device that calculates functional lower body power (FLBP) and MV. This reliable (Cronbach’s α = .98) method is validated against motion capture analysis of functional lower body sit-to-stand power and velocity (r = .76). However, the Tendo has not been utilized in discrimination or prediction of falls. We determined the discriminant validity of FLBP and MV among older adults based on the history of falls. These results lay the framework for longitudinal research in FLBP and MV in fall prediction/prevention.

Research Design and Methods

Cross-sectional investigation examining differences between FLBP and MV during 5 sit-to-stands of 98 community-dwelling older adults (aged 77.5 years, 61% female) classified by the history of fall (no = 59, yes = 39). Participants completed 5 consecutive sit-to-stands (60-second rest between each) with FLBP and MV measured by the Tendo. Multivariate analysis of variance modeling determined between-group differences in functional lower body sit-to-stand average velocity, peak velocity, relative average power, and relative peak power. Binary and forward conditional logistic regression models determined the ability of each measure to discriminate fall history.

Results

FLBP and MV were significantly lower in older adults with a fall history (p < .05). Relative average power and peak power were 15% and 16% lower and average and peak velocity were 18% and 14% slower, respectively among fallers. Logistic regression indicated average velocity was the best discriminator of fall history (p < .05).

Discussion and Implications

The Tendo detects differences in FLBP and MV during a sit-to-stand while discriminating fall history. Future longitudinal studies should determine efficacy in fall prediction and applicability toward clinically relevant interventions for fall prevention.

Mobility and Vitality Lifestyle Program (MOVE UP): A Community Health Worker Intervention for Older Adults With Obesity to Improve Weight, Health, and Physical Function

BACKGROUND AND OBJECTIVES

Obesity rates in adults ≥65 years have increased more than other age groups in the last decade, elevating risk for chronic disease and poor physical function, particularly in underserved racial and ethnic minorities. Effective, sustainable lifestyle interventions are needed to help community-based older adults prevent or delay mobility disability. Design, baseline recruitment, and implementation features of the Mobility and Vitality Lifestyle Program (MOVE UP) study are reported.

RESEARCH DESIGN AND METHODS

MOVE UP aimed to recruit 26 intervention sites in underserved areas around Allegheny County, Pennsylvania and train a similar number of community health workers to deliver a manualized intervention to groups of approximately 12 participants in each location. We adapted a 13-month healthy aging/weight management intervention aligned with several evidence-based lifestyle modification programs. A nonrandomized, pre-post design was used to measure intervention impact on physical function performance, the primary study endpoint. Secondary outcomes included weight, self-reported physical activity and dietary changes, exercise self-efficacy, health status, health-related quality of life, and accelerometry in a subsample.

RESULTS

Of 58 community-based organizations approached, nearly half engaged with MOVE UP. Facilities included neighborhood community centers (25%), YMCAs (25%), senior service centers (20%), libraries (18%), senior living residences (6%), and churches (6%). Of 24 site-based cohorts with baseline data completed through November 2017, 21 community health workers were recruited and trained to implement the standardized intervention, and 287 participants were enrolled (mean age 68 years, 89% female, 33% African American, other, or more than one race).

DISCUSSION AND IMPLICATIONS

The MOVE UP translational recruitment, training, and intervention approach is feasible and could be generalizable to diverse aging individuals with obesity and a variety of baseline medical conditions. Additional data regarding strategies for program sustainability considering program cost, organizational capacity, and other adaptations will inform public health dissemination efforts.

Dog Walking, the Human-Animal Bond and Older Adults' Physical Health

Purpose of the Study

This study explored the associations between dog ownership and pet bonding with walking behavior and health outcomes in older adults.

Design and Methods

We used data from the 12th wave (2012) of the Health and Retirement Study which included an experimental human-animal interaction module. Ordinary least squares regression and binary logistic regression models controlling for demographic variables were used to answer the research questions.

Results

Dog walking was associated with lower body mass index, fewer activities of daily living limitations, fewer doctor visits, and more frequent moderate and vigorous exercise. People with higher degrees of pet bonding were more likely to walk their dog and to spend more time walking their dog each time, but they reported walking a shorter distance with their dog than those with weaker pet bonds. Dog ownership was not associated with better physical health or health behaviors.

Implications

This study provides evidence for the association between dog walking and physical health using a large, nationally representative sample. The relationship with one's dog may be a positive influence on physical activity for older adults.

Aging and Disability Among Hispanics in the United States: Current Knowledge and Future Directions

BACKGROUND AND OBJECTIVES

Hispanics are the most rapidly aging minority population in the United States. Our objective is to provide a summary of current knowledge regarding disability among Hispanics, and to propose an agenda for future research.

RESEARCH DESIGN AND METHODS

A literature review was conducted to identify major areas of research. A life course perspective and the Hispanic Paradox were used as frameworks for the literature review and for identifying future areas of research.

RESULTS

Four research areas were identified: (1) Ethnic disparities in disability; (2) Heterogeneity of the U.S. older Hispanic population; (3) Risk factors for disability; and (4) Disabled life expectancy. Older Hispanics are more likely than non-Hispanic whites to be disabled or to become disabled. Disability varied by country of origin, nativity, age of migration, and duration in the United States. Important risk factors for disability included chronic health conditions, depression, and cognitive impairment. Protective factors included positive affect and physical activity. Older Hispanics have longer life expectancy than non-Hispanic whites but spend a greater proportion of old age disabled. Future research should continue to monitor trends in disability as younger generations of Hispanics reach old age. Attention needs to be given to regional variation within the United States for disability prevalence, early-life risk factors, and factors that may contribute to variation in disabled life expectancy. There is also an urgent need for interventions that can effectively prevent or delay the onset of disability in older Hispanics.

DISCUSSION AND IMPLICATIONS

Considerable research has examined disability among older Hispanics, but continued research is needed. It is important that research findings be used to inform public policies that can address the burden of disability for older Hispanic populations.

Genetic Influences on Functional Capacities in Aging

PURPOSE

Older populations are characterized by great heterogeneity in functional capacities and understanding the factors underlying these differences has been a major area of research for some decades. Genetic differences arguably play an important role in the heterogeneity observed for many outcomes among older individuals. However, the role of genes in the variation and trajectories of functional capacities in older age is poorly understood. This review was conducted to explore the evidence for genetic influences on physical functional capacities in aging.

DESIGN AND METHODS

This rapid review was conducted using the following criteria: journal articles retrieved from the PubMed, Embase, AgeLine, Scopus, and Web of Science electronic databases including the key words: genetics, genotype, polymorphism, physical or functional performance, functional capacity, activities of daily living, older, and elderly. In total, 118 articles were included for initial review.

RESULTS

The heritability of objective measures of physical function ranges from 30% to 60% in studies of older twins. There is a paucity of evidence about genetic influences on functional capacities, but some candidate genes related to functional capacity have been identified.

IMPLICATIONS

No strong candidate genes exist for functional capacities. Current methodologies are beginning to generate new evidence about genetic influences on overall physical function at older ages, but the variety of measures of functional capacity makes evidence difficult to compare.

Medical and Assistive Health Technology: Meeting the Needs of Aging Populations

PURPOSE OF THE STUDY

To identify policy gaps in the delivery and availability of assistive health technology (AHT) and medical devices (MD) for aging populations, particularly in low- and middle-income countries (LMICs).

DESIGN AND METHODS

The findings presented in this paper are the results of several narrative overviews. They provide a contextual analysis of the conclusions and evidence from WHO commissioned research and expert consultations in 2013 and 2014, as well as a synthesis of literature reviews conducted on AHT and MD.

RESULTS

Practical, life-enhancing support for older people through AHT, MD, and related health and social services is a neglected issue. This is particularly so in LMICs where the biggest increases in aging populations are occurring, and yet where there is commonly little or no access to these vital components of healthy aging.

IMPLICATIONS

Health technologies, especially medical and assistive health technology, are essential to ensure older people's dignity and autonomy, but their current and potential benefits have received little recognition in LMICs. Viewing these technologies as relevant only to disabled people is an inadequate approach. They should be accessible to both older adults with disabilities and older adults with functional limitation. Many countries need much greater official awareness of older adults' needs and preferences. Such attitudinal changes should then be reflected in laws and regulations to address the specificities of care for older people.

A Difficult Journey: Reflections on Driving and Driving Cessation From a Team of Clinical Researchers

Recognizing the clinical importance and safety and well-being implications for the population, a multidisciplinary team has been researching older drivers and driving cessation issues for more than 15 years. Using empirical approaches, the team has explored quality of life and participation outcomes related to driving and nondriving for older people and has developed interventions to improve outcomes after driving cessation. The team members represent occupational therapists, medical practitioners, and clinical and neuropsychologists. While building the evidence base for driving- and driving cessation-related clinical practice, the researchers have also had first-hand experiences of interruptions to their own or parents' driving; involvement of older family members in road crashes; and provision of support during family members' driving assessment and cessation. This has led to reflection on their understandings and re-evaluation and refocusing of their perspectives in driving cessation research. This work will share the narratives of the authors and note their developing perspectives and foci within research as well as their clinical practice. Personal reflections have indicated the far-reaching implications for older drivers and family members of involvement in road crashes: the potential for interruptions to driving as a time for support and future planning and the conflicting and difficult roles of family members within the driving cessation process. Overall the lived, personal experience of the authors has reinforced the complex nature of driving and changes to driving status for the driver and their support team and the need for further research and support.