07| Driving Assessment and Management in Older Adults with Cognitive Impairment

In this episode, we discuss the following topics related to driving safety with Jennifer Davis, Ph.D., ABPP-CN:

  • The impact of demographic factors (age, gender, education) on driving abilities
  • The impact of common medical, neurological, and neurodegenerative conditions on driving abilities
  • Medication effects on driving abilities
  • Relationship between specific cognitive abilities and driving safety
  • The effectiveness of compensatory strategies (e.g., driving only in good weather, driving only in familiar locales) used by aging adults
  • Available methods for assessing driving abilities, including advantages and disadvantages of each
  • Driving Rehabilitation Specialists and their evaluations
  • Aspects of a neuropsychological evaluation that are particularly relevant to driving performance
  • Neuropsychological tests with the greatest predictive power with respect to driving abilities
  • The role of a clinical neuropsychologist when an evaluation suggests concern for poor driving performance
  • Relevant legal issues pertaining to driving in the elderly
  • Useful neuropsychological recommendations pertaining to driving safety in older adults
  • How to conduct neuropsychological feedback with patients and their families when driving safety is a concern
  • The negative psychological consequences of limiting/eliminating driving in an older adult and how to mitigate these consequences

About Jenn

Jenn earned her Ph.D. from the University of Utah in Clinical Psychology (Neuropsychology track).  She completed a neuropsychology-focused internship at the Alpert Medical School of Brown University.  She then did two postdoctoral fellowships, a Clinical Neuropsychology fellowship at Brown and an NIH-funded T32 research fellowship in Dementia, also at Brown.  Her current positions are:

-Associate Professor, Clinician Educator in the Department of Psychiatry & Human Behavior at Alpert Medical School of Brown University

-Associate Director of the Clinical Neuropsychology Specialty Program in the Postdoctoral Fellowship Training Consortium at Alpert Medical School of Brown University

-Staff Neuropsychologist in the Department of Psychiatry at Rhode Island Hospital, where she specializes in Alzheimer’s disease and related disorders

Resources

Appendix 1 and 2 in Iverson et al. (2010). Practice Parameters update: Evaluation and management of driving risk in dementia. Neurology. https://doi.org/10.1212/WNL.0b013e3181da3b0f

Useful handout for patients and caregivers:https://s0.hfdstatic.com/sites/the_hartford/files/cmme-crossroads.pdf

Resources for alternative transportation: https://one.nhtsa.gov/people/injury/olddrive/alzheimers/index.html

A guide to vehicle safety technology: https://s0.hfdstatic.com/sites/the_hartford/files/vehicle-technology.pdf

Alzheimer’s Association Driving and Dementia Position/Bibliography: https://www.alz.org/national/documents/statements_driving.pdf

AAA Senior Driving Professional Assessment https://seniordriving.aaa.com/evaluate-your-driving-ability/professional-assessment/

AARP Resources https://www.aarp.org/auto/driver-safety/

Finding Driving Evaluation Locations in Your Area:

http://www.aota.org/older-driver (American OT Association)

https://www.aded.net/search/custom.asp?id=1984 (Association for Driver Rehabilitation Specialists)

Neuropsychological Recommendation Samples:

Although neuropsychological measures do not directly test for driving ability, Mr./Mrs. XXXX’s visuospatial deficits, slowed processing speed, and executive dysfunction are concerning for driving safety.  Consider a referral to occupational therapy for a formal driving evaluation.  Local options include [list name and contact information].

Mr./Mrs. XXXX is no longer driving.  Although neuropsychological testing does not directly measure driving ability, performance on testing was concerning for driving safety and suggests that continuing to abstain from driving is prudent.

Driving ability should be queried periodically. On-road or driving simulator testing might be prudent if driving ability becomes more concerning.

A few relevant articles:

Davis, J. D., et al. (2012). Road test and naturalistic driving performance in healthy and cognitively impaired older adults: Does environment matter? Journal of the American Geriatrics Society. DOI: 10.1111/j.1532-5415.2012.04206.x

Ott, B. R., Davis, J. D., et al. (2013). Assessment of driving-related skills prediction of unsafe driving in older adults in the office setting. Journal of the American Geriatrics Society. DOI: 10.1111/jgs.12306

Ott, B. R.,…Davis, J. D., et al. (2008). A longitudinal study of drivers with Alzheimer disease. Neurology. DOI: https://doi.org/10.1212/01.wnl.0000294469.27156.30

Ott, B. R., …Davis, J. D., et al. (2008). Computerized maze navigation and on-road performance by drivers with dementia. J. Geriatr Psychiatry Neurol. DOI: 10.1177/0891988707311031

Wolf, P. L., & Lehockey, K. A. (2016). Neuropsychological Assessment of Driving Capacity. Archives of Clinical Neuropsychology. DOI: https://doi.org/10.1093/arclin/acw050

 

(note: we have no affiliation with any of the information listed and have no financial incentives to disclose)

Episodes

5 Comments

  1. I’m backing John’s defense of the flawed logic applied to driving age limits. I agree the counterpoint regarding driving reserve for older adults is sound, but even that has several assumptions about the reserve being functionally adaptive. If someone was a terrible driver their whole life, is it really a good thing for them to be able to fall back on that when cognitive abilities are compromised? To put it in neuropsychology-esque terms, “years of driving” is likely an adequate but imperfect proxy of driving reserve, just like “years of education” is an imperfect proxy of “cognitive reserve,” and there are likely subgroups for which the proxy is particularly misleading. A measure of actual driving ability (analogous to word-reading/vocabulary for measuring premorbid intellect) would in theory be much more informative if wanting to use in defense of allowing someone with MCI/mild dementia to continue driving.

    Presumably, lower age limits for driving are based on some assumption that being below that limit places someone at unacceptably high risk of accidents or poor decisions. The flawed logic that John points out is that a lower age cutoff of ~16 may, ON AVERAGE, represent individuals ready to become proficient drivers, but there’s an error range there where there are very likely individuals ages 14 or 15 that are just as capable, and there are likely individuals ages 17 or 18 that are not as capable. The hypocrisy (unintentionally strong word) comes when someone is pro-lower age limit for aforementioned reasons, but then anti-upper age limit of, say, 85 years old simply because there are plenty of 86, 87, etc. year olds that can drive just fine….despite the fact that a cutoff of 85, ON AVERAGE, might represent the point that individuals are now at an unacceptably high risk of accidents or poor decisions.

    Like John, I’m not advocating for removing lower age limits, but think this broadly highlights the limitations of applying a singular cutoff value for measuring “risk” (like a lower age limit of ~16) across a population, rather than considering subgroup-specific cutoffs that have far less deviation from average.

    Stay strong, John.

  2. I also agree with John, at least in principle. Criterion-based cutoffs are always going to map onto driving ability better than age-based cutoffs. The most persuasive counterpoint, in my mind, is the fact that we don’t have perfect measures of driving ability. Our best tests might not capture how people will respond in certain situations. Still, it seems like an empirical question as to whether age cutoffs or skill cutoffs are more effective at minimizing traffic accidents.

    1. Thanks for the comment Peter! Seems like we’re on the same page. I agree that my argument for a criterion-based cutoff relies on having good measures of driving ability, but the DMV’s written and driving tests are already being used as “valid” criteria (i.e., you still need to pass them to get licensed), so the age limit seems completely arbitrary and unfair to me. You’re right though, that ultimately it’s an empirical question regarding what is most effective…maybe there was sufficient data that led to the line in the sand, but I’m not aware of it.

  3. Could you pass a road test? Could you parallel park in a place smaller than your car? Can you back in to a parking space from 90 degrees without using mirrors or looking back? Plus your car better be perfectly centered within a half inch in all dimensions. Can you maintain speed to +/- .1 mph?

    How about a written test?

    How much property damage liability does the owner of a 40,000 have to maintain?

    In 2015, how many traffic fatalities were there (exactly), and what percentage of those involved persons between 18 and 24 with a BAC between .05 and .06?

    What is the fine for a 2nd conviction of DUI within 5 years and a BAC of .85?

    What is the exact stopping distance of a vehicle going 43 mph, weighing 2754 pounds?

    I would refuse to submit to an assessment.

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