The association between diabetes and safe driving: A systematic search and review of the literature and cross-reference with the current guidelines.

AIMS: We conducted this review to characterize the quality of evidence about associations between diabetes and safe driving and to evaluate how these findings are reflected within current guidelines available to support clinicians and their patients with diabetes. METHODS: The first stage entailed a systematic search and review of the literature. Evidence surrounding harms associated with diabetes and driving was identified, screened, extracted and appraised for quality utilizing the Newcastle Ottawa Scales (NOS). Next, relevant guidelines regarding driving and diabetes were sourced and summarized. Finally, the identified guidelines were cross-referenced with the results of the systematic search and review. RESULTS: The systematic search yielded 12,461 unique citations; 52 met the criteria for appraisal. Fourteen studies were rated as 'high', two as 'medium' and 36 as 'low'. Studies with ratings of 'high' or 'medium' were extracted, revealing a body of inconsistent methods and findings. These results, cross-referenced with the guidelines, suggest a lack of agreement and a limited evidence base to justify recommendations. CONCLUSIONS: The results presented emphasize the need for a better understanding of the impacts of diabetes on safe driving to inform evidence-based guidelines.

Development and Initial Validation of the Transportation Support Scale.

IMPORTANCE: Driving cessation affects older drivers and, possibly, also care partners (most of whom tend to be women). Although tools exist to assess the effects on family and friends of providing informal care to someone who needs assistance, no tool is available to clinicians that specifically focuses on the effects of driving cessation. OBJECTIVE: To develop the Transportation Support Scale (TSS) to measure care partners' responses-both negative and positive-to driving cessation and assuming transportation responsibilities. DESIGN: We developed a list of 98 items to capture the impact on care partners of providing transportation to older adults who have stopped driving. In Phase 1, we pretested the items qualitatively with a small sample of care partners. In Phase 2, we reduced the number of items and examined several psychometric properties of the TSS with a larger sample. SETTING: Community. PARTICIPANTS: Two convenience samples of care partners who provide transportation (Phase 1, n = 11; Phase 2, n = 66). RESULTS: The initial pool of items was reduced from 98 to 22. The final TSS has an internal consistency of .88 (Cronbach's α). Thirty-five percent of care partners' scores fell above the middle possible score; these care partners were likely experiencing a high negative impact related to providing transportation after driving cessation. CONCLUSIONS AND RELEVANCE: The TSS demonstrated adequate preliminary psychometric properties. We need additional research to further evaluate the psychometric properties of the TSS (e.g., test-retest reliability). A fully validated TSS may be useful to clinicians and researchers. What This Article Adds: The TSS has the potential to help clarify the perspective of care partners as well as inform the development and evaluation of services for care partners who are providing transportation to former drivers.

Women's Spiritual Intelligence is Associated With Fewer Depression Symptoms: Exploratory Results From a Canadian Sample.

While some evidence suggests a relationship between spiritual intelligence and depression, overall, research has yielded inconclusive results. We set out to expand the literature by further exploring this relationship in a Canadian sample. We also aimed to investigate the moderating effect of gender, shedding additional light on an interaction mostly overlooked in the current research. A clinical sample of 39 participants (66.7% female) completed measures of SI and depression before receiving treatment for depression in an outpatient mental health clinic. Results indicated that overall, there was a negative relationship between SI and depression symptoms (r(39) = - 0.55, p < .001); our findings illustrate that this beneficial relationship was driven by women. Future research of interventions aimed at improving spirituality as a means of reducing depression symptoms is warranted.

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.

Canadian Older Adults' Perceptions of Transitioning from Driver to Non-Driver.

Ceasing driving is associated with many negative outcomes. We examined the perceived impact of driving cessation among current older drivers. Transcripts from 92 interviews with participants from several locations across Canada were analyzed using inductive thematic analysis. We identified five themes: planning for mobility change, mobility supports and neighborhoods, financial security, fearing loss of control and independence, and coping and acceptance as a part of aging. Findings highlight diverse attitudes toward driving cessation, ranging from avoidance to acceptance, and emphasize the importance of tailored resources for drivers at various stages of behavior change.

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.

Using Naturalistic Methods to Examine Real-World Driving Behavior in Individuals With TBI Upon Return to Driving: A Pilot Study.

OBJECTIVES: To characterize the real-world driving habits of individuals with traumatic brain injury (TBI) using naturalistic methods and to demonstrate the feasibility of such methods in exploring return to driving after TBI. METHODS: After passing an on-road driving assessment, 8 participants with TBI and 23 matched controls had an in-vehicle device installed to record information regarding their driving patterns (distance, duration, and start/end times) for 90 days. RESULTS: The overall number of trips, distance and duration or percentage of trips during peak hour, above 15 km from home or on freeways/highways did not differ between groups. However, the TBI group drove significantly less at night, and more during the daytime, than controls. Exploratory analyses using geographic information system (GIS) also demonstrated significant within-group heterogeneity for the TBI group in terms of location of travel. CONCLUSIONS: The TBI and control groups were largely comparable in terms of driving exposure, except for when they drove, which may indicate small group differences in driving self-regulatory practices. However, the GIS evidence suggests driving patterns within the TBI group were heterogeneous. These findings provide evidence for the feasibility of employing noninvasive in-car recording devices to explore real-world driving behavior post-TBI.

Self-regulation upon return to driving after traumatic brain injury.

The aim of this study was to explore self-reported driving habits and the factors associated with these within the first three months of return to driving following traumatic brain injury (TBI). Participants included 24 individuals with moderate to severe TBI (post-traumatic amnesia duration M = 33.26, SD = 29.69 days) and 28 healthy age, education, and gender-matched controls who completed an on-road assessment. Driving frequency and avoidance questionnaires were administered to assess premorbid driving, anticipated driving upon resuming, and driving at three months post-assessment. There were no differences between groups for premorbid driving frequency or avoidance. Individuals with TBI anticipated greater reductions in driving frequency, t(29.57) = -3.95, p < .001, and increases in avoidance, U = 171.00, z = -2.69, p < .01. On follow up, significant reductions in frequency, t(48) = -3.03, p < .01, but not avoidance, U = 239.00, z = -1.35, p = .18, were observed. Females were more likely to reduce their driving frequency, rs = -.43, p < .05, while increased anxiety was associated with increased avoidance r = .63, p < .05, and reduced frequency r = -.43, p < .05. It was concluded that individuals with TBI anticipated changes in their driving habits upon return to driving, indicating an expectation for post-injury changes to their driving lifestyle. On follow up, many of these intended changes to driving habits, particularly in relation to driving frequency, were reported by individuals with TBI, suggestive of some strategic self-regulation.

Self-Awareness and Self-Ratings of On-Road Driving Performance After Traumatic Brain Injury.

OBJECTIVE: To examine self-rated, clinician-rated, and self-awareness of on-road driving performance in individuals with traumatic brain injury (TBI) deemed fit and unfit to resume driving and healthy controls, and to explore their associations with demographic, injury, cognitive, and mood variables. METHODS: Participants included 37 individuals with moderate to severe TBI, and 49 healthy age, sex, and education-matched controls from Australia and Canada. Participants completed an on-road assessment, the Brain Injury Driving Self-Awareness Measure (BIDSAM), and a comprehensive neuropsychological assessment. RESULTS: Awareness scores on the BIDSAM were significantly different between groups, F(2, 83) = 28.44 (P < .001; η = 0.41), with post hoc tests indicating TBI participants who failed the on-road assessment had worse scores compared with those who passed and controls. Poor self-awareness was significantly correlated with reduced psychomotor speed (rs = -0.37; P < .01) and attentional switching (rs = 0.28; P < .01). Worse self-ratings of driving were associated with depression (rs = 0.42; P < .01) and anxiety (rs = 0.38; P < .01). CONCLUSIONS: Individuals with TBI who failed an on-road assessment significantly overestimated their driving ability. Impaired cognitive function was associated with reduced self-awareness of driving. These findings suggest impaired awareness of driving may need to be addressed as part of driver rehabilitation programs.

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.

The development and initial validation of a new tool to measure self-awareness of driving ability after brain injury.

AIM: The aim of this study was to develop and provide initial validation data for a self-awareness of on-road driving ability measure for individuals with brain injury. METHOD: Thirty-nine individuals with Traumatic Brain Injury completed an on-road driving assessment, the Self-Regulation Skills Interview (SRSI) and the newly developed Brain Injury Driving Self-Awareness Measure (BIDSAM). RESULTS: BIDSAM self, clinician and discrepancy scales demonstrated high levels of internal consistency (α = 0.83-0.92). Criterion-related validity was established by demonstrating significantly higher correlations between clinician ratings and on-road performances, rs  = 0.82, P < 0.01, compared to self-ratings, rs  = 0.45, P < 0.05. Discrepancy scores were significantly correlated with the SRSI emergent, rs  = 0.52, P < 0.01, and anticipatory awareness scores, rs  = 0.37, P < 0.05, indicative of convergent validity. CONCLUSIONS: These results provide initial support for the BIDSAM as a reliable and valid measure of self-awareness of on-road driving ability following TBI.

Looking Forward and Looking Back: Older Adults' Views of the Impacts of Stopping Driving.

This project aimed to identify the impact of driving cessation from the perspectives of older drivers and former drivers. Participants included 17 adults aged 65-88 years residing in a city in Northwestern Ontario, Canada. Using a semi-structured interview guide (with questions regarding mobility, personal impact, impact on others, engagement with life, and finances), two focus groups were held with nine current drivers, and one-on-one interviews were held with six former drivers and two current drivers. Two themes emerged concerning stopping driving. The first theme included discussions on experiencing lifestyle changes, relationship impacts, and emotional impacts. The second, the adjustment to stopping driving, included practical adaptations, and emotional responses such as appreciation, resistance, acceptance, and being positive. Although the impacts of stopping driving were substantial, there were few discrepancies between what was anticipated and what was experienced. This information could assist with developing interventions to ease the transition to former-driver status.

Prognostic Markers for Poor Recovery After Mild Traumatic Brain Injury in Older Adults: A Pilot Cohort Study.

OBJECTIVE: To identify prognostic markers associated with poor recovery from mild traumatic brain injury (MTBI) in older adults. SETTING: Three Ontario emergency departments. PARTICIPANTS: Forty-nine participants aged 65 years and older that visited an emergency department for MTBI. DESIGN: Pilot prospective cohort study. MAIN MEASURES: Recovery from MTBI determined using the Rivermead Postconcussion symptom Questionnaire, the Glasgow Outcomes Scale-Extended, physical and mental health functioning (SF-12), and a single question on self-rated recovery assessed by telephone shortly after emergency department visit (baseline) and again 6 months later. Predictors were measured at baseline. RESULTS: Markers potentially associated with poor recovery included reporting worse health 1 year before the injury, poor expectations for recovery, depression, and fatigue. CONCLUSION: Recovery after MTBI in older adults may be associated more with psychosocial than with biomedical or injury-related factors.

Psychometrics of the Fitness-to-Drive Screening Measure.

We employed item response theory (IRT), specifically using Rasch modeling, to determine the measurement precision of the Fitness-to-Drive Screening Measure (FTDS), a tool that can be used by caregivers and occupational therapists to help detect at-risk drivers. We examined unidimensionality through the factor structure (how items contribute to the central construct of fitness to drive), rating scale (use of the categories of the rating scale), item/person-level separation (distinguishing between items with different difficulty levels or persons with different ability levels) and reliability, item hierarchy (easier driving items advancing to more difficult driving items), rater reliability, rater effects (severity vs. leniency of a rater), and criterion validity of the FTDS to an on-road assessment, via three rater groups (n = 200 older drivers; n = 200 caregivers; n = 2 evaluators). The FTDS is unidimensional, the rating scale performed well, has good person (> 3.07) and item (> 5.43) separation, good person (> 0.90) and item reliability (> 0.97), with < 10% misfitting items for two rater groups (caregivers and drivers). The intraclass correlation (ICC) coefficient among the three rater groups was significant (.253, p < .001) and the evaluators were the most severe raters. When comparing the caregivers' FTDS rating with the drivers' on-road assessment, the areas under the curve (index of discriminability; caregivers .726, p < .001) suggested concurrent validity between the FTDS and the on-road assessment. Despite limitations, the FTDS is a reliable and accurate screening measure for caregivers to help identify at-risk older drivers and for occupational therapy practitioners to start conversations about driving.

Mindfulness-based cognitive therapy reduces symptoms of depression in people with a traumatic brain injury: results from a randomized controlled trial.

OBJECTIVE: We sought to determine if we could reduce symptoms of depression in individuals with a traumatic brain injury using mindfulness-based cognitive therapy. SETTING: The study was conducted in a community setting. PARTICIPANTS: We enrolled adults with symptoms of depression after a traumatic brain injury. DESIGN: We conducted a randomized controlled trial; participants were randomized to the 10-week mindfulness-based cognitive therapy intervention arm or to the wait-list control arm. MAIN MEASURES: The primary outcome measure was symptoms of depression using the Beck Depression Inventory-II. RESULTS: The parallel group analysis revealed a greater reduction in Beck Depression Inventory-II scores for the intervention group (6.63, n = 38,) than the control group (2.13, n = 38, P = .029). A medium effect size was observed (Cohen d = 0.56). The improvement in Beck Depression Inventory-II scores was maintained at the 3-month follow-up. CONCLUSION: These results are consistent with those of other researchers that use mindfulness-based cognitive therapy to reduce symptoms of depression and suggest that further work to replicate these findings and improve upon the efficacy of the intervention is warranted.

The psychological and health consequences of caring for a spouse with dementia: a critical comparison of husbands and wives.

Caring for someone with dementia can be demanding, particularly for spouses living with the care recipient. The main goal of this study was to clarify differences in the experience of caregivers who were husbands and wives with respect to burden, health, healthy behaviors, presence of difficult care recipient behaviors, social supports, and the quality of the premorbid relationship. The results of this study support research demonstrating a difference between the caregiving experiences of women and men. It is becoming increasingly apparent that female gender is a marker that places them at increased risk of high burden and less support.

Consensus statements for screening and assessment tools.

Occupational therapists, both generalists and specialists, have a critical role in providing services to senior drivers. These services include evaluating fitness-to-drive, developing interventions to support community mobility, and facilitating the transition from driving to non-driving when necessary for personal and community safety. The evaluation component and decision-making process about fitness-to-drive are highly dependent on the use of screening and assessment tools. The purpose of this paper is to briefly present the rationale and context for 12 consensus statements about the usefulness and appropriateness of screening and assessment tools to determine fitness-to-drive, within the occupational therapy clinical setting, and their implications on community mobility.

Decision tool for clients with medical issues: a framework for identifying driving risk and potential to return to driving.

This paper offers occupational therapy generalists and specialists a new framework by which to consider clinical evaluation data and an older adult's driving risk and potential to resume this previously learned skill. Based on Michon's model describing the hierarchy of driving levels, clinical questions identify the factors that may affect a client's fitness to drive. The first part is intended to support clinical judgment of whether a client needs a driving evaluation by a driver rehabilitation specialist. The second part offers a framework to organize clinical data that are already known and determine what other evaluation information is justified and necessary to make a driving recommendation. Methods and rational for use are discussed.

Older Drivers Reduced Engagement in Distracting Behaviors Over a Six-Year Period: Findings From the Candrive Longitudinal Study.

OBJECTIVES: Baltes and Baltes' "selective optimization with compensation" model is pertinent to driving but evidence about the use of compensation using longitudinal designs is scarce. Therefore, we sought to determine if older drivers reduced their engagement in distracting behaviors while driving, over a 6-year period. METHODS: We used data captured over several annual assessments from a cohort of 583 drivers aged 70 and older to determine if their engagement in 12 distracting behaviors (e.g., listening to the radio, talking with passengers) declined over time. We adjusted our multivariable model for several potential confounders of the association between our outcome variable and time. RESULTS: Overall, and after adjustment for potential confounders, the participants reduced their engagement in distracting behaviors over the study period (odds ratio [OR] = 0.96, 95% confidence interval [CI] = 0.95-0.97). Baseline age was negatively associated with engagement in distracting behaviors (OR = 0.95, 95% CI = 0.94-0.96). Men engaged in more distracting behaviors than women (OR = 1.15, 95% CI = 1.03-1.27), as did participants living in the largest urban centers compared to participants living in the smallest areas (OR = 1.21, 95% CI = 1.04-1.41). The number of kilometers driven per year (for every 10,000 km) was positively associated with the proportion of distracting behaviors drivers engaged in (OR = 1.13, 95% CI = 1.08-1.19). DISCUSSION: Drivers in our cohort reduced their engagement in distracting behaviors over the study period. This suggests that older drivers adjust their driving over time, which aligns with age-related theories and models about compensation.

Personality Is Associated with Driving Avoidance in the Canadian Longitudinal Study on Aging (CLSA).

As individuals age and become aware of changes in their driving capabilities, they are more likely to self-regulate their driving by avoiding certain driving situations (i.e., night driving, rush hour traffic, etc.). In this paper, we sought to examine the correlates of situational driving avoidance with a particular emphasis on the roles of personality traits, gender, and cognition within a large sample of mid-life and older adults from the Canadian Longitudinal Study on Aging (CLSA). Our findings show that women of older ages tend to report more driving avoidance and that personality traits, specifically extraversion, emotional stability, and openness to experience, may reduce driving avoidance. A negative association was also found between cognition and driving avoidance, such that individuals with higher cognition reported less driving avoidance.