Candrive-Development of a Risk Stratification Tool for Older Drivers.

BACKGROUND: Assessing an older adult's fitness-to-drive is an important part of clinical decision making. However, most existing risk prediction tools only have a dichotomous design, which does not account for subtle differences in risk status for patients with complex medical conditions or changes over time. Our objective was to develop an older driver risk stratification tool (RST) to screen for medical fitness-to-drive in older adults. METHODS: Participants were active drivers aged 70 and older from 7 sites across 4 Canadian provinces. They underwent in-person assessments every 4 months with an annual comprehensive assessment. Participant vehicles were instrumented to provide vehicle and passive Global Positioning System (GPS) data. The primary outcome measure was police-reported, expert-validated, at-fault collision adjusted per annual kilometers driven. Predictor variables included physical, cognitive, and health assessment measures. RESULTS: A total of 928 older drivers were recruited for this study beginning in 2009. The average age at enrollment was 76.2 (standard deviation [SD] = 4.8) with 62.1% male participants. The mean duration for participation was 4.9 (SD = 1.6) years. The derived Candrive RST included 4 predictors. Out of 4 483 person-years of driving, 74.8% fell within the lowest risk category. Only 2.9% of person-years were in the highest risk category where the relative risk for at-fault collisions was 5.26 (95% confidence interval = 2.81-9.84) compared to the lowest risk group. CONCLUSIONS: For older drivers whose medical conditions create uncertainty regarding their fitness-to-drive, the Candrive RST may assist primary health care providers when initiating a conversation about driving and to guide further evaluation.

Evaluation of Hysteroscopic Endometrectomy: A Reappraisal.

Endometrial ablation can be performed using a variety of techniques, including resectoscopic or non-resectoscopic approaches. In this study, we compared 2 resectoscopic endometrial ablation techniques. The first technique was rollerball coagulation followed by endometrectomy (type A; n = 103), and the second was the reverse (type B; n = 107). Besides excessive bleeding in 4 cases, the procedures were uneventful in both groups of patients. We did not encounter uterine perforation or cervical laceration. Satisfaction rates were 97% and 99% with an overall hysterectomy rate of 2.9%. These results compared favorably with those in the literature. The results of our study show that hysteroscopic endometrectomy is effective with few associated complications.

A Collaborative Model to Implement Flexible, Accessible and Efficient Oncogenetic Services for Hereditary Breast and Ovarian Cancer: The C-MOnGene Study.

Medical genetic services are facing an unprecedented demand for counseling and testing for hereditary breast and ovarian cancer (HBOC) in a context of limited resources. To help resolve this issue, a collaborative oncogenetic model was recently developed and implemented at the CHU de Québec-Université Laval; Quebec; Canada. Here, we present the protocol of the C-MOnGene (Collaborative Model in OncoGenetics) study, funded to examine the context in which the model was implemented and document the lessons that can be learned to optimize the delivery of oncogenetic services. Within three years of implementation, the model allowed researchers to double the annual number of patients seen in genetic counseling. The average number of days between genetic counseling and disclosure of test results significantly decreased. Group counseling sessions improved participants' understanding of breast cancer risk and increased knowledge of breast cancer and genetics and a large majority of them reported to be overwhelmingly satisfied with the process. These quality and performance indicators suggest this oncogenetic model offers a flexible, patient-centered and efficient genetic counseling and testing for HBOC. By identifying the critical facilitating factors and barriers, our study will provide an evidence base for organizations interested in transitioning to an oncogenetic model integrated into oncology care; including teams that are not specialized but are trained in genetics.

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.

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.

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.

Characterizing on-road driving performance in individuals with traumatic brain injury who pass or fail an on-road driving assessment.

OBJECTIVE: To characterise on-road driving performance in individuals with traumatic brain injury who fail on-road driving assessment, compared with both those who pass assessment and healthy controls, and the injury and cognitive factors associated with driving performance. STUDY DESIGN: Cross-sectional. METHODS: Forty eight participants with traumatic brain injury (Age M = 40.50 SD = 14.62, 77% male, post-traumatic amnesia days M = 28.74 SD =27.68) and 48 healthy matched controls completed a standardised on-road driving assessment in addition to cognitive measures. RESULTS: Individuals with traumatic brain injury who passed on-road driving assessment performed no differently from controls while individuals with traumatic brain injury who failed the assessment demonstrated significantly worse driving performance relative to controls across a range of driving manoeuvres and error types including observation of on-road environment, speed control, gap selection, lane position, following distance and basic car control. Longer time post-injury and reduced visual perception were both significantly correlated with reduced driving skills. CONCLUSIONS: This exploratory study indicated that drivers with traumatic brain injury who failed on-road assessment demonstrated a heterogeneous pattern of impaired driving manoeuvres, characterised by skill deficits across both operational (e.g., basic car control and lane position) and tactical domains (e.g., following distance, gap selection, and observation) of driving. These preliminary findings can be used for implementation of future driving assessments and rehabilitation programs. Implications for rehabilitation Clinicians should be aware that the majority of individuals with traumatic brain injury were deemed fit to resume driving following formal on-road assessment, despite having moderate to very severe traumatic brain injuries. Drivers with traumatic brain injury who failed an on-road assessment demonstrated a heterogeneous pattern of impaired skills including errors with observation, speed regulation, gap selection, and vehicle control and accordingly had difficulty executing a diverse range of common driving manoeuvres. Comprehensive, formal on-road assessments, incorporating a range of skills, and manoeuvres, are needed to evaluate readiness to return to driving following traumatic brain injury. Individually tailored driver rehabilitation programs need to address these heterogeneous skill deficits to best support individuals to make a successful return to driving post-traumatic brain injury.

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-reported violations, errors and lapses for older drivers: Measuring the change in frequency of aberrant driving behaviours across five time-points.

The current study aimed to: 1. to confirm the 21-item, three-factor Driver Behaviour Questionnaire (DBQ) structure suggested by Koppel et al. (2018) within an independent sample of Canadian older drivers; 2. to examine whether the structure of the DBQ remained stable over a four-year period; 3. to conduct a latent growth analysis to determine whether older drivers' DBQ scores changed across time. Five hundred and sixty Canadian older drivers (males = 61.3%) from the Candrive/Ozcandrive longitudinal study completed the DBQ yearly for four years across five time-points that were approximately 12 months apart. In Year 1, the average age of the older drivers was 76.0 years (SD = 4.5 years; Range = 70-92 years). Findings from the study support the 21-item, three-factor DBQ structure suggested by Koppel and colleagues for an Australian sample of older drivers as being acceptable in an independent sample of Canadian older drivers. In addition, Canadian older drivers' responses to this version of the DBQ were stable across the five time-points. More specifically, there was very little change in older drivers' self-reported violations, and no significant change for self-reported errors or lapses. The findings from the current study add further support for this version of the DBQ as being a suitable tool for examining self-reported aberrant driving behaviours in older drivers. Future research should investigate the relationship between older drivers' self-reported aberrant driving behaviours and their performance on functional measures, their responses to other driving-related abilities and practice scales and/or questionnaires, as well their usual (or naturalistic) driving practices and/or performance on on-road driving tasks.

The combined effects of on-road and simulator training with feedback on older drivers' on-road performance: Evidence from a randomized controlled trial.

OBJECTIVE: A number of training programs that seek to improve driving performance among older drivers are available accompanied by a growing interest in their effectiveness. The purpose of the present investigation was to examine the combined effect of (1) basic in-class training (BT); (2) on-road training with individualized feedback (OR); and (3) training on a driving simulator (S). METHODS: Using a randomized controlled trial study design, 78 older drivers were randomly assigned to one of 3 groups (BT, BT + OR, or BT + OR + S). All participants completed a pre- and postintervention on-road driving evaluation on a standardized route. The driving evaluations were recorded using video and Global Positioning System (GPS) equipment and were scored by a blind assessor. RESULTS: The results indicated a significant reduction of approximately 30% in overall number of driving errors/omissions among participants in the BT + OR and the BT + OR + S groups in comparison to participants in the BT group. CONCLUSIONS: This study adds to the mounting evidence demonstrating the effectiveness of individualized driver training in improving safe driving among older adults.

Letting in-vehicle navigation lead the way: Older drivers' perceptions of and ability to follow a GPS navigation system.

In-vehicle navigation systems have the potential to simplify the driving task by reducing the drivers' need to engage in wayfinding, especially in unfamiliar environments. This study sought to characterize older drivers' overall assessment of using in-vehicle GPS technology as part of a research study and to explore whether the use of this technology has an impact on participants' driving behaviour. Forty-seven older drivers completed an on-road evaluation where directions were provided by an in-vehicle GPS navigation system and their behaviour was recorded using video technology. They later completed a questionnaire to assess their perception of the navigation system. After the study, participants were grouped based on whether they were able to accurately follow the instructions provided by the navigation system. The results indicated that most drivers were satisfied with the navigation technology and found the directions it provided to be clear. There were no statistically significant differences in the number of on-road errors committed by drivers who did not follow the directions from the navigation system in comparison to drivers who did follow the directions.

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.

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.

Comparing Cognitive Profiles of Licensed Drivers with Mild Alzheimer's Disease and Mild Dementia with Lewy Bodies.

Purpose. Alzheimer's disease (AD) and dementia with Lewy Bodies (DLB) constitute two of the most common forms of dementia in North America. Driving is a primary means of mobility among older adults and the risk of dementia increases with advanced age. The purpose of this paper is to describe the cognitive profile of licensed drivers with mild AD and mild DLB. Method. Licensed drivers with mild AD, mild DLB, and healthy controls completed neuropsychological tests measuring general cognition, attention, visuospatial/perception, language, and cognitive fluctuations. Results. The results showed differences between healthy controls and demented participants on almost all neuropsychological measures. Participants with early DLB were found to perform significantly worse on some measures of attention and visuospatial functioning in comparison with early AD. Discussion. Future research should examine the relationship between neuropsychological measures and driving outcomes among individuals with mild AD and mild DLB.

CIHR Candrive Cohort Comparison with Canadian Household Population Holding Valid Driver's Licenses.

We investigated whether convenience sampling is a suitable method to generate a sample of older drivers representative of the older-Canadian driver population. Using equivalence testing, we compared a large convenience sample of older drivers (Candrive II prospective cohort study) to a similarly aged population of older Canadian drivers. The Candrive sample consists of 928 community-dwelling older drivers from seven metropolitan areas of Canada. The population data was obtained from the Canadian Community Health Survey - Healthy Aging (CCHS-HA), which is a representative sample of older Canadians. The data for drivers aged 70 and older were extracted from the CCHS-HA database, for a total of 3,899 older Canadian drivers. Two samples were demonstrated as equivalent on socio-demographic, health, and driving variables that we compared, but not on driving frequency. We conclude that convenience sampling used in the Candrive study created a fairly representative sample of Canadian older drivers, with a few exceptions.

Deficits in Attention and Visual Processing but not Global Cognition Predict Simulated Driving Errors in Drivers Diagnosed With Mild Alzheimer's Disease.

This study sought to predict driving performance of drivers with Alzheimer's disease (AD) using measures of attention, visual processing, and global cognition. Simulated driving performance of individuals with mild AD (n = 20) was contrasted with performance of a group of healthy controls (n = 21). Performance on measures of global cognitive function and specific tests of attention and visual processing were examined in relation to simulated driving performance. Strong associations were observed between measures of attention, notably the Test of Everyday Attention (sustained attention; r = -.651, P = .002) and the Useful Field of View (r = .563, P = .010), and driving performance among drivers with mild AD. The Visual Object and Space Perception Test-object was significantly correlated with the occurrence of crashes (r = .652, P = .002). Tests of global cognition did not correlate with simulated driving outcomes. The results suggest that professionals exercise caution when extrapolating driving performance based on global cognitive indicators.

Assessment of Drivers with Alzheimer's Disease in High Demand Driving Situations: Coping with Intersections in a Driving Simulator.

Intersections are one of the most complex and cognitively demanding driving situations. Individuals with dementia and, more precisely, Alzheimer's disease (AD), may face additional challenges negotiating intersections given the nature of their cognitive decline, which often includes deficits of attention. We developed a comprehensive evaluation scheme to assess simulated driving performance at intersections. The evaluation scheme captured all types of errors that could occur during preparation (i.e., prior to the intersection), execution (i.e., during the intersection), and recovery (i.e., after the intersection). Using the evaluation scheme, intersection behaviour in a driving simulator among 17 drivers with mild AD was compared to that of 21 healthy controls. The results indicated that across all types of intersections, mild AD drivers exhibited a greater number of errors relative to controls. Drivers with mild AD made the most errors during the preparation period leading up to the intersection. These findings present a novel approach to analyzing intersection behaviour and contribute to the growing body of research on dementia and driving.

Driving Competence in Mild Dementia with Lewy Bodies: In Search of Cognitive Predictors Using Driving Simulation.

Driving is a multifactorial behaviour drawing on multiple cognitive, sensory, and physical systems. Dementia is a progressive and degenerative neurological condition that impacts the cognitive processes necessary for safe driving. While a number of studies have examined driving among individuals with Alzheimer's disease, less is known about the impact of Dementia with Lewy Bodies (DLB) on driving safety. The present study compared simulated driving performance of 15 older drivers with mild DLB with that of 21 neurologically healthy control drivers. DLB drivers showed poorer performance on all indicators of simulated driving including an increased number of collisions in the simulator and poorer composite indicators of overall driving performance. A measure of global cognitive function (i.e., the Mini Mental State Exam) was found to be related to the overall driving performance. In addition, measures of attention (i.e., Useful Field of View, UFOV) and space processing (Visual Object and Space Perception, VOSP, Test) correlated significantly with a rater's assessment of driving performance.

Crash avoidance in response to challenging driving events: The roles of age, serialization, and driving simulator platform.

We examined the crash avoidance behaviors of older and middle-aged drivers in reaction to six simulated challenging road events using two different driving simulator platforms. Thirty-five healthy adults aged 21-36 years old (M=28.9±3.96) and 35 healthy adults aged 65-83 years old (M=72.1±4.34) were tested using a mid-level simulator, and 27 adults aged 21-38 years old (M=28.6±6.63) and 27 healthy adults aged 65-83 years old (M=72.7±5.39) were tested on a low-cost desktop simulator. Participants completed a set of six challenging events varying in terms of the maneuvers required, avoiding space given, directional avoidance cues, and time pressure. Results indicated that older drivers showed higher crash risk when events required multiple synchronized reactions. In situations that required simultaneous use of steering and braking, older adults tended to crash significantly more frequently. As for middle-aged drivers, their crashes were attributable to faster driving speed. The same age-related driving patterns were observed across simulator platforms. Our findings support the hypothesis that older adults tend to react serially while engaging in cognitively challenging road maneuvers.

A brief peripheral motion contrast threshold test predicts older drivers' hazardous behaviors in simulated driving.

Our research group has previously demonstrated that the peripheral motion contrast threshold (PMCT) test predicts older drivers' self-report accident risk, as well as simulated driving performance. However, the PMCT is too lengthy to be a part of a battery of tests to assess fitness to drive. Therefore, we have developed a new version of this test, which takes under two minutes to administer. We assessed the motion contrast thresholds of 24 younger drivers (19-32) and 25 older drivers (65-83) with both the PMCT-10min and the PMCT-2min test and investigated if thresholds were associated with measures of simulated driving performance. Younger participants had significantly lower motion contrast thresholds than older participants and there were no significant correlations between younger participants' thresholds and any measures of driving performance. The PMCT-10min and the PMCT-2min thresholds of older drivers' predicted simulated crash risk, as well as the minimum distance of approach to all hazards. This suggests that our tests of motion processing can help predict the risk of collision or near collision in older drivers. Thresholds were also correlated with the total lane deviation time, suggesting a deficiency in processing of peripheral flow and delayed detection of adjacent cars. The PMCT-2min is an improved version of a previously validated test, and it has the potential to help assess older drivers' fitness to drive.