Developing the Driving and Dementia Roadmap: a knowledge-to-action process.

OBJECTIVES: Despite three decades of research, gaps remain in meeting the needs of people with dementia and their family/friend carers as they navigate the often-tumultuous process of driving cessation. This paper describes the process of using a knowledge-to-action (KTA) approach to develop an educational web-based resource (i.e. toolkit), called the Driving and Dementia Roadmap (DDR), aimed at addressing some of these gaps. DESIGN: Aligned with the KTA framework, knowledge creation and action cycle activities informed the development of the DDR. These activities included systematic reviews; meta-synthesis of qualitative studies; interviews and focus groups with key stakeholders; development of a Driving and Dementia Intervention Framework (DD-IF); and a review and curation of publicly available resources and tools. An Advisory Group comprised of people with dementia and family carers provided ongoing feedback on the DDR's content and design. RESULTS: The DDR is a multi-component online toolkit that contains separate portals for current and former drivers with dementia and their family/friend carers. Based on the DD-IF, various topics of driving cessation are presented to accommodate users' diverse stages and needs in their experiences of decision-making and transitioning to non-driving. CONCLUSION: Guided by the KTA framework that involved a systematic and iterative process of knowledge creation and translation, the resulting person-centered, individualized and flexible DDR can bring much-needed support to help people with dementia and their families maintain their mobility, community access, and social and emotional wellbeing during and post-driving cessation.

Variant of TYR and autoimmunity susceptibility loci in generalized vitiligo.

BACKGROUND: Generalized vitiligo is an autoimmune disease characterized by melanocyte loss, which results in patchy depigmentation of skin and hair, and is associated with an elevated risk of other autoimmune diseases. METHODS: To identify generalized vitiligo susceptibility loci, we conducted a genomewide association study. We genotyped 579,146 single-nucleotide polymorphisms (SNPs) in 1514 patients with generalized vitiligo who were of European-derived white (CEU) ancestry and compared the genotypes with publicly available control genotypes from 2813 CEU persons. We then tested 50 SNPs in two replication sets, one comprising 677 independent CEU patients and 1106 CEU controls and the other comprising 183 CEU simplex trios with generalized vitiligo and 332 CEU multiplex families. RESULTS: We detected significant associations between generalized vitiligo and SNPs at several loci previously associated with other autoimmune diseases. These included genes encoding major-histocompatibility-complex class I molecules (P=9.05x10(-23)) and class II molecules (P=4.50x10(-34)), PTPN22 (P=1.31x10(-7)), LPP (P=1.01x10(-11)), IL2RA (P=2.78x10(-9)), UBASH3A (P=1.26x10(-9)), and C1QTNF6 (P=2.21x10(-16)). We also detected associations between generalized vitiligo and SNPs in two additional immune-related loci, RERE (P=7.07x10(-15)) and GZMB (P=3.44x10(-8)), and in a locus containing TYR (P=1.60x10(-18)), encoding tyrosinase. CONCLUSIONS: We observed associations between generalized vitiligo and markers implicating multiple genes, some associated with other autoimmune diseases and one (TYR) that may mediate target-cell specificity and indicate a mutually exclusive relationship between susceptibility to vitiligo and susceptibility to melanoma.

Evaluating medically at-risk drivers: a survey of assessment practices in Canada.

BACKGROUND: Assessing medical fitness to drive (FTD) can include both off- and on-road testing, although consistency of practice is unclear. PURPOSE: To examine actual practices being used to assess FTD at driver assessment centres (DACs) across Canada. METHOD: Surveys e-mailed to 90 DACs were returned by 47 assessors. FINDINGS: The majority of respondents (89%) were occupational therapists. Assessors reported doing an average of eight FTD assessments per month (range = I to 40) at an average cost of $366 (SD = $225; range = $40 to $985). Referrals came from physicians (96%), other health professionals (70%), and licensing authorities (66%). Clients with stroke, dementia, traumatic brain injury, mild cognitive impairment, and multiple sclerosis composed 62% of estimated caseloads. Assessments took 3 hr on average (range = 1.24 to 4.5 hr); 64% reported they always took clients on road regardless of clinic results. IMPLICATIONS: Evidence-based guidelines for training and assessment are clearly needed given the inconsistency in practice.

Using Travel Diaries to Examine the Extent to Which Older Adult Centres Are a Focal Point for Recreation and Social Activities.

This study aimed to better understand the extent to which older adult centres are a focal point for recreation and social activities for their members. Travel diaries completed by 261 members of 12 older adult centres across Ontario provided comprehensive and real-time (24-hour) data over two consecutive weeks concerning time away from home, trip purposes, and modes of travel. The data showed that nearly one-third of their trips included a stop at their older adult centre. Three-quarters also went to other community venues over the study period, possibly to access amenities (e.g., pools) not available at their centre. Notwithstanding, their local older adult centre was still a focal point in out-of-home travel, particularly for potentially more vulnerable older adults, including those who were non-drivers, had less education, and felt lonelier. The diaries also substantiated the importance of time spent socializing with peers and staff at the centre, apart from formal program participation.

The Association between Psychological Resilience and Driving Behavior among Older Drivers in Australia.

This study compared a sample of Australian drivers aged 77 years and older to participants from an older driver longitudinal cohort study (Ozcandrive) and examined the relationship between resilience and self-reported driving measures within these samples. Using a survey with a subset of questions from Ozcandrive, data were collected from 237 older drivers throughout Australia. The two samples were analyzed for differences in demographics, health, resilience, and self-reported driving behavior. A series of multiple regression models were fit for each driving outcome measure for both samples. The two samples had both similarities and differences, with the largest difference observed for resilience. Strong and consistent associations were found between resilience and driving comfort, abilities, and frequency for the Australian sample. Across samples, resilience remained a significant variable in seven of 10 regression models, more than any other independent variable.

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.

Examining the contribution of psychological resilience on self-reported and naturalistic driving behavior of older adults.

INTRODUCTION: This study examined the contribution of psychological resilience on self-reported driving comfort, abilities, and restrictions, and on naturalistic driving (ND) behavior of older adults at two time points, five years apart (N = 111; Male: 65.8%, Mean age = 86.1 years). METHOD: Participants from the Ozcandrive older driver cohort study completed a demographic questionnaire, functional assessments, psychosocial driving questionnaires, and a resilience scale. Participants' vehicles were equipped with a recording device to monitor driving behavior throughout the study. Over 1.7 million kilometers of ND data were analyzed. RESULTS: There was a significant increase in resilience over time, and both self-reported and ND measures revealed reduced driving across five years. Hierarchical regression analyses using age, sex, driving exposure, functional measures, and resilience showed that adding resilience into the models at the final step resulted in statistically significant increases in the amount of variance explained for driving comfort during the day and night, perceived driving abilities, number of trips, trip distance, and proportion of night trips. CONCLUSIONS: This research leveraged the longitudinal nature of the Ozcandrive study to provide the first insights into the role of resilience and ND. The observed patterns of reduced driving, captured by both subjective and objective measures, are suggestive of increased levels of self-regulation. As resilience is associated with adaptive coping skills, older adults with higher resilience may be able to more effectively engage in appropriate coping behaviors with regard to driving behavior, safety, and mobility. PRACTICAL APPLICATIONS: Effective methods of increasing resilience in the context of driving is worthy of future research as it will provide valuable information about how older drivers navigate the process of aging as it relates to driving and may assist stakeholders in developing suitable measures to support older driver safety.

Personal and Clinical Factors Associated with Older Drivers' Self-Awareness of Driving Performance.

Most older adults perceive themselves as good drivers; however, their perception may not be accurate, and could negatively affect their driving safety. This study examined the accuracy of older drivers' self-awareness of driving ability in their everyday driving environment by determining the concordance between the perceived (assessed by the Perceived Driving Ability [PDA] questionnaire) and actual (assessed by electronic Driving Observation Schedule [eDOS]) driving performance. One hundred and eight older drivers (male: 67.6%; age: mean = 80.6 years, standard deviation [SD] = 4.9 years) who participated in the study were classified into three groups: underestimation (19%), accurate estimation (29%), and overestimation (53%). Using the demographic and clinical functioning information collected in the Candrive annual assessments, an ordinal regression showed that two factors were related to the accuracy of self-awareness: older drivers with better visuo-motor processing speed measured by the Trail Making Test (TMT)-A and fewer self-reported comorbid conditions tended to overestimate their driving ability, and vice versa.

Changes in older drivers' self-awareness of driving ability over one year.

Older drivers' self-awareness of driving ability can prompt self-regulatory behaviors and modifications of their everyday driving performance. To date, studies have yet to examine how older drivers' self-awareness of changes in driving ability over time or identify the characteristics of those who can accurately monitor such changes. 64 older drivers (Age: Mean = 80.0 years, SD = 5.4; male: 70 %) were recruited and categorized into four groups based on the correspondence of changes in their perceived and actual driving ability over one year: 40 % of the participants were accurate in their stable or better driving ability over time, 30 % did not detect their driving performance had worsened and over-estimated their driving ability, and the remainder either accurately detected their performance had worsened or under-estimated their driving performance. No demographic or clinical factors were associated with older drivers' self-awareness of changes in driving ability over time, except the mental processing and executive functioning measured using the Trail Making Tests Part B, showed a marginal effect. Implications for clinical importance are discussed.

Speeding and Speed Modification of Older Drivers: Does Vehicle Type Make a Difference?

The purpose of this study was to examine whether vehicle type based on size (car vs. other = truck/van/SUV) had an impact on the speeding, acceleration, and braking patterns of older male and female drivers (70 years and older) from a Canadian longitudinal study. The primary hypothesis was that older adults driving larger vehicles (e.g., trucks, SUVs, or vans) would be more likely to speed than those driving cars. Participants (n = 493) had a device installed in their vehicles that recorded their everyday driving. The findings suggest that the type of vehicle driven had little or no impact on per cent of time speeding or on the braking and accelerating patterns of older drivers. Given that the propensity for exceeding the speed limit was high among these older drivers, regardless of vehicle type, future research should examine what effect this behaviour has on older-driver road safety.

Transportation and Aging: An Updated Research Agenda to Advance Safe Mobility among Older Adults Transitioning From Driving to Non-driving.

Engagement in civic, social, and community life plays an important role in health, well-being, and quality of life, and requires individuals to be mobile in their environment. In this article, we review what is currently known about 2 areas relevant to safe mobility for older drivers and identify future research in these areas. Using a framework for transportation and safe mobility, 2 key areas were selected for review: the process of transitioning to non-driving and the maintenance of mobility after driving has ceased. This article serves as a companion to another article that used the same approach to explore safe mobility issues for older adults who are still driving. We found that although there has been progress in supporting transitioning process to non-driving and improving mobility options for older adults following driving cessation, many knowledge gaps still exist. We identified several research topics that would benefit from continued scientific inquiry. In addition, several themes emerged from the review, including the need for: multidisciplinary, community-wide solutions; large-scale, longitudinal studies; improved education and training for older adults and the variety of stakeholders involved in older adult transportation; and the need for programs and interventions that are flexible and responsive to individual needs and situational differences.

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.

Conceptualizing and measuring confidence in older drivers: development of the day and night driving comfort scales.

OBJECTIVE: To examine and measure driving confidence from the perspective of older adults. DESIGN: Used focus groups for construct examination, item generation, and ratings; conducted psychometric testing using Rasch analysis for scale refinement; examined test-retest reliability and associations with driver characteristics and driving habits. SETTING: Retirement complexes and seniors' housing and centers in Ontario, Canada. PARTICIPANTS: Convenience samples of current drivers (n=143) (range, 66-92y) and 7 counselors. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Day (DCS-D) and Night (DCS-N) Driving Comfort Scales developed inductively with older drivers. RESULTS: Older drivers believed that it was important to consider confidence in their own abilities and discomfort caused by other drivers, to separate day and night driving, and to specify the driving context (eg, traffic flow, speed). Rasch analysis showed that the final 13-item DCS-D and 16-item DCS-N were both hierarchic and unidimensional, with good person (.89, .96) and item (.98, .97) reliabilities, respectively. Test-retest reliability was adequate for the DCS-D (intraclass correlation coefficient [ICC]=.7) and good for the DCS-N (ICC=.88). Scores were significantly associated with reported driving frequency, situational avoidance, and perceived abilities (P<.001). CONCLUSIONS: The Driving Comfort Scales are promising new tools for research and practice.

Implementation, process, and preliminary outcome evaluation of two community programs for persons with stroke and their care partners.

PURPOSE: This evaluation compared a new self-management program with land and water exercise (Moving On after STroke or MOST) to a standard education program (Living with Stroke or LWS). PARTICIPANTS: Of 30 persons with stroke (average age 68 and 2 years post stroke), 18 selected MOST and 12 chose LWS. Sixteen care partners participated. METHOD: Assessments at baseline, program completion, and 3-month follow-up included the Reintegration to Normal Living (RNL) Index, Activity-specific Balance Confidence (ABC) scale, exercise participation, and goal attainment (for the MOST group). Program delivery costs were calculated and focus groups conducted to examine participant expectations and experiences. RESULTS: Social support was an important benefit of both programs, but only MOST participants improved significantly on the RNL (p < .05) and ABC (p < .001). Seventy-eight percent of all short-term personal goals in MOST were achieved, and overall goal attainment was above the expected level. At follow-up, a higher percentage of MOST participants were enrolled in exercise programs (p < .05). CONCLUSION: Although self-management programs with exercise are more costly to deliver than standard educational programs, these preliminary results indicate that such programs may be more effective in helping persons with stroke and care partners deal with the challenges of living with stroke.

Development and Evaluation of Let's Do Lunch: A Congregate Meal Program at an Urban Senior Center.

A mixed-methods needs assessment was conducted in an urban senior center serving lower-income seniors in Toronto, Ontario, to determine whether they should offer a congregate meal program. Methods included three focus groups with participants (n = 31), a focus group with staff (n = 8), a center-wide survey (n = 36), and a community scan of programs in the area. Interviews with five coordinators at other seniors' centers who offered meal programs were also used to gauge interest and assist with program development. The results of these activities supported offering a twice weekly lunch program with user fees. Over a 6-month pilot period, process evaluation was conducted, comprising observations, record review, and focus groups with participants (n = 9) and staff/volunteers (n = 7) to examine delivery, usage, and costs. Results indicated that the program was well-received and affordable, and that demands on staff were reasonable when a facilitator with culinary training was available. The lessons learned can be used to guide other senior centers in developing and evaluating congregate meal programs.

Changes in Physical Activity and Function with Transition to Retirement Living: A Pilot Study.

This pilot study examined changes in physical activity and function among older adults moving from community dwellings to retirement living. Twelve community-dwelling older adults, recruited from the wait-lists of two retirement living facilities, were assessed prior to and following the transition to retirement living. Physical activity was assessed using an Actigraph (GT3X+) activity monitor; physical activity by type was reported with the CHAMPS activity questionnaire. Physical function was assessed using the Senior Fitness Test. Objectively monitored total physical activity decreased after the transition to retirement living (p = 0.02). Reports of physical activity by type indicated that only activities of daily living decreased (p < 0.01) although intentional exercise increased (p < 0.03) with the transition. Endurance and strength also improved (p < 0.05 and p < 0.04). Pilot results indicate that possible physical benefits accrue from retirement living, although efforts to reduce sedentary time are needed.

Attitudes: Mediators of the Relation between Health and Driving in Older Adults.

We examined the relations between perceived health (e.g., self-perceived health status) and driving self-regulatory practices (e.g., frequency of driving, avoiding challenging driving situations) as mediated by driving attitudes and perceptions (i.e., driving comfort, positive and negative attitudes towards driving) in data collected for 928 drivers aged 70 and older enrolled in the Candrive II study. We observed that specific attitudes towards driving (e.g., driving comfort, negative attitudes towards driving) mediate the relations between health symptoms and self-regulatory driving behaviours at baseline and over time. Only negative attitudes towards driving fully mediated the relationships between changes in perceived health symptoms and changes in driving behavior. Perceived health symptoms apparently influence the likelihood of avoiding challenging driving situations through both initial negative attitudes towards driving as well as changes in negative attitudes over time. Understanding influences on self-regulatory driving behaviours will be of benefit when designing interventions to enhance the safety of older drivers.

Driving Task: How Older Drivers' On-Road Driving Performance Relates to Abilities, Perceptions, and Restrictions.

This study examined a cohort of 227 older drivers and investigated the relationship between performance on the electronic Driver Observation Schedule (eDOS) driving task and: (1) driver characteristics; (2) functional abilities; (3) perceptions of driving comfort and abilities; and (4) self-reported driving restrictions. Participants (male: 70%; age: M = 81.53 years, SD = 3.37 years) completed a series of functional ability measures and scales on perceived driving comfort, abilities, and driving restrictions from the Year 2 Candrive/Ozcandrive assessment protocol, along with an eDOS driving task. Observations of participants' driving behaviours during the driving task were recorded for intersection negotiation, lane-changing, merging, low-speed maneuvers, and maneuver-free driving. eDOS driving task scores were high (M = 94.74; SD = 5.70) and significantly related to participants' perceived driving abilities, reported frequency of driving in challenging situations, and number of driving restrictions. Future analyses will explore potential changes in driving task scores over time.

Psychosocial Constructs as Possible Moderators of Self-Reported Driving Restrictions.

To date, associations between psychosocial driving variables and behaviour have been examined only cross-sectionally. Using three waves of data collected annually from 928 older drivers (mean age = 76.21 years; 62% male) enrolled in the Candrive II cohort, we examined in this study whether changes in attitudes and perceptions towards driving (decisional balance and day and night driving comfort) were associated with changes in older adults' reported restrictions in driving practices and perceived driving abilities. Multi-level models revealed that older adults who showed an increase in negative attitudes towards driving over time were more likely to report more-restricted practices (greater avoidance of challenging driving situations) and perceived declines in driving abilities compared to individuals whose attitudes towards driving remained stable across two years. This work supports previous findings and offers a new understanding of how attitudes relate to driving perceptions (e.g., comfort) and self-regulation in older adults over time.

Cognitive Performance, Driving Behavior, and Attitudes over Time in Older Adults.

We hypothesized that changes over time in cognitive performance are associated with changes in driver perceptions, attitudes, and self-regulatory behaviors among older adults. Healthy older adults (n = 928) underwent cognitive assessments at baseline with two subsequent annual follow-ups, and completed scales regarding their perceptions, attitudes, and driving behaviours. Multivariate analysis showed small but statistically significant relationships between the cognitive tests and self-report measures, with the largest magnitudes between scores on the Trails B cognitive task (seconds), perceptions of driving abilities (ß = -0.32), and situational driving avoidance (ß = 0.55) (p < 0.05). Cognitive slowing and executive dysfunction appear to be associated with modestly lower perceived driving abilities and more avoidance of driving situations over time in this exploratory analysis.