Alexander M. Crizzle

Parkinson disease and driving An evidence-based review

ABSTRACT The growing literature on driving in Parkinson disease (PD) has shown that driving is impaired in PD compared to healthy comparison drivers. PD is a complex neurodegenerative disorder leading to motor, cognitive, and visual impairments, all of which can affect fitness to drive. In this review, we examined studies of driving performance (on-road tests and simulators) in PD for outcome measures and their predictors. We searched through various databases and found 25 (of 99) primary studies, all published in English. Using the American Academy of Neurology criteria, a study class of evidence was assigned (I–IV, I indicating the highest level of evidence) and recommendations were made (Level A: predictive or not; B: probably predictive or not; C: possibly predictive or not; U: no recommendations). From available Class II and III studies, we identified various cognitive, visual, and motor measures that met different levels of evidence (usually Level B or C) with respect to predicting on-road and simulated driving performance. Class I studies reporting Level A recommendations for definitive predictors of driving performance in drivers with PD are needed by policy makers and clinicians to develop evidence-based guidelines.

Naturalistic Study of Winter Driving Practices by Older Men and Women: Examination of Weather, Road Conditions, Trip Purposes, and Comfort

La plupart des études sur les pratiques de conduite des aînés sont basées sur des données d’autoévaluation ; aucune n’a examiné objectivement leurs habitudes de conduite hivernale. Nous avons utilisé des appareils électroniques associés à des journaux de voyages, des cartes numériques et des archives météorologiques, afin d’examinerétudier les modes de conduite des personnes âgées de 65 à 91 sur deux semaines consécutives entre novembre 2008 et mars 2009. La conduite de nuit différait selon le mois, montrant l’importance des facteurs saisonniers, en particulier la quantité de lumière du jour. Bien que 69 pour cent de notre échantillon ait conduit les jours de mauvais temps, les aînés ont montré être significativement plus susceptibles de faire des voyages à des fins sociales ou de divertissement les jours de beau temps, et ils ont entrepris des voyages plus longs les jours offrant de bonnes conditions routières. Les scores de confort de conduite, notamment pour la conduite de nuit, étaient liés de manière significative aux indicateurs multiples de l’exposition et des habitudes, y compris au rayon autour du domicile. Comparativement aux hommes, les femmes ont obtenu des scores de conduite significativement plus bas, et ont été moins susceptibles de conduire quand les conditions metéorologiques et routières étaient défavorables. Most studies on seniors’ driving practices are based on self-reports; none have objectively examined winter driving patterns. We used electronic devices, together with trip logs, digital maps, and weather archives, to examine the driving patterns of seniors aged 65 to 91 over two consecutive weeks between November 2008 and March 2009. Night driving differed by month showing the importance of seasonal factors, particularly the amount of daylight. Although 69 per cent of the sample drove on days with adverse conditions, seniors were significantly more likely to make trips for social/entertainment purposes on days with good weather, and out-of-town trips on days with good road conditions. Driving comfort scores, particularly for night driving, were significantly related to multiple indicators of exposure and patterns, including radius from home. Compared to men, women had significantly lower driving comfort scores and were less likely to drive on days with adverse weather and road conditions.

Evidence-based review on epilepsy and driving.

OBJECTIVE The aim of this study was to synopsize the evidence on predictors of crashes and driving status in people with epilepsy (PWE). METHODS Evidence-based review of the published English literature was the method used. We searched various databases and extracted data from 16 (of 77) primary studies. On the basis of American Academy of Neurology criteria, we assigned each study a class of evidence (I-IV, where I indicates the highest level of evidence) and made recommendations (Level A: predictive or not; Level B: probably predictive or not; Level C: possibly predictive or not; Level U: no recommendations). RESULTS For PWE, the following characteristics are considered useful: For identifying crash risk, epilepsy (level B) and short seizure-free intervals (≥3 months) (Level C) are not predictive of motor vehicle crash (MVC). For self/proxy-reported crash risk, epilepsy surgery (Level B), seizure-free intervals (6-12 months) (Level B), few prior non-seizure-related crashes (Level B), and regular antiepileptic drug adjustments (Level B) are protective against crashes; seizures contribute to MVCs (Level C); mandatory reporting does not contribute to reduced crashes (Level C). No recommendations for reliable auras, age, and gender (Level U), as data are inadequate to make determinations. For self-reported driving or licensure status, employment and epilepsy surgery are predictive of driving (Level C); there are no recommendations for antiepileptic drug use, self-reported driving, gender, age, receiving employment benefits, or having reduced seizure frequency (Level U). CONCLUSION Limitations, that is, heterogeneity among studies, examining the English literature from 1994 to 2010, must be considered. Yet, this is the first evidence-based review to synopsize the current PWE and driving literature and to provide recommendation(s) to clinicians and policy makers. Class I studies, matched for age and gender, yielding Level A recommendations are urgently needed to define the risks, benefits, and causal factors underlying driving performance issues in PWE.

Predicting older driver on-road performance by means of the useful field of view and trail making test part B

The Useful Field of View(®) (UFOV) and Trail Making Test Part B (Trails B) are measures of divided attention. We determined which measure was more accurate in predicting on-road outcomes among drivers (N = 198, mean age = 73.86, standard deviation = 6.05). Receiver operating characteristic curves for the UFOV (Risk Index [RI] and Subtests 1-3) and Trails B significantly predicted on-road outcomes. Contrasting Trails B with the UFOV RI and subtests, the only difference was found between the UFOV RI and Trails B, indicating the UFOV RI was the best predictor of on-road outcomes. Misclassifications of drivers totaled 28 for the UFOV RI, 62 for Trails B, and 58 for UFOV Subtest 2. The UFOV RI is a superior test in predicting on-road outcomes, but the Trails B has acceptable accuracy and is comparable to the other UFOV subtests.

The relationship between cognitive performance, perceptions of driving comfort and abilities, and self-reported driving restrictions among healthy older drivers

The objective of the present study was to examine the relationship between cognitive performance, driver perceptions and self-reported driving restrictions. A cross-sectional analysis was conducted on baseline data from Candrive II, a five-year prospective cohort study of 928 older drivers aged 70-94 years from seven cities. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) as well as the Trail Making Test, parts A and B. Driver perceptions were assessed using the Day and Night Driving Comfort Scales and the Perceived Driving Abilities scale, while driving practices were captured by the Situational Driving Frequency and Avoidance scales, as well as the Driving Habits and Intentions Questionnaire. The baseline data indicates this cohort is largely a cognitively intact group. Univariate regression analysis showed that longer Trails A and B completion times were significantly, but only modestly associated with reduced driving frequency and perceived driving abilities and comfort, as well as a significant tendency to avoid more difficult driving situations (all p<.05). Most of these associations persisted after adjusting for age and sex, as well as indicators of health, vision, mood and physical functioning. Exceptions were Trails A and B completion times and situational driving frequency, as well as time to complete Trails B and current driving restrictions. After adjusting for the confounding factors, the total MoCA score was not associated with any of the driving measure scores while the number of errors on Trails A was significantly associated only with situational driving frequency and number of errors on Trails B was significantly associated only with situational driving avoidance. Prospective follow-up will permit examination of whether baseline cognition or changes in cognition are associated with changes in driver perceptions, actual driving restrictions and on-road driving outcomes (e.g., crashes, violations) over time.

MMSE as a predictor of on-road driving performance in community dwelling older drivers.

Screening tools such as the MMSE have been used extensively in driving research studies to determine mild cognitive impairment or dementia. While some studies have shown the MMSE to correlate with driving performance, few studies have shown the predictive validity of the MMSE in determining on-road performance. In a sample of 168 community dwelling older adults, including 20 with Parkinsons disease (PD), the primary objective was to determine the validity of the MMSE to predict pass/fail outcomes of an on-road driving test using receiver operating characteristics curves. The area under the curve (AUC), an index of discriminability, for the total sample was .654, 95% CI=0.536-0.772, p=.009. Meanwhile, the AUC for the PD group was 0.791, 95% CI=0.587-0.996, p=.036. The total sample showed statistically significant yet poor predictive validity. However, the PD group showed statistically significant and good predictive validity of the MMSE to predict pass/fail outcomes on the road test, but caution is warranted as the confidence intervals are wide (due to small sample) and the positive and negative predictive values are less than desirable due to the associated error. The findings show that using the current cut-off point of ≤24 on the MMSE is not adequately sensitive to predict on-road performance in both community dwelling older drivers and in drivers with PD. This study offers strong evidence to support the current best practice of not using the MMSE in isolation to predict on-road performance.

Self-regulatory practices of drivers with Parkinson's disease: Accuracy of patient reports

BACKGROUND Studies suggest that drivers with Parkinsons disease (PD) are more likely than controls to restrict their exposure and avoid challenging situations possibly to compensate for declining abilities; however it is questionable whether patient reports should be taken at face value. To address this issue, this study examined agreement between self-reported and actual driving practices in drivers with and without PD. METHODS Two electronic devices (one with GPS) were installed in the vehicles of 26 drivers with PD (mean age 71.5 ± 6.8, 77% men) and 20 controls (mean age 70.6 ± 7.9, 80% men) for two weeks. Participants completed a questionnaire on usual driving patterns, scales on Situational Driving Frequency (SDF) and Avoidance (SDA), the MoCA and an interview. RESULTS Self-estimates of distance driven (km) over the two weeks were inaccurate in both groups; however the tendency to under-estimate was more pronounced in PD drivers. Drivers with PD reported more self-restrictions (higher SDA scores, p < .01; lower SDF scores, p < .05), yet drove more at night, in bad weather, in rush hour and on highways than they reported. Drivers with PD had significantly lower MoCA scores overall (p < .01) and on the memory subtest (p < .05), however, MoCA scores were not correlated with self-reported restrictions, or actual driving distance in either group. CONCLUSIONS These findings indicate that patient reports of driving behavior should not be taken at face value by researchers or clinicians. Patients with PD may be more likely than drivers in general to have problems with recall and possibly less awareness of their driving practices.

Gender differences among older drivers in a comprehensive driving evaluation

Research studies typically consider older drivers as a homogenous group and do not report on the influence of gender on driving performance. Prior studies report that females are over-represented in crashes compared to males, caused by errors of yielding, gap acceptance, and speed regulation, all of which are assessed in a comprehensive driving evaluation (CDE). In a sample of 294 community dwelling older drivers, we examined and compared specific and total driving errors of both genders, and determined predictors of gender-specific driving errors and pass/fail outcomes who completed a CDE assessed by a certified driving rehabilitation specialist. No differences in specific or total number of driving errors on the CDE were found between older males (Mean age 73.4±6.0) and older females (Mean age 73.8±5.7). Education, days of driving, Useful Field of View™ (UFOV), Rapid Paced Walk Test (RPW) and the Mini-Mental State Exam (MMSE) were all independent predictors of failing a road test for both genders (p<0.05). However, older females were 22% less likely than older males to fail an on-road test. Within group comparisons showed that older males and females >75 years were 3.2 and 3.5 times more likely to fail the on-road test compared to younger males and females (aged between 63 and 75), respectively. Our findings suggest that focusing on older old (75+) and old-old (85+) age groups may be more efficient for future investigations of driving performance.

Examination of naturalistic driving practices in drivers with Parkinson's disease compared to age and gender-matched controls

A few studies suggest that drivers with Parkinsons disease (PD) may self-regulate or modify their driving behavior more than drivers without neurological disorders; however findings are limited to self-report. The purpose of this study was to objectively examine whether drivers with PD show more restrictive driving practices (exposure and patterns). Electronic devices were installed in the vehicles of 27 drivers with PD (71.6±6.6; 78% men) and 20 matched controls (70.6±7.9; 80% men) for two weeks and driving data were matched with aerial maps, weather and daylight archives and trip logs to examine driving context. Compared to controls, the PD group drove significantly less overall (number of trips, kilometres, duration), and proportionately less at night and on days with bad weather suggesting more restricted driving practices, congruent with lower ratings of driving comfort and abilities. However, they may not necessarily drive more cautiously or safely as they drove significantly faster (and over the speed limit) on highways and freeways and 19% reported driving problems over the two weeks. These preliminary findings need to be replicated and longitudinal studies using objective indicators are needed to examine changes in driving practices, as well as crash outcomes, as disease severity progresses.

Themes Associated With Exercise Adherence in Persons With Parkinson's Disease: A Qualitative Study

ABSTRACT The purpose of this study was to examine motivators important to exercise adherence in a group of older adults with Parkinsons disease (PD). Four participants with PD completed a 6-week hydrotherapy program, followed by participation in a focus group along with their caregivers (n = 4) to examine motivators that were important to exercise adherence. A semi-structured focus group was transcribed verbatim and analyzed using content analysis to identify common patterns and themes. Multiple themes were found that were important to exercise adherence. Constant reassurance and support from the exercise leader was a primary theme for remaining enrolled in an exercise program. Exercising in a group environment and social interaction with other persons with PD were also the themes. Perceived changes in physical ability increased participants’ confidence and motivation to continue to exercise. The findings suggest that the perceived needs of PD exercise participants can be influenced and addressed by exercise leaders, provide opportunities to improve physical function, and support social interaction. Future exercise programs should be designed to provide a venue where the symptoms of PD are not a deterrent to exercise participation.