geriatrics
Functional Assessment of the Older Driver
Cognitive function
Changes in cognitive function with aging that may affect driving include Declines in aspects of cognition that impact working and/or semantic memory Slowed speed of processing Decreased basic and complex attention skills (eg, sustained and divided attention) Decreased executive function (eg, trip planning, working memory) Decreased visual processing and perceptual skills Medical conditions (including use of drugs needed to treat them) that can impact cognitive function include Psychologic factors (eg, anxiety, depression) Neurologic disorders (eg, stroke, Parkinson disease, mild cognitive impairment, Alzheimer disease and related dementias, traumatic brain injury, multiple sclerosis) Sleep disorders Cardiac disorders Diabetes The incidence of cognitive impairment increases in people ≥ 65. People with cognitive impairment often do not recognize their limitations, do not modify or restrict their driving, and are at higher risk of MVCs; risk increases with severity of impairment. Those with insight into their cognitive limitations often modify their driving to better accommodate their limitations (eg, driving in familiar areas, at less busy times of the day, and during daytime hours), resulting in safer driving. Although no one screening test has been found to completely and accurately predict driving safety, some are able to provide some level of predictability regarding the potential for impaired driving performance in older adults, can be done in the practitioner's office, and can be used to determine who may need to be referred to a driving rehabilitation specialist. Combinations of some of the following screening tests help improve prediction accuracy: The Freund Clock Drawing Test: This brief test is used to screen for visual perception, visuospatial skills, selective attention, semantic memory, and executive skills. Scores of 4 and under indicate potential concern related to driving. The Trail-Making Test: These tests are used to assess attention and visual scanning. Part A is easier and should always be given prior to part B. Part B is more challenging and assesses alternating attention and executive function. Drivers with an abnormal score on Part B (eg, > 180 seconds) may be candidates for more specialized testing by a driving rehabilitation specialist. The Mini-Mental State Examination: Examination of Mental Status is done to screen for cognitive impairments. However, this test has not been validated for use in determining driving privileges, and traffic safety experts do not agree whether it is a useful for this purpose. Maze tests: Various maze tests (eg, the Snellgrove Maze Test) require people to navigate through a maze printed on paper. These tests help assess visual search and executive skills. Montreal Cognitive Assessment (MoCA): This 30-item test is used to screen for mild cognitive impairment in older adults by testing attention, concentration, executive functions, memory, language, visuospatial skills, abstraction, calculation, and orientation. Low scores have been associated with increased risk of driving impairment. It should be noted that practitioners must be trained and certified to give the MoCA. Multi-model approaches that include a combination of screening tests are more useful in predicting driving performance in older adults with medical impairments, but none approaches 100% accuracy in prediction. Most of these multi-model screening tools (eg, probability calculator for dementia or stroke, 4 C’s) are easily administered in most office settings and provide an outcome score that is more predictive of risk of unsafe driving and need for Interventions With the Older Driver . Further information on multi-model approaches can be found in the American Geriatrics Society’s People with mild cognitive impairment may benefit from referral to occupational therapists or speech pathologists to help provide various interventions to improve function (eg, compensatory strategies). Additionally, referral may be indicated for neuropsychologic assessment to assist in determining underlying diagnoses and further recommendations. 