Driving Problems in the Elderly and Cognitively Impaired

• Abstract
• Introduction
• Aging and Driving
• Pathophysiology of Age-Related Driving Impairment
• Driving and Pharmacotherapy
• Driving in the Cognitively Impaired
• Driving Assessment in the Elderly
• References

Abstract

Driving ability in the elderly and cognitively impaired is of growing demographic relevance. Driving represents a complex task for which multiple central resources are needed. In mild cognitive impairment and dementia, we need to closely monitor driving ability, as it gets irrecoverably lost in the course of the disease. In normal aging, people are often able to self-regulate driving behavior with respect to their medical conditions. Some studies demonstrated that older drivers perform well compared with younger drivers. Others suggest a decline of driving ability in the process of normal aging and an increasing involvement of older drivers in car crashes. However, these findings have been questioned because of several possible biases. Therefore, unnecessary driving restrictions need to be avoided. The reliable evaluation of driving ability requires a specialist assessment with detailed neurocognitive evaluation, investigation of medical history and medical history by proxy, as well as on-the-the-road tests. Highlighting current knowledge in this field, we would like to increase our readers’ awareness for the complexity of driving-associated challenges in an aging population.

Introduction

In an aging society there is increasing awareness of or even concern about potential or presumed challenges that elderly people may have as motor vehicle drivers and whether or not they may be susceptible to involvement in traffic accidents. Besides accumulating physical changes within the process of normal aging, age-related cognitive decline and cognitive disorders are believed to significantly affect driving skills. When we also appreciate the high value of elderly people’s mobility, it becomes obvious that changes of driving ability need to be evaluated with clarity and sensitivity. Aspects of road safety and individual autonomy have to be weighted responsibly and in-depth. Since physicians have access to information about their patients’ somatic comorbidities and cognitive impairments, the evaluation of driving ability is a medical obligation. The assessment of cognitive dysfunction possibly underlying age-related driving impairment requires an evaluation by a specialist, for example, in a memory clinic. Frequently used neuropsychological tests, such as the CERAD-Plus (Consortium to Establish a Registry for Alzheimer’s Disease), are not designed to provide information on reaction time or complex attention performance and, thus, are not sufficient for the evaluation of driving ability. Clinicians need to be aware that neuropsychological tests alone do not provide valid information regarding driving impairment. For this reason, a specific driving assessment is necessary to complement cognitive assessments when evaluating driving capability. Furthermore, there are opportunities to improve driving capabilities through training programs. This article focuses on how normal aging and cognitive decline affect driving ability. We discuss the underlying pathophysiology as well as the responsibilities of physicians and their patients.

Aging and Driving

Driving represents a complex task during which the information from multiple sources needs to be processed. For example, information about other drivers, traffic lights, road signs, and car-specific and individual factors must be integrated, which poses an enormous challenge, especially to older drivers [1] [2]. For younger people, driving is a highly automated process, but older drivers have to recruit additional cognitive resources due to the decreasing reliability of sensorimotor systems, which is known as “deautomation” [3]. Older drivers often use self-regulation strategies. They may avoid rush hour, driving at night and driving in unfamiliar areas. However, such self-restricting behaviors seem to be associated with a higher risk for driving accidents, as they might indicate poorer health [4] [5]. For older people, driving is of high relevance with regard to mobility, social activities, and independence [4]. Although road traffic safety must always be given top priority, against that background, unnecessary driving restrictions to capable older drivers have to be avoided. A recent study investigating driving ability in almost 400 people over the age of 60 demonstrated that age, male sex, self-restrictions of driving, and the use of larger amounts of prescription drugs were predictors of high-risk status for age-related driving problems [6].

Physiological aging does not necessarily have a negative impact on driving skills per se, but since cognitive decline and somatic and sensory deficits accumulate with age, older drivers are at risk for car crashes [4] [7]. The risk of car accidents (specifically the relative risk, which is the number of accidents per driven distance) seems to increase with age, whereas especially low-mileage older drivers are at greater crash risk [4] [8] [9] [10]. However, these data may underlie a so-called low mileage bias, which refers to the association between the extent of driving exposure and crash involvement within each age group [10] [11]. Older and middle-aged drivers significantly differ in driving exposure, and age-independent low driving exposure is associated with more accidents [11]. In research studies, older drivers are typically compared with middle-aged drivers, which may lead to an overestimation of crash risks in the elderly [11]. When controlling for driving exposure, older and younger drivers with equivalent annual driving distances do not differ in crash rates per distance driven [10]. Furthermore, older drivers more often drive in inner cities where the crash risk is highest in all age groups. Additionally, due to general frailty in older age, injuries caused by car accidents are more severe, which potentially balloons the existing impact of age-related changes of driving capability [11]. Recent studies suggest that most older drivers responsibly evaluate their driving capabilities and stop driving in case of health care utilization, use of relevant medication and specific medical conditions [12] [13]. It could be demonstrated that older adults are willing to use, if available, alternative transportation possibilities. This has been predominantly described in older women [12]. In contrast to elderly drivers below age 70, the number of older drivers decreases with higher comorbidity levels, which underlines the ability of self-regulation [14]. These data illustrate that drivers below age 70 are more likely to continue driving despite of higher comorbidity rates, whereas standardized comorbidity indices predict vehicle crash involvement in these drivers independent of gender and driving exposure [14]. This shows that the accurate self-monitoring of relevant driving-related impairments represents a sine qua non requirement in self-regulation strategies [7].

With respect to cognitive function in the elderly, there is a great inter-individual variability, especially in executive functioning skills and attention, which sometimes complicates the differentiation between normal and pathological aging [4]. Recent data illustrate that reaction time, error rates, and no-response rates in driving-related tasks increase with normal aging and increasing difficulty of task conditions [1] [15]. In studies that utilize on-the-road tests of situations with low or average cognitive load, older drivers perform as well as younger drivers [11] [16]. It is noteworthy that approximately 25% of older drivers perform equally well or even better than younger drivers [15].

Drivers of different age groups show different types of accidents. Whereas younger drivers are more often involved in “violation crashes” caused by violation of rules, older drivers are more likely to cause “errors crashes” resulting from mistakes—for example, overlooking red traffic lights or misjudging distances [3] [11]. Car crashes in the elderly typically occur due to complex situations under time pressure (e. g., at intersections or left turns in inner cities) [3]. Considering crash-involved elderly people, there are 2 different types of drivers: (a) comparatively older, cognitively impaired drivers with high rates of comorbidity and medication and (b) comparatively younger drivers with risky driving patterns [3].

Illness-related factors impairing driving skills are studied quite well whereas non-illness-related factors potentially influencing older drivers’ safety have not been studied that intensely [11]. A literature review by Nef et al. identified relevant non-illness-related factors as possible pro-safety intervention targets in older drivers [11]. They found that older drivers benefit from a simpler road and, especially, simpler intersection design, easily decipherable road signs, and street lighting. Additionally the authors highlight that avoidance of in-vehicle systems can improve safety of older drivers as they reduce required coordination performance. Considering driver-related factors, they illustrated that a better traffic-related knowledge is associated with fewer car crashes. Furthermore, they described the improvement of self-awareness via post-licensing training and education aimed at improving compensation strategies as well as avoiding complex traffic situations and extreme weather conditions as potential strategies to improve the safety of older drivers [11].

Pathophysiology of Age-Related Driving Impairment

Changes in driving performance develop progressively throughout adult years, leading to increased reaction times and a decreasing capability to adapt to complex situations [15]. The active participation in road traffic requires multiple and complex skills that might be best summarized as cognitive, motor, visual, and sensory functions [4] [7]. The most relevant cognitive functions being essential for driving can be described as visual information selection, visual perception, and executive functions as well as episodic, semantic, and procedural memory [4] [7] [17] [18]. Correct visual information selection includes visual attention in terms of selecting visual stimuli and their correct spatial location (e. g., for identifying roadside targets) [4] [17] [18], but skills like divided or sustained attention are also included here. Besides intact visual attention, visual perception is crucial to interpret visual information in a correct way while driving [4] [17] [18]. Since active participation in road traffic also poses unpredictable challenges, executive functions, defined as planning, adapting to new situations, and anticipating, also belong to the driving requirement profile [4] [17] [18]. Additionally, the registration, acquisition, and encoding of information is facilitated by an intact episodic memory [4] [17] [18]. Prospective memory including the ability to process future intentions at the right time also mediates cognitive functions like information selection and inhibition as well as action control, which are essential for driving ability [19]. Within physiological aging there is little impairment of semantic and procedural memory, but in demented drivers, deficits in these domains can additionally affect driving capabilities.

Aging affects various cognitive domains [4]. The inter-individual variation in cognitive functioning increases with age. Specific domains like speed of processing, attention, and executive performance show greater variability whereby others are relatively preserved [4]. The reasons for increasing inter-individual variability in older age are related to mild sensory impairment and differences in education [4].

Cognitive and functional impairments including visual and physical disability, as well as polypharmacy, contribute to poorer driving performances in the elderly [3] [14] [20] [21] [22] [23]. In 20% of the cases, morbidity is the major cause of accidents [3]. Since the prevalence of eye diseases increases in an aging population, the evaluation of driving skills needs to include visual functions [7]. Cataract, glaucoma, and age-related maculopathy are the most frequent ophthalmologic diseases in the elderly [7]. Conditions affecting vision acuity, contrast, and darkness vision as well as visual field constrictions are of high relevance for driving safety [7]. Furthermore, the mobility of the cervical spine is essential for looking over the shoulder when turning or overtaking. Most drivers older than 75 years are not able look over their shoulders due to a limited flexibility of the cervical spine [3]. Regarding motor function and driving-related impairment, new data suggest that impaired motor control instead of motor strength essentially mediates deficits in reactive driving—for example, reacting to unexpected brake lights of the car ahead [24]. Further investigations revealed that impaired postural balance is significantly associated with a slower braking time in older adults [25]. It becomes increasingly obvious that the evaluation of driving capability in elderly people needs to take a holistic perspective concerning health problems [26], including assessments of system-specific and overall functioning [27] ( [Table 1]).

Driving and Pharmacotherapy

In general, older age is associated with a growing prevalence of drug prescription. Besides common analgesic, cardiovascular, and gastrointestinal drugs, older drivers frequently consume sedating substances like benzodiazepines and opiates that can potentially interfere with driving ability [28]. Almost 70% of the people with driving impairments due to medical reasons are estimated to be under the influence of medication associated with significant daytime sleepiness [29]. However, in addition to sedating substances, the total number of (routine) medications also shows a positive correlation with daytime sleepiness [29]. Clinicians need to keep in mind that elderly drivers are more susceptible to the sedating effects of medication [30].

According to data obtained from meta-analyses, benzodiazepines are associated with a 60–80% increase of accident risk and a 40% risk of accident responsibility, although this effect was even more pronounced in drivers younger than 65 years [31]. Consumption of alcohol increases the crash risk associated with benzodiazepines almost 8-fold [31]. A Canadian case-control study of drivers aged 67–84 found an increased risk for motor vehicle crashes associated with long-acting benzodiazepines (OR: 1.23), which increased further with the concurrent use of selective serotonin reuptake inhibitors (OR: 1.37) [32].

Another study evaluating the association between current zolpidem use and motor vehicle collision rates demonstrated that zolpidem users, especially women and drivers older than 80 years, showed higher crash rates than non-users [33]. A double-blind, balanced, cross-over driving simulator study by Bocca et al. demonstrated significant residual effects on driving ability after a single nighttime intake of zopiclone and zolpidem in middle-aged drivers (55–65 years) [34]. A meta-analysis by Roth et al. showed that the residual effect of hypnotics on driving ability depends on half-life, dosage, and the time between intake and driving [35]. According to these data, “z-substances” such as zolpidem and zopiclone as well as benzodiazepines significantly impair driving performance and increase the risk of car crashes. Thus, driving is not recommended due to a potential increase of reaction time.

Anxiolytic drugs in single or multiple daytime dosing regimens impair driving ability independent of substance-specific half-lives [31]. Considering antidepressants, the use of tricyclic substances is associated with a higher crash risk in older drivers (older than 65 years) [31]. Non-sedative antidepressants were not found to cause impairment of driving performance [31]. Opioids are associated with an increased accident risk within the first weeks of treatment [31]. Rudisill et al. found a significantly increased risk of motor vehicle crashes in drivers older than 65 years taking tramadol [28].

In neurodegenerative disorders like Parkinson’s disease, the management of the medically impaired driver becomes even more challenging. Although the exact numbers may vary across studies, up to 50% of Parkinson’s disease patients report daytime sleepiness under dopaminergic therapy, and 2–30% of these patients even suffer from almost unpredictable sleep attacks [36]. Patients with Parkinson’s disease and daytime sleepiness or sleep attacks need to be clearly informed about the increased accident risk. In such circumstances, physicians have to recommend to avoid driving.

Regarding the influence of acetylcholine esterase inhibitors on driving capabilities, the effects of donepezil treatment on computer-simulated driving have been studied in healthy older drivers [37]. Donepezil did not influence attention or the number of collisions, but the medication was associated with a tendency toward longer reaction times and more frequent road position deviations. This may indicate that donepezil does not preserve driving ability in older drivers [37].

Driving in the Cognitively Impaired

The number of older drivers who continue driving despite mild dementia increases exponentially [3]. More than 60% of men and approximately 20% of women with a Mini-Mental State Examination (MMSE) score of 24–26 points (maximum: 30 points) continue to drive, and more than 40% of men with an MMSE score of <24 points continue driving as well [38]. Many drivers with cognitive impairment underestimate their deficits due to anosognosia [26]. The phenomenon of anosognosia is typical in dementia syndromes as well as in mild cognitive impairment (MCI) [26]. Anosognosia potentially causes an overestimation of one’s driving capabilities and, thus, sometimes interferes with deciding about driving cessation during the course of cognitive decline [26]. Drivers with MCI and dementia avoid complex driving situations, but there is no significant difference in driving cessation rates compared with cognitively healthy drivers [39]. Only late dementia symptoms like agitation, hallucinations, and apathy were shown to be valid predictors of driving cessation. This underlines the lack of perception of driving impairment during early dementia stages [26] [40].

The driving characteristics of older drivers without cognitive impairment and drivers with MCI and mild dementia are quite similar. In this spectrum, more distinct driving patterns can be found towards mild dementia, which suggests gradual rather than principle changes [3] [41]. Drivers with MCI already show significantly lower global driving ratings compared with cognitively healthy drivers, but not at the level of an overt impairment [41]. Compared with drivers with MCI, demented drivers need more time for identical distances, are more likely to cause collisions and to go off the road, and show longer reaction times [42]. Due to orientation deficits, often accompanied by additional concentration and coordination problems, cognitively impaired drivers show an insecure driving style, especially in unknown areas [3]. Drivers with early-stage dementia are more likely to have wayfinding problems [43]. Approximately 20% of demented drivers cause car crashes [3] [44]. Because of the prominent visuospatial skills impairment, car body damages are the most frequent type of crashes [44].

Driving Assessment in the Elderly

During the course of dementia progression, the patient will lose driving capability. In moderate and severe disease stages, the ability to drive is always irrecoverably lost [27]. However, in mild dementia, driving capability can be preserved for some time [27]. There are different methods to assess driving performance. Such an evaluation is a complex process, so there is no single test to answer the question [27], but there are relatively elaborated algorithms and scoring systems serving as a tool to assess driving capability in aging and cognitive impairment [45] [46].

The assessment and clarification of traffic-relevant deficits in mild dementia exceeds cognitive performance testing [27]. The rating of overall functioning seems to have the highest value compared with all other criteria [45]. For evaluating overall functioning, the Clinical Dementia Rating (CDR) is recommended to distinguish between no, very mild, mild, moderate, and severe cognitive impairment [27]. Although proper implementation of the CDR requires sufficient time and effort, often restricting its use to clinical science, an approximate grading is often possible.

Medical history and medical history by proxy are invaluable with regard to specific driving- and dementia-related problems like personality changes, other diseases, medication, and sensory and motor impairment [27]. Thereby, medical history by proxy regarding potentially dangerous driving behavior is very important information [27]. Due to the complex driving requirement profile, cognitive screening tests like the MMSE and clock-drawing test are insufficient to evaluate driving performance. Beside global cognitive functioning, neurocognitive tests assessing driving capability in the elderly should focus on executive functions including attention, visuospatial skills, and reaction times [27] [47] [48]. One meta-analysis demonstrated that the trail-making test B (TMT-B) is one of the best predictors of passing the on-the-road test [49]. The TMT-B is recommended as a component of cognitive screening assessment in the evaluation of driving ability in the elderly driver [46]. In Germany, there is an instrument called “SAFE” (Seniorenberatung Aufgrund Fahreignungsrelevanter Einschränkungen). It aids to counsel elderly drivers with respect to limitations of driving performance and includes the possibility to download a manual and original publications (www.dggpp.de/publik_mat.html) [50]. The neuropsychological assessment should always be complemented by medical history by proxy regarding driving-specific behavior and on-the-road tests [27] ([Table 2]).

There is an ongoing and controversial debate on whether neuropsychological testing, driving simulator tests, or on-the-road-tests are able to validly identify unsafe drivers [51]. It is yet unknown whether driving assessments ultimately help to prevent car crashes and whether they can guide people with dementia on how to continue or cease driving [51]. It is remarkable that neurocognitive (“office-based”) tests barely correlate with road test performance in demented people, whereby studies demonstrated a correlation between results in such tests and future crashes in older drivers without dementia [51]. Improving the correlation between these tests in demented drivers would require complex test batteries causing an assessment of unpractical length [51]. Considering the value of on-the-road tests, it has been criticized that there is no standard in the assessment, resulting in considerable variability [51]. Driving simulator tests have not yet been shown to predict future crashes and do not seem to correlate well with the driving tasks in older drivers with and without dementia [51]. In contrast to these findings, new data with non-demented drivers show that error rates in simulator tests seem to predict unsafe driving on the road. However, they are no alternative to on-the-road tests when accurate data about the patterns of impairments are required [52]. Future studies should contribute to improve assessment methods that will identify unsafe drivers and prevent car accidents but will also help to avoid unnecessary restrictions for elderly people.

Conflict of Interest

R. Haussmann and M. Buthut have no conflict of interest to declare. M. Donix has received consulting fees from Trommsdorff and lecture fees from Mundipharma.

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Correspondence

• References

• 1 Salvia E, Petit C, Champely S. et al. Effects of age and task load on drivers’ response accuracy and reaction time when responding to traffic lights. Front Aging Neurosci 2016; 8: 169
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