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Contreversies in geriatric medicine Elderly drivers: Assessing performance or predicting driving safety? § S. Bonin-Guillaume * Department of Internal Medicine, Geriatrics and Therapeutics, faculte ´ de me ´decine de la Timone, ho ˆpital Sainte-Marguerite, Assistance publique des hoˆpitaux de Marseille, universite ´ de la Me ´diterrane ´e, 270, boulevard de Sainte-Marguerite, 13274 Marseille cedex, France Demographic changes are leading to an increase in the number of elderly drivers. In Western countries, driving has become essential to maintaining functional ability, psychological well- being and social network. Moreover, driving cessation has negative consequences in older adults [1,2] in terms of depression, disability and mortality. Thus, it is important to ensure that older people can continue driving while at the same time ensuring that those who are unsafe to drive are identified. Therefore maintaining driving activity in the elderly raises several questions: should driving performance or driving safety be a priority? Should driving skills assessment be similar for healthy old drivers and for drivers with cognitive impairment or physical disability? Ageing is related to cognitive, psychological and physical changes (mainly visual and musculoskeletal). Ageing is associated with a slowing of global processing that affects every stage of information processing [3] especially under time restraint. In addition, the elderly are more impaired for divided attention tasks. Yet performance assessment may be impaired in complex road situations that need a rapid series of decisions [4] such as intersections [5]. But the ageing related impairment of function observed in assessment does not have the effect expected on daily performance as great as one would expect [6]. To compensate for driving difficulties, older drivers develop self-regulation and avoidance of specific driving situations considered as complex and risky [7]. This is part of a theory of the selective optimisation with compensation developed by gerontologists as the ‘‘successful ageing theory’’ [8]. Strategic compensation is not associated with mileage reduction but with avoidance of difficult situations. Elderly drivers tend to compensate by avoiding turning left, driving alone, at night and tend to prefer main roads and familiar areas [7]. Tactical compensation strategy seems to be successful in avoiding accidents. Studies have shown little correlation between driving perfor- mance and accidents [6], even if car accident data have several limitations because of inaccuracy of self-report crashes or biases of state report accidents [9]. Studies have shown the importance of associating visual, cognitive and motor tests to objectivise on-road driving tests to assess performance and driving skills in healthy old drivers [9,10]. Yet, prospective studies are still needed to validate performance predictors of unsafe driving and car crashes in healthy elderly drivers. Another approach is the study of the role of driving behaviour and involvement in traffic accidents [11]. There are three main types of aberrant driving behaviour: violations which are intentional, errors which are mistakes with potentially dangerous consequences and lapses which are related to attention failure. Each of these behaviour types has different road safety implica- tions [4]. The Aging Driving Behaviour Scale is a self-rating scale that assesses a variety of different aberrant behaviour in elderly drivers. Elderly drivers are more likely to commit errors and lapses when driving; some of these are associated with involvement in accident [12,13]. Although self-rating scales have the drawback of subjective responses, they are useful for large survey studies. In fact, elderly drivers like younger adults often overestimate their driving skills [13]. Clinicians are often asked to judge the driving performance and driving safety of their elderly patients without proper guidelines [14], but rarely force for driving cessation. Family members are more influential in the decision to cease driving than physicians [15] but with variations in their proxy driving skills evaluation according to their personal driving situation (for example, over- estimating skills by a non driving spouse) [16]. Professor O’Neill [17] accurately pleads for the importance of the Comprehensive Geriatric Assessment in determining the medical fitness to drive in cognitively impaired patients. Cognitive assessment alone is insufficient to predict car crashes. Moreover, several follow-up studies in memory clinics showed that driving cessation of cognitive impaired patients was indeed associated to the severity of impairment but also to demographical factors such as ‘‘living in the city’’ [15] or behavioural symptoms of dementia such as ‘‘apathy’’ and ‘‘hallucinations’’ [18]. Most of the studies evaluating European Geriatric Medicine 1 (2010) 93–94 ARTICLE INFO Article history: Received 18 January 2010 Accepted 7 March 2010 Available online 20 April 2010 Keywords: Elderly drivers Driving performance Driving safety § Comments on the paper: Deciding on driving cessation and transport planning in older drivers with dementia by Desmond O’Neill. * Tel.: +33 491 74 46 12; fax: +33 491 74 60 33. E-mail address: [email protected]. 1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.03.001

Elderly drivers: Assessing performance or predicting driving safety?

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Page 1: Elderly drivers: Assessing performance or predicting driving safety?

European Geriatric Medicine 1 (2010) 93–94

Contreversies in geriatric medicine

Elderly drivers: Assessing performance or predicting driving safety?§

S. Bonin-Guillaume *

Department of Internal Medicine, Geriatrics and Therapeutics, faculte de medecine de la Timone, hopital Sainte-Marguerite, Assistance publique des hopitaux de Marseille, universite

de la Mediterranee, 270, boulevard de Sainte-Marguerite, 13274 Marseille cedex, France

A R T I C L E I N F O

Article history:

Received 18 January 2010

Accepted 7 March 2010

Available online 20 April 2010

Keywords:

Elderly drivers

Driving performance

Driving safety

Demographic changes are leading to an increase in the numberof elderly drivers. In Western countries, driving has becomeessential to maintaining functional ability, psychological well-being and social network. Moreover, driving cessation has negativeconsequences in older adults [1,2] in terms of depression, disabilityand mortality. Thus, it is important to ensure that older people cancontinue driving while at the same time ensuring that those whoare unsafe to drive are identified.

Therefore maintaining driving activity in the elderly raisesseveral questions: should driving performance or driving safety bea priority? Should driving skills assessment be similar for healthyold drivers and for drivers with cognitive impairment or physicaldisability?

Ageing is related to cognitive, psychological and physicalchanges (mainly visual and musculoskeletal). Ageing is associatedwith a slowing of global processing that affects every stage ofinformation processing [3] especially under time restraint. Inaddition, the elderly are more impaired for divided attention tasks.Yet performance assessment may be impaired in complex roadsituations that need a rapid series of decisions [4] such asintersections [5]. But the ageing related impairment of functionobserved in assessment does not have the effect expected on dailyperformance as great as one would expect [6]. To compensate fordriving difficulties, older drivers develop self-regulation andavoidance of specific driving situations considered as complexand risky [7]. This is part of a theory of the selective optimisationwith compensation developed by gerontologists as the ‘‘successful

§ Comments on the paper: Deciding on driving cessation and transport planning

in older drivers with dementia by Desmond O’Neill.

* Tel.: +33 491 74 46 12; fax: +33 491 74 60 33.

E-mail address: [email protected].

1878-7649/$ – see front matter � 2010 Elsevier Masson SAS and European Union Ger

doi:10.1016/j.eurger.2010.03.001

ageing theory’’ [8]. Strategic compensation is not associated withmileage reduction but with avoidance of difficult situations.Elderly drivers tend to compensate by avoiding turning left, drivingalone, at night and tend to prefer main roads and familiar areas [7].Tactical compensation strategy seems to be successful in avoidingaccidents.

Studies have shown little correlation between driving perfor-mance and accidents [6], even if car accident data have severallimitations because of inaccuracy of self-report crashes or biases ofstate report accidents [9]. Studies have shown the importance ofassociating visual, cognitive and motor tests to objectivise on-roaddriving tests to assess performance and driving skills in healthy olddrivers [9,10]. Yet, prospective studies are still needed to validateperformance predictors of unsafe driving and car crashes inhealthy elderly drivers.

Another approach is the study of the role of driving behaviourand involvement in traffic accidents [11]. There are three maintypes of aberrant driving behaviour: violations which areintentional, errors which are mistakes with potentially dangerousconsequences and lapses which are related to attention failure.Each of these behaviour types has different road safety implica-tions [4]. The Aging Driving Behaviour Scale is a self-rating scalethat assesses a variety of different aberrant behaviour in elderlydrivers. Elderly drivers are more likely to commit errors and lapseswhen driving; some of these are associated with involvement inaccident [12,13]. Although self-rating scales have the drawback ofsubjective responses, they are useful for large survey studies. Infact, elderly drivers like younger adults often overestimate theirdriving skills [13].

Clinicians are often asked to judge the driving performance anddriving safety of their elderly patients without proper guidelines[14], but rarely force for driving cessation. Family members aremore influential in the decision to cease driving than physicians[15] but with variations in their proxy driving skills evaluationaccording to their personal driving situation (for example, over-estimating skills by a non driving spouse) [16]. Professor O’Neill[17] accurately pleads for the importance of the ComprehensiveGeriatric Assessment in determining the medical fitness to drive incognitively impaired patients. Cognitive assessment alone isinsufficient to predict car crashes. Moreover, several follow-upstudies in memory clinics showed that driving cessation ofcognitive impaired patients was indeed associated to the severityof impairment but also to demographical factors such as ‘‘living inthe city’’ [15] or behavioural symptoms of dementia such as‘‘apathy’’ and ‘‘hallucinations’’ [18]. Most of the studies evaluating

iatric Medicine Society. All rights reserved.

Page 2: Elderly drivers: Assessing performance or predicting driving safety?

S. Bonin-Guillaume / European Geriatric Medicine 1 (2010) 93–9494

driving skills in patients with dementia have several methodolo-gical limitations such as retrospective car crashes data or lack ofoutcomes [16]. Prospective studies with objective outcomes areneeded.

Elderly drivers will be more and more present on roads. Ageingper se is not sufficient to cease driving. By now, there is still no testaccurate enough to identify unsafe older drivers or predict caraccident. The Comprehensive Geriatric Assessment is a goodapproach for a global evaluation of cognitive, psychological andmotor impairments in medically ill or demented patients. But littleis known in healthy old drivers. Caution must be exercised beforeasking for driving cessation because of possible negative outcomeson everyday life.

Conflict of interest statement

Nothing declared.

References

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