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Improving older adults’ fitness to drive

Specialists at Washington University School of Medicine are working to help improve older drivers’ skills so they can safely remain on the road longer

March 18, 2014

As medical advances extend lifespans and baby boomers age, the number of drivers aged 65 and over on the road is increasing dramatically. Making sure these drivers aren’t putting themselves or others at risk has been a growing priority for physicians and law enforcement, but geriatrics specialist David Carr, MD, is hoping to shift the focus of this work.

“There continues to be a need for fitness-to-drive evaluations, but it’s also time for us to start focusing on how we can help people get back behind the wheel or maintain their driving longevity as long as they are driving safely,” said Carr, MD, clinical director of the Division of Geriatrics and Nutritional Science. “It can be devastating to lose the privilege to drive. Depression and anxiety increase, social connections are lost, and risk of nursing home placement rises.”

Carr and colleagues clinically evaluate older drivers with potential for driving impairments through a program cooperatively run by The Rehabilitation Institute of St. Louis, Washington University School of Medicine’s Program in Occupational Therapy and Department of Internal Medicine, and a private company called Independent Drivers LLC. If an initial off-road evaluation suggests the patient may be able to drive, the researchers conduct an in-traffic evaluation.

Three outcomes may result:

• approval to drive without restrictions

• approval to drive pending retraining and/or adaptive equipment (e.g., larger mirrors)

• recommendation that the patient not drive and counseling on options for alternative transportation

Driving evaluations typically cost around $300. But that’s an expense typically borne by the patient, which can be prohibitive for some. Carr and colleagues are gathering evidence of the effectiveness of driving evaluations that they hope will eventually lead to insurance and Medicare coverage.

Driving and preclinical Alzheimer’s

Carr is co-investigator on a new five-year National Institutes of Health (NIH) grant on driving and preclinical Alzheimer’s disease headed by Catherine Roe, PhD, a research scientist at the Knight Alzheimer’s Disease Research Center (ADRC).

“We know that for 10-15 years or longer before people show signs of memory loss, they can start accumulating the pathologic brain changes that are characteristic of Alzheimer’s,” he said. “These individuals may seem fine to drive until they start having Alzheimer’s symptoms, but are they really? Maybe their attention span is down, maybe their reaction time is slow, and perhaps they have difficulty with the driving task even before they become clinically symptomatic with short-term memory loss.”

Through this new initiative, researchers will study 180 older adults with not only initial driving evaluations, but also repeat driving studies for three additional years.  Using PET scans of participants’ brains and analyses of their spinal fluid, researchers will identify which participants have preclinical Alzheimer’s disease.  (In this protocol participants are not aware of their research results.) In collaboration with Denise Head, PhD, in the Department of Psychology, the study will also examine novel computerized measures of navigational abilities and determine whether these abilities are predictors of longitudinal decline in driving skills.

Training to improve driving

David Carr, MD, director of the division of geriatrics and nutritional science, helps older adults assess their driving skills.
David Carr, MD, director of the division of geriatrics and nutritional science, helps older adults assess their driving skills.

“If we do find significant driver errors in older adults with Alzheimer’s pathology, then that hopefully would set us up for developing an educational intervention for patients as a follow-up to this study,” Carr said. “If we identify patients with functional decline before their short-term memory is impaired, they probably can still be trained to improve their driving behaviors, avoid accidents and prolong the time they can continue safe driving.”

Carr and longtime collaborator and occupational therapist Peggy Barco, OTD, BSW, OT/L, SCDCM, are now setting up a driving laboratory to evaluate patients with stroke and traumatic brain injury. The driving simulator includes a full-scale seat, pedals, steering wheel and other controls, realistic driving scenarios and equipment for precise tracking of eye and head movements.

“The major purpose of this new driving lab is to give our patients with brain injury or stroke an opportunity to get back behind the wheel through retraining,” Carr said. “Eventually we may use the laboratory as an alternative to in-traffic fitness-to-drive evaluations, but we would first have to show that the simulator is as good at predicting driving problems as an actual on-the-road evaluation.”