Self-regulation of older drivers with cognitive impairment : a systematic review

Background
Cognitive decline contributes significantly to the safety risk of older drivers. Some drivers may be able to compensate for the increased crash risk by avoiding complex driving situations or restricting their driving.

Objective and Method
A comprehensive English-language systematic review was conducted to determine the level of evidence for older adult drivers with cognitive impairment engaging in self-regulation.

Results
Twelve studies were included in the review. The majority of studies investigated driver avoidance, followed by driver restriction. Few studies ascertained the reasons for changing driving behaviour.

Conclusions
The evidence supports the view that drivers with cognitive impairment do restrict their driving and avoid complex driving situations. However, it remains to be determined whether the drivers who do engage in self-regulation require insight into their own driving abilities or whether external factors result in self-regulation of driving behaviour.

Investigating fitness to drive in older drivers with cognitive impairment

This thesis investigated driving behaviour of senior drivers with cognitive impairment in order to gain an understanding of how cognition impacts on driver behaviour and fitness to drive.

Self-regulatory driving behaviours amongst older drivers according to cognitive status

Self-regulation of older drivers was explored according to their cognitive status in this pilot study by examining situations commonly avoided by older drivers. In addition, the role of driver insight on self-regulation was examined via passenger reports. Telephone interviews were conducted comprising 49 drivers aged 65 years and above and 40 passengers who acted as informants. Self-regulation was found to be common, with the majority of drivers (71.4%) reporting sometimes or always avoiding one of seven driving situations. However, drivers with cognitive impairment reported self-regulating more often than drivers without cognitive impairment. The largest discrepancy between passenger and driver reports of self-regulation behaviours was found for the drivers with cognitive impairment. These results possibly reflect a decreased awareness of self-regulatory driving behaviours in this subgroup of older drivers and may suggest that other external factors are contributing to self-regulation in older drivers with cognitive impairment. A discussion of these factors is provided with the aim of maintaining mobility and enhancing quality of life in this growing segment of the driver population.

Risky driving habits and motor vehicle driver injury

Risky driving is an important cause of motor vehicle injury, but there is a lack of good epidemiological data in this field, particularly data comparing risky driving in younger drivers to those of other age groups. We examined the relationship between risky driving habits, prior traffic convictions and motor vehicle injury using cross-sectional data amongst 21,893 individuals in New Zealand, including 8029 who were aged 16–24 years. Those who reported frequently racing a motor vehicle for excitement or driving at 20 km/h or more over the speed limit, and those who had received traffic convictions over the past 12 months, were between two and four times more likely to have been injured while driving over the same time period. Driving unlicensed was a risk factor for older but not younger drivers, and driving at 20 km/h or more above the speed limits was a stronger risk factor for younger (<25 years) than older drivers. These results confirm the need for interventions targeting risky driving and suggest that different strategies may be required for different high-risk groups.

Risky driving in young adults : A review of the literature

Young drivers aged between 16 and 25 are consistently over-represented in fatal crash statistics and are more likely than older drivers to be involved in a range of intentional risky driving behaviours, such as drink driving, speeding, drag racing, and tailgating. This paper reports the fndings of a systematic search of published peer-reviewed literature, identifying the association between age and the characteristics of risky drivers, as well as interventions that have been developed to improve their safety. The results suggest that it is young males who are predominantly involved in unsafe driving and that these drivers are generally high in reward sensitivity, have antisocial peers, and believe that they are not dangerous drivers. Further to this, deterrence-based interventions have shown limited efectiveness for the specifc category of 'hoon' drivers, suggesting the need for targeted interventions across a multitude of domains. Efective intervention requires an understanding of the antecedents of dangerous driving behaviour, and it is concluded that interventions might be most efective when targeted towards these identifed criminogenic needs.

Responsible management of motor vehicle drivers with dementia

When Bridget Driscoll, a 44-year-old mother of two died after being struck by a motor vehicle, considered to be the first motor vehicle fatality in UK and possibly the world, the coroner stated 'I trust this sort of nonsense will never happen again'.1 Sadly, the coroner, medical practitioners and general public would be deeply and repeatedly disappointed. It was 1896. Motor vehicles were a curiosity. Drivers did not undergo any form of testing, be it medical fitness, driving ability or otherwise, and there were no licensing regulatory agencies. By 2010, road injury was the ninth most common cause of death globally (1.3 million deaths per annum) and dementia the fourth most common in high income countries.2 By 2030 the number of all licensed UK drivers who are 65 years or older will increase by almost 50% to almost one in every four drivers.3 If the juxtaposition of driving with dementia in an ageing population is not already a contentious social, political and medical issue, it certainly will become so.

Inequity in health: older rural driving and dementia

Introduction The number of drivers with dementia is expected to increase exponentially over the coming decades. Most individuals with moderate-to-severe dementia (table 1) are unfit to drive.1 Drivers with moderate-to-severe dementia have higher rates of MVCs than age-matched controls.2 Identifying and preventing these individuals from driving is crucial, particularly in urban areas. The density of cars and pedestrians, and the complexity of traffic typically place greater demands on drivers in urban areas, and, therefore, require greater reactivity and forward planning than in rural environments.3 ,4 The ability to drive is a critical means of maintaining one's social inclusion, and is commonly a practical necessity. Therefore, decisions about the entitlement to drive should not unfairly restrict mobility or unnecessarily compound the disadvantages experienced by older people with mild cognitive impairment and early dementia (table 1), particularly as diagnoses are now being made earlier.1 This paper describes the difficulties inherent in addressing the question of when and in what circumstances a diagnosis of dementia might render a person unfit to drive and focuses on those who live in rural areas. We examine the consequences of dementia diagnosis on driving, driver testing requirements and licensing procedures, and the impacts of driving cessation. We then discuss how living in rural areas may alter the level of risk of drivers with dementia and practical implications for licensing policies.