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Driving assessment for maintaining mobility in drivers with dementia

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Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

Primary objectives:
1. To assess whether driving assessment facilitates continued driving in people with dementia
2. To assess whether driving assessment reduces accidents in people with dementia

Secondary objective:
To assess the quality and quantity of research on assessment of drivers with dementia

Background

With an increasingly aged population the number of older drivers is on the increase. Driving is the most common form of transport for older people, with only 3% of journeys by older people in the US undertaken by public transport. Transport and access to transport is an important factor in maintaining social inclusion and participation for older people: there is also considerable evidence that limiting this access (i.e. by driving cessation) is associated with poor health and depression (Marottoli 2000). Exclusion of the elderly from driving has been demonstrated to have many negative effects; loneliness, lower life satisfaction and lower activity levels. Drivers with dementia both limit their driving and eventually withdraw, with profound negative effects on their mobility (Taylor 2001).
We do not know what interventions will maintain safe mobility for the longest period for people with dementia. A full assessment (often including an on‐road assessment) may have beneficial effects for drivers with many illnesses (Stutts 2003), and restricted driving licences following assessment are associated with a lower crash risk (Vernon 2002). An assessment in dementia also allows for advance planning of driving withdrawal and substitution of other transportation modalities, by way of the so‐called modified Ulysses pact (Robinson 2004). It also allow for regular re‐testing to guide this process (Duchek 2003).
Although there is no standardized neuropsychological assessment battery, most driving assessment protocols include medical, occupational therapy and/or neuropsychology assessment and an on‐road driving assessment as required. We have no evidence that this intervention enhances either mobility or safety.

We will seek evidence that formalized driving assessments are effective in maintaining safety and mobility in drivers with dementia rather than merely excluding those who are unfit to drive. Continued driving and outdoor mobility is important to older people and is a sufficient outcome measure in its own right. Safety is a secondary end‐point, as crashes are relatively infrequent events, and fatal crashes even more so, 1 per 50 million km. RCTs of driving assessment should involve a careful design, randomizing patients who drive to either formal testing or usual care and assessment, with longitudinal follow‐up of satisfaction with transport (Rosenbloom 2003) and crashes or violations. Ethically, this should not pose a public health hazard in view of memory clinic studies which suggest no increase in crashes in those with dementia (Carr 2000; Drachman 1993; Trobe 1996), but due care will need to be given to advice to participating drivers on informing driver licensing authorities and insurance companies, depending on the jurisdiction(s) within which the study is taking place.

Objectives

Primary objectives:
1. To assess whether driving assessment facilitates continued driving in people with dementia
2. To assess whether driving assessment reduces accidents in people with dementia

Secondary objective:
To assess the quality and quantity of research on assessment of drivers with dementia

Methods

Criteria for considering studies for this review

Types of studies

All relevant randomised controlled trials (RCTs) will be included. Non‐randomised trials (N‐RCTs) will be discussed in the Background and Discussion sections as appropriate. N‐RCTs will be excluded from the meta‐analysis.

Types of participants

Patients with dementia of any type, without age restriction, will be included.

Types of interventions

Any formal on‐road driving assessment. The driving assessment may also involve standardized neuropsychological assessment battery, medical or occupational therapy assessment, but the intervention which is randomised should include formal on‐road assessment.

Types of outcome measures

Our primary outcome will be the number of people who remain driving after assessment compared to the control or placebo group. A second primary outcome will be the number of road traffic accidents (RTAs) after assessment.

Search methods for identification of studies

We will search the Cochrane Dementia group's Specialised Register which contains trial reports from most major health care databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS) and many ongoing trial databases. We will use the terms: "(medical or occupational) and therapy", "(neuropsycholog* or on‐road) and assessment*", "Accidents, Traffic", "Motor Vehicles", "Automobile Driving" and "Automobile Driver Examination".

Data collection and analysis

Studies will be selected from lists generated by the search strategy. Hard copies of all relevant studies will be retrieved. Two reviewers (AM, DON) blinded with respect to authors, institution and journal will independently assess trial quality and extract data from studies that meet the inclusion criteria. Meta‐analysis and narrative review will be performed where appropriate for each of the nominated outcomes. The RevMan software package will be used where appropriate to perform the meta‐analysis for continuous and dichotomous outcome measures. Non‐randomised controlled studies will not be included in the primary analysis but may be included in the discussion

Data Extraction
Data will be extracted independently by two authors (AM, DON). A data extraction form will be used to record methodological and outcome data.

Quality Assessment
The quality assessment of the included trials will be undertaken independently and in duplicate by two reviewers (AM, RM). The quality criteria that will be examined are: allocation concealment, (recorded as: adequate, unclear, inadequate or not used), and completeness of follow‐up and intention to treat analysis. Given the nature of the study blinding would not be expected.

Data Analysis
Data will be analysed on an intention to treat basis. Continuous data will be analysed using weighted mean differences and 95% confidence intervals. Dichotomous data will be expressed as odds ratios with 95% confidence intervals.