Interventions

A clinical recommendation to revoke driving privileges should be made only after careful consideration of all of the available evidence. In the absence of pressing safety concerns, the driver should retain his/her license. Conversations about driving cessation should take place as early as possible in individuals with evidence of progressive cognitive decline, allowing the driver and his/her care network to navigate through the process of driving cessation and adjust to mobility losses in the event that the client experiences further cognitive decline.

With cognitive impairment, it is important for drivers to gain awareness about their deficits and how those deficits may be related to driving fitness. There is some evidence that cognitively healthy drivers may benefit from optimizing their driving skills by participating in a targeted intervention involving education, on-road feedback, cognitive training, or a combination of these approaches [134]. While there is a lack of evidence to suggest that individuals with cognitive impairment benefit to the same extent, there are ongoing research studies investigating this issue. Researchers have suggested some of the negative outcomes associated with driving cessation may be mitigated through activities centered around early planning [e.g., 133]. For example, advanced driving directives (ADDs) may facilitate early planning and involve the driver identifying a professional, family member, or trusted friend to help make a decision about driving cessation. ADDs have received empirical support as a means to facilitate conversations between drivers and health professionals and aid planning for driving cessation [135, 136]. Educational resources such as brochures about the impact of cognitive impairment and driving as well as how to approach the issue of driving cessation could also facilitate conversations about driving cessation [137 ] . Numerous examples of educational resources are available at Older Drivers in Canada and Their Families website (http://www.older- driversafety.ca/) [138] which is hosted by the Canadian Association of Occupational Therapists.

When an older adult either makes the decision to cease driving or has his/her driving privileges removed, he/she is faced with a number of practical and emotional adjustments. To help cope with the end of driving, evidence suggests that working with a trained therapist to explore emotions associated with loss, promote maintained self-efficacy, and facilitate a process of resolution (i.e., grief counseling) may be of use [131]. Similarly, having access to peers who can offer support during the transition has been shown to be effective in helping former drivers and family members to cope with driving cessation [139, 140].

Following driving cessation, drivers must come to terms with their loss and find new ways of remaining mobile. Research shows that former drivers primarily rely on friends and family to act as the primary driver following cessation [141]. Health professionals may consider referring patients to community resources (e.g., mobility centers, volunteer drivers, subsidized transportation, etc.), OTs, social workers, or targeted interventions designed to support former drivers [e.g., 124, 137]. Available in the United Kingdom, a network of mobility centers are designed to support individuals with mobility impairments and help facilitate access to public and private transit services [ [142] ; mobility-centres.org.uk]. Targeted evidence- based interventions to support mobility following driving cessation show promising effectiveness [e.g., [143]]. A program named the UQDRIVE, for example, aims to promote community engagement and mobility and prevent depression and isolation in older adults faced with driving cessation [144,145]. The program is facilitated by a former driver who successfully transitioned and takes place over six separate sessions each lasting between 3 and 4 h. Results showcasing the effectivity of the program indicate that non-demented older drivers who received the UQDRIVE used public transportation more frequently, walked more frequently, and had high self-efficacy related to community mobility and higher satisfaction with transportation in comparison to individuals who did not receive the intervention [146]. While the UQDRIVE is not specifically designed for individuals with MCI or dementia, it is reasonable to suspect that an education-based intervention for individuals with mild impairments may be beneficial to mobility and quality of life.

Maintaining mobility after driving cessation may require a multipronged approach that involves (a) residing in an accessible neighborhood within walking distance to critical services, (b) the use of public or private forms of transportation for regularly scheduled appointments or events, and (c) reliance on informal transportation from friends and family to reach destinations that are difficult to access through other means. Relocating to a residence that is within close proximity to essential services may be one approach to countering mobility losses associated with driving cessation. In practice, however, older adults are reluctant to relocate and prefer to stay in their family homes despite evidence to support making a move [147].

While the majority of nondriving individuals rely on informal rides from family and peers, formalized initiatives that seek to improve the transportation options within communities could be an enormous benefit to nondriving cognitively impaired older adults. An example of this is the Independent Transportation Network of America (ITNAmerica), a national non-profit transportation system with the goal of supporting sustainable, community-based transportation services for seniors. ITNAmerica matches older adults with rides at a rate that costs less than a taxi. The system also gives drivers the opportunity to volunteer and earn credits toward rides for their nondriving family members or toward addressing their future transportation needs.

Research on the use of public transportation among individuals with cognitive impairments is scarce [148], yet experts in the field have argued that any alternative transportation option must match the needs and capabilities of the former driver so that they may ultimately make use of alternatives [59]. Using appropriate alternative transportation options may be even more challenging in North America as many older adults reside in rural and remote regions where transportation options, such as buses, trains, and taxis, are unavailable [137].

Broad policy approaches to support individuals with cognitive impairment may involve making decisions at the community level that directly address the needs of residents with dementia, making the community more inclusive and accessible. Such approaches can be applied to service delivery, infrastructure, and public service spheres and have been characterized as a community’s dementia friendliness (see [149]). In the United Kingdom, for example, bus drivers receive specific awareness training related to dementia, equipping them with knowledge and skills to address the needs of riders with cognitive impairment [150]. It follows that features of the community, whether part of the built or social environment, can moderate older adults’ success in transitioning to nondriving status and their ability to maintain outdoor mobility.

 
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