Abstract
Purpose:
The objective is to assess associations between visual function and on-road driving performance evaluated by a certified driving rehabilitation specialist (CDRS).
Methods:
Adults aged 70 and older enrolled and completed assessments of visual acuity, contrast sensitivity, visual processing speed, visual field sensitivity, motion perception, and spatial ability. At follow-up, on-road driving performance was evaluated on a 15-mile route. Age-adjusted odds ratios and 95% confidence intervals (95% CIs) were used to associate worse CDRS composite score and CDRS global rating for those with worse visual function compared to those with better.
Results:
For the 144 participants who enrolled, completed vision testing, and the on-road driving evaluation, the mean age was 79.2 (5.1) and 45.8% were female. The odds of worse CDRS global rating and composite score were significantly associated with moderately and severely impaired visual processing speed under divided attention (all p<0.05). Those with worse motion perception were at greater odds of a worse CDRS composite score (OR: 2.67, 95% CI: 1.14-6.26).
Conclusions:
The CDRS composite score of on-road driving performance by older adults was associated with slowed visual processing and impaired motion perception, suggesting that older driver performance, as rated by a CDRS, relies on visual skills. The CDRS global rating was also associated with impaired visual processing speed. The literature suggests impairments in these same visual functions elevate crash risk. While the results provide additional evidence suggesting these functional measures are associated with driving, work is needed to further identify and assess visual measures most closely related to driving safety and performance among older adults to better inform interventions, policy, and future research.
Keywords: vision, aging, vision impairment, driving evaluation, certified driving rehabilitation specialist
Introduction
Older drivers represent the fastest growing group of drivers.1 The crash rate among those aged 70 years and older is similar to those 18-30 years old, the age group with the highest crash rate.2 At even greater risk of crash involvement are older drivers with vision impairment.3, 4 Older drivers in the United States and Canada with medical or functional impairments can be referred to a certified driving rehabilitation specialist (CDRS) for evaluation.5 CDRSs complete training through the Association for Driver Rehabilitation Specialists (ADED), which in the US and Canada is considered the gold standard for driving assessment and rehabilitation.6-10 This training is recognized among driving professionals as the primary resource for driver assessment and rehabilitation expertise.11
A prior study found worse CDRS evaluations are significantly associated with at-fault crash and near-crash rate among older drivers with vision impairment.6 While some prior work has examined the relationship between various visual functions and on-road performance evaluations,12-16 most on-road evaluations were completed by occupational therapists or a driver educator, not a CDRS. In the one study which used a CDRS, participants were referred for an on-road evaluation, making findings limited to those with suspected issues.14 Given the prior work, performance evaluations completed by a CDRS and visual functions have yet to be examined among typical older drivers.
The objective of this study is to examine the associations between various types of visual functions and on-road driving performance as evaluated by a CDRS in older drivers, many of whom have vision impairment. This work seeks to fill the gaps in the current literature to determine which visual functions are associated with the clinical gold standard on-road performance evaluation in the U.S. and Canada.
Methods
Study design and sample
Data used in this analysis were part of a 6-month prospective cohort study on older drivers.9 Participants were recruited based on a patient care visit to an ophthalmologist or optometrist at the Callahan Eye Hospital and Clinics at the University of Alabama in Birmingham (UAB), with a focus on persons with eye diseases which can cause vision impairment. This was to ensure varied visual function in the study sample. To be eligible, participants were required to be aged 70 years or older, self-reported driving four or more days per week, and licensed to drive in Alabama. This study was approved by the institutional review boards of UAB and adhered to the tenets of the Declaration of Helsinki.
Baseline assessments
After informed consent was obtained and participants enrolled, baseline assessments were completed at one of two visits. At the baseline visit, general demographic information (i.e., age, sex, race) and education level were obtained by interview. Participants responded to questions regarding 17 common health conditions (e.g., diabetes, cancer, heart disease) to obtain general health status.17 The Mini-Mental Status Exam (MMSE) and Center for Epidemiological Studies – Depression (CES-D) were used to assess cognitive function and depression, respectively.18, 19 MMSE scores less than 24 indicates impairment and CES-D scores > 16 suggests depression.18, 19 Eye disease and intraocular lens status were abstracted from the medical record.
Participants completed assessments testing visual acuity, contrast sensitivity, visual field sensitivity, visual processing speed, motion perception, spatial ability, and processing speed in combination with executive function and working memory. All assessments were completed binocularly, using the standard test protocol referenced, under photopic conditions, and with the participant wearing their habitual correction (near or distance as required by the standard test protocol) unless otherwise noted. Habitual distance visual acuity (VA) was assessed using the standard protocol of the electronic visual acuity tester and expressed as the log of the minimum angle of resolution (logMAR).20 VA impairment was defined by worse than 20/40 (>0.3 logMAR), the impairment definition used for licensing standards by many government jurisdictions for driving. The Pelli-Robson chart was used to test contrast sensitivity, was scored by the letter-by-letter method, and expressed as log sensitivity.21, 22 Persons with worse than 1.5 log sensitivity were impaired.23
Visual processing speed under divided attention was measured by the Useful Field of View (UFOV) subtest 2.24 This test determines the time (milliseconds) for a subject to discriminate between two targets in central vision while simultaneously locating a peripheral target at 10° eccentricity at one of eight potential radial directions. Processing speeds were categorized into moderate (150-350 ms) and severe impairment (> 350 ms).25 The UFOV testing protocol began later, thus those who enrolled early in the study did not complete it. Visual processing speed, executive function, and working memory were assessed using the Trail Making Test part B (Trails B).26 Trails B measures the time in minutes for a participant to draw a line from numbers and letters alternately, following the numerical and alphabetical order. Times greater than or equal to 2.47 minutes were impaired.27 Spatial ability was evaluated using the Visual Closure Subtest of the Motor-Free visual perception version 3 test (MVPT3).28 The MVPT3 presents cards of objects drawn completely and incompletely. Participants are tasked with matching the two versions; impairment is defined as 8 or less correct matches.29
Visual field sensitivity was evaluated using the Humphrey Field Analyzer (HFA), Model II-I, and measured in decibels (dB). The custom test used 20 white stimulus-size III targets and the full-threshold procedure.30 The area evaluated corresponds to view of the roadway environment and upper dashboard while driving and spans 15° superiorly, 30° inferiorly, and 60° degrees horizontally to the right and left.30 Eyes were evaluated monocularly so the HFA’s eye tracking could be used. Monocular fields were combined to create binocular visual field sensitivities.31 The most sensitive measurement of the two eyes at each test location defined the binocular visual field sensitivity.30 Visual field sensitivity regions of interest included overall (all test points), superior (points above the horizontal meridian), inferior (points below the horizontal meridian), left (points to the left of the vertical meridian), right (points to the right of the vertical meridian), and peripheral (points at or temporal to ± 45°). Visual field sensitivity impairment for each region was defined by the first quartile of the sample.30
A drifting Gabor test was used to assess motion perception threshold.32 A 3 cycle/degree vertical sinusoidal grating filtered with a Gaussian envelope is presented to participants. The participant is to determine the direction of the grating (right versus left) with a drift rate (hertz, Hz) varying during a 2-down/1-up staircase with 8 reversals. The threshold was defined as the average of the last 6 reversals and expressed in hertz. Motion perception impairment was defined by the median value of the sample, with values below the median considered impaired.33, 34
On-road evaluation
Six months after the baseline assessment, participants completed an on-road evaluation with a CDRS. The CDRS had 20 years of experience working with older drivers, including those with vision impairment, and also was an occupational therapist. Past work indicated a high level of agreement between the evaluations by this CDRS and a backseat evaluator (kappa=0.96).35 The CDRS was masked to all other participant study information (e.g., crash history, visual function). Participants completed a one hour on-road evaluation on a standard route in everyday traffic that lasted approximately 45-60 minutes. The 15-mile route went through suburban and urban environments with varying types of roadway (e.g., two lane, four lane, one-way, with and without medians and turn lanes) and intersection scenarios. In all, participants made eight left and five right turns at signalized intersections, two unprotected left turns, one right turn at a yield sign, one right turn at a stop sign, one left turn at a stop sign, and traveled straight through 22 signalized intersections. Evaluations were completed in a 2009 Chevy Impala equipped with a front passenger-brake for the CDRS to use if necessary.
The evaluation assessed twelve driving behaviors and has been published in prior work.35 Rated on a 1 to 5 scale (1=poor, 5=no errors) were right turns and curves, left turns and curves, lane control, gap judgement while changing lanes and turning, gap while driving, maintaining speed, and steering steadiness. Evaluated on a 1 to 3 scale (1=problematic, 3=no problems), were scanning, appropriate use of brake, appropriate use of blinkers, obeying traffic signs, and checking blind spots. A composite score of the CDRS ratings was derived from the twelve behaviors assessed. The scored rating was divided by the highest possible value for that element and multiplied by 100 to create a percent, which were averaged for the composite CDRS percent score. In addition to the composite CDRS score, the CDRS made a global rating for driving performance on a 1-5 scale, with half-units as a choice, and 1=terminate drive and 5=optimal. Like a CDRS passes or fails a driver, both scores were categorized into better and worse, with those in the upper three quartiles classified as better and those in the first quartile as worse.
Statistical analysis
Logistic regression was used to calculate age-adjusted odds ratios (ORs) and 95% CIs for the odds of worse CDRS composite score and CDRS global rating for those with worse visual function compared to better visual function, as defined above. Confounding was assessed by examining stratified measures of association36 but not determined to be present for gender, race, MMSE score, CES-D, years of education, number of medical conditions, lens status, glaucoma, AMD, and diabetic retinopathy/diabetic macular edema. The level of significance was set a p <0.05 (two-sided test). All statistical analyses were completed in SAS Version 9.4 (SAS Institute, Cary, NC).
Results
In all, 159 drivers enrolled in the study of which 144 completed the on-road evaluation. Those who did not complete the CDRS evaluation were too ill (6), dead (1), declined (3), or terminated participation soon after the baseline visit (5). As shown in Table 1, most participants were in their 70s (55.6%) or 80s (42.2%) and the sample had fewer women (45.8%) than men (54.2%).
Table 1.
Demographic and health characteristics of study sample (N=144).
| Characteristic | ||
|---|---|---|
| n (%) | Mean (standard deviation) |
|
| Age group, years | 79.2 (5.1) | |
| 70-79 | 80 (55.6) | |
| 80-89 | 61 (42.4) | |
| 90-99 | 3 (2.1) | |
| Sex | ||
| Women | 66 (45.8) | |
| Men | 78 (54.2) | |
| Race | ||
| Black | 26 (18.1) | |
| White | 118 (81.9) | |
| Education category | 15.1 (2.7) | |
| Less than high school graduate | 4 (2.8) | |
| High school graduate | 68 (47.2) | |
| College graduate | 61 (42.4) | |
| Professional or graduate school | 11 (7.6) | |
| MMSE | 27.8 (1.8) | |
| ≥ 24 (not impaired) | 142 (98.6) | |
| < 24 (impaired) | 2 (1.4) | |
| Medical conditions, number | ||
| 0-1 | 19 (13.2) | |
| 2-3 | 43 (29.9) | |
| 4-5 | 54 (37.5) | |
| ≥6 | 28 (19.4) | |
| CES-D | 3.7 (4.3) | |
| ≤ 16 (not depressed) | 141 (97.9) | |
| > 16 (depressed) | 3 (2.1) | |
| Eye diagnoses (one or both eyes)† | ||
| Age-related macular degeneration | 23 (16.3) | |
| Cataract | 60 (42.6) | |
| Diabetic retinopathy or macular edema | 10 (7.1) | |
| Primary open angle glaucoma | 40 (28.4) | |
| Pseudophakia | 86 (61.0) | |
| Other‡ | 63 (44.7) |
Participants could have more than 1 diagnosis. Medical records could not be located for 3 participants.
Examples of other conditions include dry eye disease, hypertensive retinopathy, Fuchs’ dystrophy, lattice degeneration, macular cyst hole, macular pucker, ocular prosthesis, and retinal tear.
No participant had visual acuity worse than 20/40 (Table 2). Nearly a fifth had impaired contrast sensitivity (18.8%). Visual processing speed under divided attention was moderately impaired in 37.9% and severely impaired in 11.2%. Trails B was impaired in 34%. The majority (93.1%) of the sample did not have impaired spatial ability as assessed by the MVPT3. The average (standard deviation) overall visual field sensitivity was 23.9 (2.6) dB and had a range of 14.1 to 29.8 dB. All visual field sensitivity impairments were defined by the first quartile, which ranged from 21.7 dB in the left subfield to 22.4 dB overall. The median motion perception threshold was 0.14 Hz, inter-quartile range of 0.10 to 0.20 Hz, and it ranged from 0.03 to 0.57 Hz. The mean CDRS score was 89.8% (8.5) and scores ranged from 63.3-100%. CDRS global ratings ranged from 2 to 5, had an average rating of 4.5 (0.73), and the first quartile defined by ≤ 4. In all, 38 and 57 participants were graded as having a worse CDRS composite score and global rating, respectively.
Table 2.
Visual function of participants (N=144).
| Visual function | n (%) | mean (standard deviation) |
|---|---|---|
| Visual acuity, logMAR | 0.03 (0.11) | |
| ≤ 0.3 (better) | 144 (100.0) | |
| > 0.3 (worse) | 0 (0.0) | |
| Contrast sensitivity, log sensitivity | 1.70 (0.15) | |
| ≥ 1.5 (better) | 117 (81.3) | |
| < 1.5 (worse) | 27 (18.8) | |
| UFOV subtest 2†, ms | 170.91 (128.00) | |
| < 150 (better) | 59 (50.9) | |
| 150-350 | 44 (37.9) | |
| > 350 (worse) | 13 (11.2) | |
| Trails B, minute | 2.47 (1.38) | |
| < 2.47 (better) | 95 (66.0) | |
| ≥ 2.47 (worse) | 49 (34.0) | |
| MVPT3, score | 9.58 (1.41) | |
| ≥ 8 (better) | 134 (93.1) | |
| < 8 (worse) | 10 (6.9) | |
| Visual field sensitivity, dB | ||
| Overall | 23.87 (2.58) | |
| > 22.4 (better) | 110 (76.4) | |
| ≤ 22.4 (worse) | 34 (23.6) | |
| Peripheral (≥ 45°) | 21.05 (3.02) | |
| > 19.5 (better) | 107 (74.3) | |
| ≤ 19.5 (worse) | 37 (25.7) | |
| Superior | 23.97 (3.33) | |
| > 22.2 (better) | 104 (72.2) | |
| ≤ 22.2 (worse) | 40 (27.8) | |
| Inferior | 23.69 (2.77) | |
| > 22.1 (better) | 107 (74.3) | |
| ≤ 22.1 (worse) | 37 (25.7) | |
| Left | 23.23 (2.98) | |
| > 21.7 (better) | 106 (73.6) | |
| ≤ 21.7 (worse) | 38 (26.4) | |
| Right | 23.61 (2.82) | |
| > 21.9 (better) | 106 (73.6) | |
| ≤ 21.9 (worse) | 38 (26.4) | |
| Gabor drifting grating threshold, Hz | 0.17 (0.11) | |
| < 0.14 (better) | 77 (53.5) | |
| ≥ 0.14 (worse) | 67 (46.5) |
116 participants completed this testing.
Drivers with slowed visual processing speed were more likely to have worse composite scores (moderate slowing, OR 3.24, 95% CI 1.12–9.32; severe slowing, OR 16.47, 95% CI 3.65-74.38) (Table 3). In addition, those with impaired motion perception were more likely to have worse composite scores (OR 2.67, 95% CI 1.14-6.26). With respect to CDRS global scores, those with slowed visual processing speed (moderate slowing, OR 3.15, 95% CI 1.18–8.40; severe slowing, OR 17.09, 95% CI 3.55-82.31) were more likely to have worse global scores, with associations similar in magnitude to those found for the CDRS composite score. No other visual functions were associated with CDRS composite or global scores.
Table 3.
Age-adjusted odds ratio (OR) and 95% confidence intervals (CI) for worse CDRS score and CDRS global rating versus better for those with worse visual function compared to those with better visual function (worse score or rating, worse performance) (N=144).
| Worse CDRS composite score vs. better |
Worse CDRS global rating vs. better |
|||
|---|---|---|---|---|
| (N events = 38) | (N events = 57) | |||
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Contrast sensitivity, log sensitivity | ||||
| ≥ 1.5 (better) | REF† | REF | ||
| < 1.5 (worse) | 1.56 (0.59-4.09) | 0.37 | 1.85 (0.74-4.65) | 0.19 |
| UFOV subtest 2‡, ms | ||||
| < 150 (better) | REF | REF | ||
| 150-350 | 3.24 (1.12-9.32) | 0.03 | 3.15 (1.18-8.40) | 0.02 |
| > 350 (worse) | 16.47 (3.65-74.38) | 0.0003 | 17.09 (3.55-82.31) | 0.0004 |
| Trails B, minute | ||||
| < 2.47 (better) | REF | REF | ||
| ≥ 2.47 (worse) | 1.44 (0.61-3.42) | 0.40 | 2.11 (0.94-4.71) | 0.07 |
| MVPT3, score | ||||
| ≥ 8 (better) | REF | REF | ||
| < 8 (worse) | 2.23 (0.52-9.51) | 0.28 | 2.40 (0.58-9.90) | 0.23 |
| Overall visual field sensitivity, dB | ||||
| > 22.4 (better) | REF | REF | ||
| ≤ 22.4 (worse) | 2.22 (0.89-5.52) | 0.09 | 2.32 (0.97-5.58) | 0.06 |
| Peripheral visual field sensitivity, dB | ||||
| > 19.5 (better) | REF | REF | ||
| ≤ 19.5 (worse) | 1.78 (0.73-4.34) | 0.21 | 2.17 (0.93-5.08) | 0.07 |
| Upper visual field sensitivity, dB | ||||
| > 22.2 (better) | REF | REF | ||
| ≤ 22.2 (worse) | 1.42 (0.59-3.42) | 0.43 | 1.40 (0.61-3.22) | 0.43 |
| Lower visual field sensitivity, dB | ||||
| > 22.1 (better) | REF | REF | ||
| ≤ 22.1 (worse) | 2.19 (0.90-5.34) | 0.08 | 2.18 (0.93-5.10) | 0.07 |
| Left visual field sensitivity, dB | ||||
| > 21.7 (better) | REF | REF | ||
| ≤ 21.7 (worse) | 1.73 (0.71-4.21) | 0.23 | 1.74 (0.75-4.04) | 0.19 |
| Right visual field sensitivity, dB | ||||
| > 21.9 (better) | REF | REF | ||
| ≤ 21.9 (worse) | 2.24 (0.93-5.39) | 0.07 | 2.18 (0.94-5.05) | 0.07 |
| Gabor drifting grating threshold, Hz | ||||
| ≤ 0.14 (better) | REF | REF | ||
| > 0.14 (worse) | 2.67 (1.14-6.26) | 0.02 | 1.71 (0.79-3.71) | 0.17 |
Reference
116 participants completed this testing.
Discussion
Among older drivers, many of whom with eye conditions which can cause vision impairment, slowed visual processing speed under divided attention and impaired motion perception were associated with increased odds of worse CDRS composite score. Slowed processing speed was also associated with the CDRS global rating, which is consistent with previous work.14 Previous research has shown that worse CDRS ratings are significantly associated with at-fault crash and near-crash rates as assessed through naturalistic driving methods.37 The associations reported here indicate that the CDRS’s on-road evaluation detected driving problems that can be related to certain visual deficits identified through in-clinic, off-road testing. This study is the first to show on-road driving performance as evaluated by the clinical gold standard on-road examiner for older drivers in the United States and Canada is associated with vision among older drivers without driving issues warranting evaluation.
There has been a growing literature indicating that slowed visual processing speed deleteriously impacts older driver safety and performance. A previous report found that slowed processing speed in older drivers was associated with at-fault crash and near-crash rates as assessed by naturalistic driving techniques.34 In addition, several studies have reported associations between slowed processing speed and elevated crash rates defined by government accident reports.29, 38, 39 Older drivers’ on-road performance is also impaired in drivers with slowed processing speed,13, 15, 16 however a CDRS did not perform these evaluations. It is interesting that the CDRS’s ratings of on-road driving performance are alinked to processing speed, in spite of the fact that the CDRS was masked to the in-clinic test results.
Although we did not find an association between motion perception and the global CDRS rating, motion perception was related to the CDRS composite score. These differences could be explained by the fact the global rating is a single judgement and the composite score was based on multiple items evaluated. Motion perception deficits in older drivers have been associated with an increased rate of crash involvement over the previous five years and future at-fault crash/near crash events.33, 34 Our finding of driving performance problems associated with motion perception deficits is also consistent with previous research on this topic. Movement perception was significantly correlated with on-road performance score among older drivers referred for driving evaluation.13 Among older drivers with age-related macular degeneration, motion perception was associated with driving performance.40 Another work has shown that older drivers with impaired motion sensitivity (minimum displacement thresholds using random dot kinematograms) were more likely to exhibit driving problems on a closed road circuit such as performance problems in time-sensitive tasks, detecting and avoiding road hazards, dividing attention while driving, and overall driving skills in general.41 Motion perception deficits in older drivers were also associated with pedestrian detection problems at night42 and hazard detection in videos from the Hazard Perception Test,32 which is a screening tool used for driver licensure in the United Kingdom and Australia.
CDRS global ratings of on-road driving have also been linked to other more severe visual limitations in drivers. In homonymous hemianopia and quadrantanopia a large part of the visual field is missing due to brain injury; in hemianopia, half of the binocular field is blinded, whereas in quadrantanopia, one quarter of the field is blinded. In a study on this population,43 a CDRS evaluated driving during a 45-60 minute route, finding that approximately 59.1-81.1% of hemianopic participants had no or only minor driving errors. A skill that was commonly problematic (40.9% of drivers) was lane-keeping, but many of these errors were minor. Of eight quadrantanopic drivers, all but one had no or minor errors. The results of this study are similar to our study in that our older drivers, some with identifiable visual impairment, demonstrated adequate driving performance as evaluated by a CDRS which was maintained in spite of the impairment.
As with Wood et al.,12 a study using similar on-road performance evaluation methods (i.e., studies not using closed-course circuits or simulators), the current study reports no association between on-road performance and visual field sensitivity. Contrary to this previous study,12 we found no association between contrast sensitivity and on-road performance. Our use of a dichotomous definition of contrast sensitivity impairment and analytic method could account for differences in associations between these two studies. Of note, formal impairment definitions are lacking for visual field sensitivity and motion perception. With each of these functions representing different components of vision, the sample-based definitions, i.e. the first quartile and the median, are not surprisingly unique. Well-powered work should be conducted to derive formal definitions of impairment for these functions for use in research and clinical settings.
The current study has strengths and limitations. Strengths include we focused on evaluations by a CDRS whose assessment is the gold standard in the United States and Canada. Additionally, our CDRS had 20 years of clinical experience with older drivers and those with vision impairment. Only one CDRS performed the on-road assessment, a limitation, and there could be individual differences among CDRSs in judgments about on-road skills. Further research comparing the ratings among a group of CDRSs on the same drivers can address to what extent individual differences in ratings are trivial or an issue to be seriously addressed. A strength of the design was driving was performed in everyday driving conditions, although each driver had varying traffic levels and timing of traffic signals which could limit the uniformity of conditions. However, all drives took place between 9am and 3pm to avoid rush hour, when traffic levels were more constant. All drives were conducted during the day, so unfortunately night driving and low levels of illumination could not be evaluated. A limitation is that visual function was assessed at baseline with the CDRS evaluation occurring six months later. However, visual functional changes in older adults often occur slowly, if at all, over a six month period.44, 45
In conclusion, the composite rating of on-road driving performance assessed by a CDRS was significantly associated with visual processing speed under divided attention and motion perception among older drivers, with these visual functional deficits indicative of worse on-road scores. Processing speed under divided attention was also significantly associated with the CDRS global rating. Further work examining these associations is needed to develop visual screening and intervention tools for older drivers and better inform engineering advances for roadways, intersections, and vehicles to improve road safety.
Key points.
In drivers aged 70 years and older, slowed visual processing speed under divided attention was associated with increased odds of worse certified driving rehabilitation specialist composite on-road evaluation score.
Drivers with impaired motion perception were at greater odds of a worse composite and a worse global on-road rating as evaluated by a certified driving rehabilitation specialist.
A certified driving rehabilitation specialist’s on-road ratings of driving performance were associated with vision among older drivers.
Funding information:
National Institutes of Health grants R01EY18966, P30AG22838, P30EY03039, the EyeSight Foundation of Alabama, Alfreda J. Schueler Trust, and Research to Prevent Blindness.
Footnotes
Disclosures: None.
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