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Driving Cessation and Health Outcomes in Older Adults

Driving Cessation and Health Outcomes in Older Adults CLINICAL INVESTIGATION † ‡ § Stanford Chihuri, MPH,* Thelma J. Mielenz, PhD, MS,* Charles J. DiMaggio, PhD, Marian E. Betz, ¶ †† †‡ MD, MPH, Carolyn DiGuiseppi, MD, PhD,** Vanya C. Jones, PhD, and Guohua Li, MD, DrPH* vention programs ensuring mobility and social functions OBJECTIVES: To determine what effect driving cessation may be needed to mitigate the potential adverse effects of may have on subsequent health and well-being in older driving cessation on health and well-being in older adults. adults. J Am Geriatr Soc 64:332–341, 2016. DESIGN: Systematic review of the evidence in the Key words: driving cessation; older adults; motor research literature on the consequences of driving cessation vehicle; health outcomes in older adults. SETTING: Community. PARTICIPANTS: Drivers aged 55 and older. MEASUREMENTS: Studies pertinent to the health conse- quences of driving cessation were identified through a comprehensive search of bibliographic databases. Studies that presented quantitative data for drivers aged 55 and ar ownership and driving are highly correlated with 1–4 older; used a cross-sectional, cohort, or case–control Cindependence and life satisfaction in older adults. design; and had a comparison group of current drivers In the United States and other industrialized countries, were included in the review. driving is often the most-preferred mode of personal trans- RESULTS: Sixteen studies met the inclusion criteria. Driv- port, is regarded as an important aspect of personal free- ing cessation was reported to be associated with declines dom, and is associated with a sense of control over one’s 4–7 in general health and physical, social, and cognitive func- life. The capacity to drive is an important mechanism tion and with greater risks of admission to long-term care through which many adults, young and old, fulfill their facilities and mortality. A meta-analysis based on pooled social roles and engage with their environments. Driving data from five studies examining the association between has also been identified as an important instrumental activ- driving cessation and depression revealed that driving ces- ity of daily living (IADL). In a study in Australia, older sation almost doubled the risk of depressive symptoms in adults rated driving as the second most important activity older adults (summary odds ratio = 1.91, 95% confidence of daily living (ADL) task, behind use of transportation interval = 1.61–2.27). but ahead of leisure, reading, and medication manage- CONCLUSION: Driving cessation in older adults appears ment. to contribute to a variety of health problems, particularly Driving safety is especially relevant given the growing depression. These adverse health consequences should be older adult population; the proportion of the U.S. popula- considered in making the decision to cease driving. Inter- tion aged 65 and older will increase from 13% in 2010 to 20% in 2040. Most adults continue driving in older age; 81% of the 39.5 million adults aged 65 and older in the From the *Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York City, New York; Department of United States held a driver’s license. These older drivers Anesthesiology, College of Physicians and Surgeons; Department of face unique challenges because driving is a complex task Epidemiology, Mailman School of Public Health, Columbia University; that requires a variety of skills, including physical, Department of Surgery, New York University School of Medicine, New ¶ cognitive, behavioral, and sensory-perceptual abilities. York City, New York; Department of Emergency Medicine, School of Because of age-related declines in health and physical and Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; **Department of Epidemiology, Colorado School of Public cognitive function, driving becomes more difficult for older Health, University of Colorado Anschutz Medical Campus, Aurora, adults. Many older adults eventually reduce or stop their †† Colorado; and Department of Health, Behavior and Society, Bloomberg driving activities, which may have adverse health School of Public Health, Johns Hopkins University, Baltimore, Maryland. 12–14 consequences. Address correspondence to Dr. Guohua Li, Center for Injury Health problems are the most commonly cited reasons Epidemiology and Prevention, Columbia University Medical Center, 722 15,16 West 168th Street, Room 524, New York, NY 10032. E-mail: for driving cessation. Several community-based studies gl2240@cumc.columbia.edu have identified specific medical and socioeconomic factors DOI: 10.1111/jgs.13931 associated with driving cessation, such as recent hospital- JAGS 64:332–341, 2016 © 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society. 0002-8614/16/$15.00 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 333 izations, neurological disorders (e.g., Parkinson’s disease, MELVYL (the online catalog of the University of Califor- stroke), visual disorders (e.g., cataracts, retinal hemor- nia library system) (1970-present). One author (SC) rhage, macular degeneration), low income, and unemploy- screened all the titles and abstracts using the inclusion and 15,17–19 ment. Other factors that may precipitate driving exclusion criteria. The full text of studies with uncertain cessation include advice and warning from a physician, eligibility was reviewed using these criteria. Information crash involvement, and intervention from a family mem- was abstracted from each included study on primary 2,20,21 ber. Sociodemographic variables such as age, sex, author, publication year, country of study population or education, marital status, co-resident status, urban resi- where study data originated, study design, source of driv- dence, and geographic location may also influence the ing cessation status, comparison group, outcomes assessed, 5,15,19,22–24 decision to cease driving. methods of outcome assessment, and results. For the meta- It is likely that the relationship between health status analysis, two authors (SC, GL) independently extracted the and driving cessation is mutually causative; that is, declin- data needed to calculate the individual odds ratio (OR) ing health may lead to driving cessation, and driving cessa- and summary OR for the health outcome. tion in turn may result in adverse health outcomes. In addition, health declines can result from reduced access to Quality Assessment, Data Synthesis, and Analysis out-of-home medical care and difficulty picking up medica- tions and making other health purchases. Although risk The quality of all included studies was evaluated using the Newcastle-Ottawa Scale (NOS) for assessing the quality factors for driving cessation have been studied exten- 3,15,17–19,22 sively, there is less research examining the effect of nonrandomized studies in meta-analyses, as recom- of driving cessation on health outcomes. The objective of mended by the Cochrane Collaboration on bias assess- this review was to assess and synthesize evidence in the ment. The best possible score varies according to study research literature on the consequences of driving cessation design; higher scores indicate better quality. In this version of the scale, the highest possible score is 9 for a cohort in older adults. study. For the cross-sectional studies, the NOS was modified to disregard the follow-up period and absence of outcome at METHODS the start of the study; the highest possible score was 10. This systematic literature review included a narrative syn- Because of the numerous possible health-related conse- thesis and a meta-analysis. The meta-analysis component quences for driving cessation, studies were grouped followed standard methodology and adhered to reporting according to health outcomes for synthesis. The most-com- and procedures outlined in the Preferred Reporting Items mon health outcomes were identified and verified for con- for Systematic Reviews and Meta-Analyses and Meta-ana- sistency in outcome assessment to determine their lysis Of Observational Studies in Epidemiology guidelines. inclusion in the meta-analysis. Meta-analysis was consid- ered for health outcomes that were measured consistently in at least five studies. Eligibility For each health outcome, the Q and I tests were used 29 2 Studies were eligible for inclusion if they included com- to assess heterogeneity. P ≤ .05 and I > 0.5 were consid- munity-dwelling adults aged 55 and older, examined the ered heterogeneous. When visual examination of results consequences of driving cessation, used an epidemiologi- and test statistics indicated homogeneity, results were com- cal design (cross-sectional, cohort, or case–control) that bined quantitatively. The individual odds ratio (OR) for compared driving cessation with continued driving, pre- each study and the summary OR were calculated using sented quantitative data on any health-related outcome Comprehensive Meta-Analysis software. A fixed-effects (e.g., physical, social, emotional), and were published in model was used unless significant heterogeneity was present, English language. No date restrictions were applied. in which case a random-effects model would be preferred. Qualitative studies, letters, editorials, opinion pieces, Data from each study were manually entered into the commentaries, and reviews were excluded. In this appropriate effect size column in the Comprehensive review, driving cessation was defined as total discontinu- Meta-Analysis software; for studies reporting the standard- ation of operating a motor vehicle for productive, social, ized mean difference (d), results were converted to ORs spiritual, or any other purposes. Studies that exclusively using the following formula : focused on driving reduction, which implies some contin- uation of driving, were excluded. Driving cessation could Log odds ratio ¼ dpffiffiffi be voluntary or involuntary, with or without loss of dri- ver’s license. where p is the mathematical constant. The variance of the Search Strategy, Data Sources, and Extraction log OR was calculated using this formula : A medical librarian was consulted to review the search strategy and terms. Relevant literature was identified p V ¼ V Logoddsratio d through a comprehensive search of the following electronic databases on November 15, 2014: American Psychological Association PsychINFO (1967-present), Scopus (1960-pre- sent), Transport Research International Documentation A forest plot was created to show the distribution of (TRID) (1970-present), Medline OVID (1946-present), and the effect of driving cessation across each study. Funnel 334 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS plots and Rosenthal’s fail-safe N were used to assess in some cases marital status and education. A variety of publication bias. health outcomes were examined in the 16 studies, including general, physical, social, and mental health; entry to long-term care (LTC) facilities; and mortality RESULTS risk (Table 3). The comprehensive database search returned 226,410 potentially relevant results; 24,362 duplicates were Study Quality removed, leaving 202,048 citations to be screened. After excluding studies that did not meet eligibility criteria, 161 Based on the NOS, all 12 cohort studies were of high studies were reviewed in full text (Figure 1), 16 of which quality, with an average assessment score of 7.2 out of 9 met the inclusion criteria and were included in this system- (range 7–8). The four cross-sectional studies varied in atic review. quality, with two scoring 9 out of 10 and two scoring 5 out of 10. Study Characteristics Summary of Findings Twelve of the 16 studies were conducted in the United 1–4,14,17,19,32–36 6,20 States, two in Australia, and one each in General Health 31 7 Finland and Kuwait (Table 1). Two publications reported outcomes from the same population sample (New Four studies evaluated general health outcomes through 14,31–33 Haven Established Populations for Epidemiologic Studies self-reported participant measures. One of these 3,17 31 14 for the Elderly). All but one study included adults of studies found a rapid decline in general health trajectory both sexes. The majority included adults aged 65 and after driving cessation in adults aged 65 and older over a older. 5-year period. Nondrivers were significantly more likely Included studies used cohort (n = 12) and cross-sec- than drivers to report having poor health, as indicated by tional (n = 4) designs (Tables 1, 2). No case–control scores on the Medical Outcomes Study 36-item Short- studies were identified. All included studies examined Form Survey (SF-36), a widely used self-report measure of potential confounding factors such as baseline health sta- health-related quality of life. tus and sociodemographic factors such as age, sex, and Additional records Records identified through identified through other database searching (n=226,410) sources (n=8) Records after duplicates removed (n=202,048) Records excluded Records screened (n=201,887) (n=202,048) Full-text articles excluded Full-text articles (n=144) assessed for eligibility (n=161) Subjects not aged 55 and older (n=19) Did not examine consequences of driving cessation (n=67) Adult driving cessation program evaluation (n=34) Studies included in Driving cessation in qualitative synthesis patient groups (n=24) (n=16) Studies included in quantitative synthesis; meta-analysis (n=5) Figure 1. Flow diagram of identification, review, and selection of articles included in the systematic review of health outcomes after driving cessation in older drivers. Adapted from Mohar et al. 2009 . Eligibility Screening Identification Included JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 335 Table 1. Characteristics of Studies Evaluating Driving Cessation for Health-Related Outcomes Source of Study Study Outcome Source of Driving Status Author, Year Study Subjects Data Source Design Location Time Period Information Information Al-Hassani et al. 2014 114 community-dwelling adults Convenience sample through Cross-sectional Kuwait 2012–2013 Geriatric Depression Study questionnaire aged ≥55 Kuwait University Scale Choi et al. 2014 9,135 adults aged ≥65 HRS Cohort United States 1998–2008 Telephone Interview HRS for Cognitive Status Curl et al. 2013 4,788 adults aged ≥65 HRS Cohort United States 1998–2010 RAND Corporation HRS questionnaires Edwards et al. 2009a 690 community-dwelling adults ACTIVE Study Cohort United States 1999–2004 CES-D DHQ within the ACTIVE aged ≥65 Study Edwards et al. 2009b 660 community-dwelling adults Staying Keen in Later Life Study Cohort United States 2004–2007 Social Security Mobility questionnaire aged 63–97 Death Index Fonda et al. 2001 5,239 adults aged ≥70 AHEAD Study Cohort United States 1993–1988 CES-D AHEAD Freeman et al. 2006 1,593 adults aged 65–84 living in Salisbury Eye Evaluation Study Cohort United States 1993–2003 Study questionnaire Study questionnaire Salisbury, MD Liddle et al. 2012 234 community-dwelling adults Convenience sample from around Cross-sectional Australia 2009–2011 Face-face interviews Face-face interviews aged ≥65 urban Queensland, Australia Mann et al. 2005 697 adults aged 60–106 with at Rehabilitation Engineering Cross-sectional United States 2004–2005 CAS-IB CAS-IB least one activity of daily living Research Center on Aging, difficulty Consumer Assessments Study Marottoli et al. 1997 1,316 adults aged ≥65 living in EPESE Cohort United States 1982–1988 CES-D EPESE New Haven, CT Marottoli et al. 2000 1,316 adults aged ≥65 living in EPESE Cohort United States 1982–1988 EPESE EPESE New Haven, CT Mezuk et al. 2008 398 adults aged ≥60 ECA Cohort United States 1993–2005 Likert scale ECA O’Connor et al. 2013 2,793 community-dwelling adults ACTIVE Study Cohort United States 1999–2004 Turn 360 Test, DHQ within the ACTIVE aged ≥65 Medical Outcomes Study Study 36-item Short-Form Health Survey, Likert scale, family members death confirmation Ragland et al. 2005 1,772 adults aged ≥55 in Sonoma SPPARCS Cohort United States 1993–1994 CES-D SPPARCS County, CA Siren et al. 2004 1,251 Finnish women born in Finish Vehicle Administration Cross-sectional Finland 2003–2004 Survey questionnaire Driver license register 1927 (aged ≥70) center Windsor et al. 2007 700 community-dwelling adults ALSA Cohort Australia 1992–1994 CES-D ALSA aged ≥70 HRS = Health and Retirement Study; ACTIVE = Advanced Cognitive Training for Independent and Vital Elderly; CES-D = Center for Epidemiological Studies Depression Scale; DHQ = Driving Habits Ques- tionnaire; AHEAD = Asset and Health Dynamics Among the Oldest Old; CAS-IB = Consumer Assessment Study Interview Battery; EPESE = Established Populations for Epidemiologic Studies for the Elderly; ECA = Baltimore Epidemiologic Catchment Area Study; SPPARCS = Study of Physical Performance and Age-Related Changes in Sonomans; ALSA = Australian Longitudinal Study of Aging. 336 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS Table 2. Variables Measured in Studies Evaluating Driving Cessation and Health-Related Outcomes Author, Year Exposure and Covariates Assessed Outcomes Measured Al-Hassani et al. 2014 Driving cessation, age, sex, marital status, education, self- Depressive symptoms (Geriatric Depression Scale), rated health perceived control, self-reported health, life satisfaction (Likert scale) Choi et al. 2014 Driving cessation, baseline cognitive function, health Cognitive function (Health and Retirement Study cognitive status, age, sex, race, marital status, education battery) Curl et al. 2013 Driving cessation, sex, race, marital status, self-rated Productive engagement and social engagement health status Edwards et al. 2009a Driving cessation, baseline depressive symptoms, general Depressive symptoms (CES-D), self-rated health (Likert health, self-rated health, physical performance scale), physical performance (Turn 360 test), general health and functioning (SF-36) Edwards et al. 2009b Driving cessation, age, health, visual acuity, baseline Three-year mortality risk depressive symptoms, baseline cognitive function Fonda et al. 2001 Driving cessation, spouse’s driving status, age, race, sex, Depressive symptoms (CES-D) education, geographical location, baseline health, physical and cognitive functioning Freeman et al. 2006 Driving cessation, baseline health, cognitive function, Long-term care entry (interviewer-administered depressive symptoms, demographic characteristics questionnaire) Liddle et al. 2012 Driving cessation, health, ADLs, sex, age, living situation Functional status (physical self-maintenance scale, IADL scale), life satisfaction (Life Satisfaction Index), role participation (role checklist), time use (semistructured interview) Mann et al. 2005 Driving cessation, age, race, sex, health status Self-rated health status (OARS physical health scale), functional status (OARS IADL scale, Sickness Impact Profile, Functional Independence Measure), mental status (Mini-Mental State Examination) Marottoli et al. 1997 Driving cessation, health status, ADLs, age, sex, education, Depressive symptoms (CES-D) marital status, housing type Marottoli et al. 2000 Driving cessation, health status, ADLs, age, sex, education, Self-reported out-of-home activity levels (home interviews) marital status, housing type Mezuk et al. 2008 Driving cessation, age, race, education, self-rated health, Social network characteristics; friends and relatives (Likert cognitive function scale) O’Connor et al. 2013 Driving cessation, age, sex, race, education, health status, Self-rated health (Likert scale), physical performance (Turn self-rated health, physical performance, geographic 360 test), general health and functioning (SF-36) location, Ragland et al. 2005 Driving cessation, health status age, sex, education, Depressive symptoms (CES-D) marital status, cognitive function, baseline depression status Siren et al. 2004 Driving cessation, physical health, psychological well- Self-rated health (self-report), life satisfaction (Satisfaction being, marital status Life Scale) Windsor et al. 2007 Driving cessation, health and sensory function, age, sex, Depressive symptoms (CES-D), self-rated health and education, marital status, income, perceived control, sensory function (Likert scale), perceived control baseline depressive symptoms (Expectancy of Control subscale of the Desired Control 40,41 Measure ) CES-D = Center for Epidemiologic Studies Depression Scale; SF-36 = Medical Outcomes Study 36-item Short Form Survey; ADLs = activities of daily liv- ing; IADL = instrumental activity of daily living; OARS = Older Americans Resources and Services. A Finnish study found that drivers were more likely gitudinal studies even after adjusting for sociodemographic to assess their health as good (59.4%) than ex-drivers factors and baseline health. Although one study reported (42.5%), and another study found that former drivers a 6.7-point decline in the physical functioning domain and had poorer overall health than current drivers, but because a 12-point decline in the physical role domain of the SF- both of these studies were cross-sectional, it is possible that 36, they examined a small sample of ex-drivers (n = 37) in former drivers stopped driving because of poor health. a cohort of 690 older adults. Physical Health Social Health 7,14,20,32,33 Of the five studies that found declines in physi- Social health refers to the capacity to interact in society, 7,20,33 cal functioning, three were cross-sectional, making it which can be measured according to social engagement, difficult to discern temporality, but these studies showed social contacts, and satisfaction with social roles and social 7,14,20,32,34,35 that former drivers had less participation in outside activi- support. Decline in social health after driving ties and lower productivity in daily life activities than cur- cessation appeared greater in women than in men. The rent drivers (Table 3). The association between driving reported declines in social health were not as rapid as 14,35 34 cessation and poor physical functioning was strong in lon- those in physical health. For example, one study JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 337 Table 3. Categorical Health Outcomes Associated with Driving Cessation for the 16 Studies Poorer Less Lower Out- Greater Greater Less Functional Greater Productive Poorer Greater of-Home Dependency Greater Risk Depressive Social Status (Role Cognitive Engagement General Risk of Activity and Loss of Entry into Author, Year Symptoms Engagement Playing) Decline (e.g., Work) Health Mortality Level of Control Long-Term Care Al-Hassani et al. 2014 ++ + Choi et al. 2014 + Curl et al. 2013 + Edwards et al. 2009a  ++ Edwards et al. 2009b + Fonda et al. 2001 + Freeman et al. 2006 + Liddle et al. 2012 ++ + Mann et al. 2005 ++ + Marottoli et al. 1997 + Marottoli et al. 2000 + Mezuk et al. 2008 O’Connor et al. 2013 ++ + + Ragland et al. 2005 + Siren et al. 2004 ++ Windsor et al. 2007 + + Studies, n 6 6 5 2 2 4 2 1 2 1 += Significant association;  = No significant association. 338 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS reported that, over a 13-year period, driving cessation was 3-year mortality, with nondrivers four to six times as associated with a 51% reduction in the size of social net- likely to die as drivers after adjusting for baseline psycho- works of friends and relatives, which was not mediated by logical and general health, sensory function, and cognitive the availability of or access to alternative transport. In abilities. The other study found that 5-year mortality risk addition, support from family and friends remained for nondrivers was 68% higher than in drivers. The stron- unchanged. Former drivers were likely to spend less time ger association reported in the first study may be due in in social activities and more time in solitary leisure or to part to the fact that its study subjects were less healthy 7,20 32 abandon previous social activities. than those in the latter. Cognitive Decline Depressive Symptoms 34 2,4,6,7,14 One longitudinal study reported that former drivers had Five cohort studies that examined the effect of driv- poorer cognitive abilities as measured according to the ing cessation on depressive symptoms in older adults were Mini-Mental State Examination than current drivers. Simi- included in a meta-analysis. Four of the studies reported sig- larly, another study found that former drivers had faster nificantly greater depressive symptoms in ex-drivers after cognitive decline over a 10-year period than active drivers adjustment for potential confounding factors. Effect esti- even after controlling for baseline cognitive function and mates did not show significant heterogeneity (Q = 3.266, general health. Current drivers were also healthier and had df = 4, P = .51; I = 0.000), indicating that the studies were better cognitive function than former drivers in a cross- fairly homogenous, so a fixed-effects model was used. Over- sectional study. all, driving cessation almost doubled the risk of greater depressive symptoms in older adults (summary OR = 1.91, Entry into Long-Term Care 95% CI = 1.61–2.27) (Figure 2). A funnel plot for the five studies did not indicate any major publication bias because The only study to evaluate entry into LTC reported that the summary OR was near the estimated effects from the former drivers were nearly five times (hazards ratio two largest studies. A cross-sectional study that used a dif- (HR) = 4.85, 95% confidence interval (CI) = 3.26–7.21) ferent measure for depression also found that greater depres- as likely as current drivers to be admitted to LTC facilities sive symptoms were associated with driving cessation. (e.g., nursing home, assisted living community, retirement home). Even after adjusting for marital status or co-resi- dence, the authors found a strong association between DISCUSSION driving cessation and LTC entry. Having no other driver Driving cessation in older adults is associated with a vari- in the house was independently associated with LTC entry ety of adverse health outcomes, particularly greater depres- (HR = 1.72, 95% CI = 1.15–2.57). sive symptoms. These findings are generally consistent with a previous review but update and expand the find- Risk of Mortality ings of that review with more than 10 additional years of There was a general agreement between the two stud- empirical research. Evidence of the association between 32,36 ies that exclusively examined the relationship between driving cessation and depression is robust and compelling. driving cessation and risk of mortality. One of these stud- Depressive symptoms were measured using the Center for ies found that driving cessation was a strong predictor of Epidemiologic Studies Depression Scale in all five cohort Figure 2. Forest plot, summary odds ratios (ORs), and 95% confidence intervals (CIs) of depressive symptoms associated with driving cessation. The size of each square is proportional to the relative weight that each study contributed to the summary OR. The diamond indicates the summary OR. Horizontal bars indicate the 95% CIs. Heterogeneity: Q statistic: 3.266, df = 4, P = .51, I = 0.000. JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 339 studies included in the meta-analysis. Moreover, these five adults may combine errands such as a trip to the drug studies were of high quality, as indicated by NOS scores. store with seeing a friend. Although declines in social 4 35 With the exception of one study, the underlying popula- activities may be gradual, they have been found to tions studied were nationally representative samples of the strongly mediate the association between driving cessation U.S. population. Because of the integral role that driving and mortality over time. plays in personal identity and independence, driving cessa- Exdrivers tend to have poorer cognitive abilities than tion may lead to psychological reactions. The perceived current drivers. Although most studies have shown that loss of control that accompanies driving cessation may declines in cognitive abilities contribute to driving cessa- partly explain the association between driving cessation tion, there is a paucity of studies focusing on the effect of and greater depressive symptoms. Not much is known driving cessation on cognitive abilities. Findings from one about the extent to which existing transition services and study indicate a possible bidirectional association between programs contribute to the maintenance of control beliefs driving status and cognitive abilities. and social functioning, but studies have found that avail- Factors that are likely to precipitate mortality are ability and access of alternative transport may not mitigate also likely to affect driving status, making it difficult to 2,34 the observed risk of increased depressive symptoms. establish a causal relationship between driving cessation 32,36 Given the observational nature of the included studies, the and mortality, but the two studies included in this possibility that driving cessation and depression are both review adjusted for baseline covariates that could con- consequences of some other common factor (e.g., declining found the association between driving cessation and mor- health) cannot be completely excluded. Nevertheless, addi- tality. Both studies indicate that driving cessation is a tional research may identify effective interventions that strong risk marker for mortality, possibly by worsening can avoid the worsening of depressive symptoms associ- the diminishing functional capabilities of the normal ated with driving cessation. aging process. Prior research reported conflicting findings on the The aforementioned adverse health consequences effect of driving cessation on general health. Although notwithstanding, reducing or ceasing driving in older some researchers found nondrivers to have more medical adults may have safety benefits. One study reported a conditions and poorer health than drivers, others have 45% reduction in the annual rate of crash injury in medi- 22,38 reported the opposite. There is growing evidence that cally unfit drivers after they received warnings from their driving cessation may exacerbate decline in general physicians. health. The prospective nature of the study on health tra- Although this review provides an up-to-date synthe- jectories, adjusting for baseline covariates, offers com- sis of the research literature on driving cessation and pelling evidence of this effect. The conflicting evidence in health outcomes, it has several notable limitations. With the literature might be explained in part by the fact that the exception of one study, the studies examining the healthier people adapt better to driving cessation than effect of driving cessation on depressive symptoms those in poorer health. Additional large, prospective included a self-report depression scale rather than a clin- studies controlling for location and medical conditions are ical diagnosis and thus were able to examine changes required to further establish the effect of driving cessation only on the scale and not in the proportion of partici- on health. pants classified as clinically depressed. In addition, the Based on the current findings, driving cessation may assessments of other health outcomes varied substantially hasten declines in physical and social health in older across the studies reviewed. The use of standardized adults. Older ex-drivers tend to have markedly fewer out- measures could allow for quantitative synthesis to obtain 14,32 of-home activities as they substitute indoor activities for robust estimates of effect size. Two studies used outside activities. Although older adults tend to find sub- data from the same project, but the respective study stitute activities to do around the home, those activities samples did not overlap. Finally, this review was limited may not benefit physical functioning as much as produc- to studies published in English and excluded qualitative tive work or volunteerism outside the home does. The studies, which can provide rich and deep—although not health implications of markedly poorer physical function- generalizable—information about the effects of driving ing are profound in terms of worsening of underlying cessation. Additional longitudinal studies using standard- physical and emotional problems, deconditioning, and ized measures of health outcomes are needed to better need for support with IADLs. As older adults transition to understand the effects of driving cessation on health and stopping driving, programs should be in place to facilitate well-being in older adults, particularly as to how these continued physical and social activities. effects may differ according to geographic location and Although there were discrepancies in the assessment of other driver characteristics. social functioning after driving cessation, the findings are generally consistent. In some qualitative studies, older ex- CONCLUSIONS drivers mentioned loss of spontaneity and the increasing 5,39 need to plan things ahead of time, which can limit There is mounting evidence that driving cessation in older adults may contribute to a variety of health problems. Of opportunities for out-of-home social engagement and activities. Loss of social functioning appears to affect special note is the apparent effect of driving cessation on women more than men, but women who voluntarily cease self-reported depressive symptoms. Pooled data from five driving seem prepared to adapt to a nondriving lifestyle, studies indicate that driving cessation nearly doubles the risk of greater depressive symptoms in older adults. The whereas those who were forced to stop had a more diffi- strength of the association between driving cessation and cult transition. Because of lifestyle changes, many older 340 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS 9. Colby S, Ortman J. The Baby Boom Cohort in the United States: 2012 to self-reported depressive symptoms is generally consistent 2060. Population Estimates and Projections. Washington, DC: U.S. Census across studies. This finding may be generalizable to the Bureau, 2014. older adult population in the United States because the 10. United States Department of Transportation. FHWA: Highway Finance underlying population in four of the five studies came from Data Collection. Our National Highways. Washington, DC: Office of Highway Policy Information, 2011. nationally representative samples in the United States, and 11. Frey EH. Baby boomers and the new demographics of American’s seniors. the fifth came from a fairly comparable Western Aus- J Am Soc Aging 2010;34:28–37. tralian population. This review also sheds light on other 12. Foley D, Heimovitz H, Guralnik J et al. Driving life expectancy of persons health outcomes of driving cessation, including declines in aged 70 years and older in the United States. Am J Public Health 2002;92:1284–1289. cognitive abilities, diminished physical and social function- 13. Harrison A, Ragland D. Consequences of driving reduction or cessation for ing, and greater risks of LTC entry and mortality. These older adults. Transport Res Rec 2003;1843:96–104. adverse health consequences should be taken into consider- 14. Edwards J, Lunsman M, Perkins M et al. Driving cessation and health trajec- ation when an older adult ceases driving. Access to alter- tories in older adults. J Gerontol A Biol Sci Med Sci 2009;64A:1290–1295. 15. Ragland D, Satariano W, MacLeod K. Reasons given by older people for native transportation may not necessarily mediate the limitation or avoidance of driving. Gerontologist 2004;44:237–244. association between driving cessation and greater depres- 16. Adler G, Rottunda S. Older adults’ perspectives on driving cessation. J 2,34 sive symptoms. Effective intervention programs to Aging Stud 2006;20:227–235. ensure and prolong mobility and physical and social func- 17. Marottoli R, de Leon C, Glass T et al. Consequences of driving cessation: Decreased out-of-home activity levels. J Gerontol B Psychol Sci Soc Sci tioning for older adults are needed. 2000;55B:S334–S340. 18. Freund B, Szinovacz M. Effects of cognition on driving involvement among ACKNOWLEDGMENTS the oldest old: Variations by gender and alternative transportation opportu- nities. Gerontologist 2002;42:621–633. The authors are thankful to Dr. David W. Eby of the 19. Freeman E, Munoz B, Turano K et al. Measures of visual function and time to driving cessation in older adults. Optom Vis Sci 2005;82:765–773. University of Michigan Transportation Research Institute 20. Liddle J, Gustafsson L, Bartlett H et al. Time use, role participation and for his helpful comments. life satisfaction of older people: Impact of driving status. Aust Occup Ther Conflict of Interest: The authors have no conflict of J 2011;59:384–392. interests to disclose. 21. Redelmeier D, Yarnell C, Thiruchelvam D et al. Physicians’ warnings for unfit drivers and the risk of trauma from road crashes. N Engl J Med This research was supported in part by the AAA 2012;367:1228–1236. Foundation for Traffic Safety’s Longitudinal Research on 22. Dellinger A, Sehgal M, Sleet D et al. Driving cessation: What older former Aging Drivers (LongROAD) Project and the National Cen- drivers tell us. J Am Geriatr Soc 2001;49:431–435. ter for Injury Prevention and Control, Centers for Disease 23. Johnson J. Why rural elders drive against advice. J Community Health Nurs 2002;19:237–244. Control and Prevention (Grant 1 R49 CE002096). 24. Freeman E, Gange S, Munoz B et al. Driving status and risk of entry into Author Contributions: Chihuri: literature review; long-term care in older adults. 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© 2016 American Geriatrics Society and Wiley Periodicals, Inc.
ISSN
0002-8614
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1532-5415
DOI
10.1111/jgs.13931
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Abstract

CLINICAL INVESTIGATION † ‡ § Stanford Chihuri, MPH,* Thelma J. Mielenz, PhD, MS,* Charles J. DiMaggio, PhD, Marian E. Betz, ¶ †† †‡ MD, MPH, Carolyn DiGuiseppi, MD, PhD,** Vanya C. Jones, PhD, and Guohua Li, MD, DrPH* vention programs ensuring mobility and social functions OBJECTIVES: To determine what effect driving cessation may be needed to mitigate the potential adverse effects of may have on subsequent health and well-being in older driving cessation on health and well-being in older adults. adults. J Am Geriatr Soc 64:332–341, 2016. DESIGN: Systematic review of the evidence in the Key words: driving cessation; older adults; motor research literature on the consequences of driving cessation vehicle; health outcomes in older adults. SETTING: Community. PARTICIPANTS: Drivers aged 55 and older. MEASUREMENTS: Studies pertinent to the health conse- quences of driving cessation were identified through a comprehensive search of bibliographic databases. Studies that presented quantitative data for drivers aged 55 and ar ownership and driving are highly correlated with 1–4 older; used a cross-sectional, cohort, or case–control Cindependence and life satisfaction in older adults. design; and had a comparison group of current drivers In the United States and other industrialized countries, were included in the review. driving is often the most-preferred mode of personal trans- RESULTS: Sixteen studies met the inclusion criteria. Driv- port, is regarded as an important aspect of personal free- ing cessation was reported to be associated with declines dom, and is associated with a sense of control over one’s 4–7 in general health and physical, social, and cognitive func- life. The capacity to drive is an important mechanism tion and with greater risks of admission to long-term care through which many adults, young and old, fulfill their facilities and mortality. A meta-analysis based on pooled social roles and engage with their environments. Driving data from five studies examining the association between has also been identified as an important instrumental activ- driving cessation and depression revealed that driving ces- ity of daily living (IADL). In a study in Australia, older sation almost doubled the risk of depressive symptoms in adults rated driving as the second most important activity older adults (summary odds ratio = 1.91, 95% confidence of daily living (ADL) task, behind use of transportation interval = 1.61–2.27). but ahead of leisure, reading, and medication manage- CONCLUSION: Driving cessation in older adults appears ment. to contribute to a variety of health problems, particularly Driving safety is especially relevant given the growing depression. These adverse health consequences should be older adult population; the proportion of the U.S. popula- considered in making the decision to cease driving. Inter- tion aged 65 and older will increase from 13% in 2010 to 20% in 2040. Most adults continue driving in older age; 81% of the 39.5 million adults aged 65 and older in the From the *Center for Injury Epidemiology and Prevention, Columbia University Medical Center, New York City, New York; Department of United States held a driver’s license. These older drivers Anesthesiology, College of Physicians and Surgeons; Department of face unique challenges because driving is a complex task Epidemiology, Mailman School of Public Health, Columbia University; that requires a variety of skills, including physical, Department of Surgery, New York University School of Medicine, New ¶ cognitive, behavioral, and sensory-perceptual abilities. York City, New York; Department of Emergency Medicine, School of Because of age-related declines in health and physical and Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; **Department of Epidemiology, Colorado School of Public cognitive function, driving becomes more difficult for older Health, University of Colorado Anschutz Medical Campus, Aurora, adults. Many older adults eventually reduce or stop their †† Colorado; and Department of Health, Behavior and Society, Bloomberg driving activities, which may have adverse health School of Public Health, Johns Hopkins University, Baltimore, Maryland. 12–14 consequences. Address correspondence to Dr. Guohua Li, Center for Injury Health problems are the most commonly cited reasons Epidemiology and Prevention, Columbia University Medical Center, 722 15,16 West 168th Street, Room 524, New York, NY 10032. E-mail: for driving cessation. Several community-based studies gl2240@cumc.columbia.edu have identified specific medical and socioeconomic factors DOI: 10.1111/jgs.13931 associated with driving cessation, such as recent hospital- JAGS 64:332–341, 2016 © 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society. 0002-8614/16/$15.00 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 333 izations, neurological disorders (e.g., Parkinson’s disease, MELVYL (the online catalog of the University of Califor- stroke), visual disorders (e.g., cataracts, retinal hemor- nia library system) (1970-present). One author (SC) rhage, macular degeneration), low income, and unemploy- screened all the titles and abstracts using the inclusion and 15,17–19 ment. Other factors that may precipitate driving exclusion criteria. The full text of studies with uncertain cessation include advice and warning from a physician, eligibility was reviewed using these criteria. Information crash involvement, and intervention from a family mem- was abstracted from each included study on primary 2,20,21 ber. Sociodemographic variables such as age, sex, author, publication year, country of study population or education, marital status, co-resident status, urban resi- where study data originated, study design, source of driv- dence, and geographic location may also influence the ing cessation status, comparison group, outcomes assessed, 5,15,19,22–24 decision to cease driving. methods of outcome assessment, and results. For the meta- It is likely that the relationship between health status analysis, two authors (SC, GL) independently extracted the and driving cessation is mutually causative; that is, declin- data needed to calculate the individual odds ratio (OR) ing health may lead to driving cessation, and driving cessa- and summary OR for the health outcome. tion in turn may result in adverse health outcomes. In addition, health declines can result from reduced access to Quality Assessment, Data Synthesis, and Analysis out-of-home medical care and difficulty picking up medica- tions and making other health purchases. Although risk The quality of all included studies was evaluated using the Newcastle-Ottawa Scale (NOS) for assessing the quality factors for driving cessation have been studied exten- 3,15,17–19,22 sively, there is less research examining the effect of nonrandomized studies in meta-analyses, as recom- of driving cessation on health outcomes. The objective of mended by the Cochrane Collaboration on bias assess- this review was to assess and synthesize evidence in the ment. The best possible score varies according to study research literature on the consequences of driving cessation design; higher scores indicate better quality. In this version of the scale, the highest possible score is 9 for a cohort in older adults. study. For the cross-sectional studies, the NOS was modified to disregard the follow-up period and absence of outcome at METHODS the start of the study; the highest possible score was 10. This systematic literature review included a narrative syn- Because of the numerous possible health-related conse- thesis and a meta-analysis. The meta-analysis component quences for driving cessation, studies were grouped followed standard methodology and adhered to reporting according to health outcomes for synthesis. The most-com- and procedures outlined in the Preferred Reporting Items mon health outcomes were identified and verified for con- for Systematic Reviews and Meta-Analyses and Meta-ana- sistency in outcome assessment to determine their lysis Of Observational Studies in Epidemiology guidelines. inclusion in the meta-analysis. Meta-analysis was consid- ered for health outcomes that were measured consistently in at least five studies. Eligibility For each health outcome, the Q and I tests were used 29 2 Studies were eligible for inclusion if they included com- to assess heterogeneity. P ≤ .05 and I > 0.5 were consid- munity-dwelling adults aged 55 and older, examined the ered heterogeneous. When visual examination of results consequences of driving cessation, used an epidemiologi- and test statistics indicated homogeneity, results were com- cal design (cross-sectional, cohort, or case–control) that bined quantitatively. The individual odds ratio (OR) for compared driving cessation with continued driving, pre- each study and the summary OR were calculated using sented quantitative data on any health-related outcome Comprehensive Meta-Analysis software. A fixed-effects (e.g., physical, social, emotional), and were published in model was used unless significant heterogeneity was present, English language. No date restrictions were applied. in which case a random-effects model would be preferred. Qualitative studies, letters, editorials, opinion pieces, Data from each study were manually entered into the commentaries, and reviews were excluded. In this appropriate effect size column in the Comprehensive review, driving cessation was defined as total discontinu- Meta-Analysis software; for studies reporting the standard- ation of operating a motor vehicle for productive, social, ized mean difference (d), results were converted to ORs spiritual, or any other purposes. Studies that exclusively using the following formula : focused on driving reduction, which implies some contin- uation of driving, were excluded. Driving cessation could Log odds ratio ¼ dpffiffiffi be voluntary or involuntary, with or without loss of dri- ver’s license. where p is the mathematical constant. The variance of the Search Strategy, Data Sources, and Extraction log OR was calculated using this formula : A medical librarian was consulted to review the search strategy and terms. Relevant literature was identified p V ¼ V Logoddsratio d through a comprehensive search of the following electronic databases on November 15, 2014: American Psychological Association PsychINFO (1967-present), Scopus (1960-pre- sent), Transport Research International Documentation A forest plot was created to show the distribution of (TRID) (1970-present), Medline OVID (1946-present), and the effect of driving cessation across each study. Funnel 334 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS plots and Rosenthal’s fail-safe N were used to assess in some cases marital status and education. A variety of publication bias. health outcomes were examined in the 16 studies, including general, physical, social, and mental health; entry to long-term care (LTC) facilities; and mortality RESULTS risk (Table 3). The comprehensive database search returned 226,410 potentially relevant results; 24,362 duplicates were Study Quality removed, leaving 202,048 citations to be screened. After excluding studies that did not meet eligibility criteria, 161 Based on the NOS, all 12 cohort studies were of high studies were reviewed in full text (Figure 1), 16 of which quality, with an average assessment score of 7.2 out of 9 met the inclusion criteria and were included in this system- (range 7–8). The four cross-sectional studies varied in atic review. quality, with two scoring 9 out of 10 and two scoring 5 out of 10. Study Characteristics Summary of Findings Twelve of the 16 studies were conducted in the United 1–4,14,17,19,32–36 6,20 States, two in Australia, and one each in General Health 31 7 Finland and Kuwait (Table 1). Two publications reported outcomes from the same population sample (New Four studies evaluated general health outcomes through 14,31–33 Haven Established Populations for Epidemiologic Studies self-reported participant measures. One of these 3,17 31 14 for the Elderly). All but one study included adults of studies found a rapid decline in general health trajectory both sexes. The majority included adults aged 65 and after driving cessation in adults aged 65 and older over a older. 5-year period. Nondrivers were significantly more likely Included studies used cohort (n = 12) and cross-sec- than drivers to report having poor health, as indicated by tional (n = 4) designs (Tables 1, 2). No case–control scores on the Medical Outcomes Study 36-item Short- studies were identified. All included studies examined Form Survey (SF-36), a widely used self-report measure of potential confounding factors such as baseline health sta- health-related quality of life. tus and sociodemographic factors such as age, sex, and Additional records Records identified through identified through other database searching (n=226,410) sources (n=8) Records after duplicates removed (n=202,048) Records excluded Records screened (n=201,887) (n=202,048) Full-text articles excluded Full-text articles (n=144) assessed for eligibility (n=161) Subjects not aged 55 and older (n=19) Did not examine consequences of driving cessation (n=67) Adult driving cessation program evaluation (n=34) Studies included in Driving cessation in qualitative synthesis patient groups (n=24) (n=16) Studies included in quantitative synthesis; meta-analysis (n=5) Figure 1. Flow diagram of identification, review, and selection of articles included in the systematic review of health outcomes after driving cessation in older drivers. Adapted from Mohar et al. 2009 . Eligibility Screening Identification Included JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 335 Table 1. Characteristics of Studies Evaluating Driving Cessation for Health-Related Outcomes Source of Study Study Outcome Source of Driving Status Author, Year Study Subjects Data Source Design Location Time Period Information Information Al-Hassani et al. 2014 114 community-dwelling adults Convenience sample through Cross-sectional Kuwait 2012–2013 Geriatric Depression Study questionnaire aged ≥55 Kuwait University Scale Choi et al. 2014 9,135 adults aged ≥65 HRS Cohort United States 1998–2008 Telephone Interview HRS for Cognitive Status Curl et al. 2013 4,788 adults aged ≥65 HRS Cohort United States 1998–2010 RAND Corporation HRS questionnaires Edwards et al. 2009a 690 community-dwelling adults ACTIVE Study Cohort United States 1999–2004 CES-D DHQ within the ACTIVE aged ≥65 Study Edwards et al. 2009b 660 community-dwelling adults Staying Keen in Later Life Study Cohort United States 2004–2007 Social Security Mobility questionnaire aged 63–97 Death Index Fonda et al. 2001 5,239 adults aged ≥70 AHEAD Study Cohort United States 1993–1988 CES-D AHEAD Freeman et al. 2006 1,593 adults aged 65–84 living in Salisbury Eye Evaluation Study Cohort United States 1993–2003 Study questionnaire Study questionnaire Salisbury, MD Liddle et al. 2012 234 community-dwelling adults Convenience sample from around Cross-sectional Australia 2009–2011 Face-face interviews Face-face interviews aged ≥65 urban Queensland, Australia Mann et al. 2005 697 adults aged 60–106 with at Rehabilitation Engineering Cross-sectional United States 2004–2005 CAS-IB CAS-IB least one activity of daily living Research Center on Aging, difficulty Consumer Assessments Study Marottoli et al. 1997 1,316 adults aged ≥65 living in EPESE Cohort United States 1982–1988 CES-D EPESE New Haven, CT Marottoli et al. 2000 1,316 adults aged ≥65 living in EPESE Cohort United States 1982–1988 EPESE EPESE New Haven, CT Mezuk et al. 2008 398 adults aged ≥60 ECA Cohort United States 1993–2005 Likert scale ECA O’Connor et al. 2013 2,793 community-dwelling adults ACTIVE Study Cohort United States 1999–2004 Turn 360 Test, DHQ within the ACTIVE aged ≥65 Medical Outcomes Study Study 36-item Short-Form Health Survey, Likert scale, family members death confirmation Ragland et al. 2005 1,772 adults aged ≥55 in Sonoma SPPARCS Cohort United States 1993–1994 CES-D SPPARCS County, CA Siren et al. 2004 1,251 Finnish women born in Finish Vehicle Administration Cross-sectional Finland 2003–2004 Survey questionnaire Driver license register 1927 (aged ≥70) center Windsor et al. 2007 700 community-dwelling adults ALSA Cohort Australia 1992–1994 CES-D ALSA aged ≥70 HRS = Health and Retirement Study; ACTIVE = Advanced Cognitive Training for Independent and Vital Elderly; CES-D = Center for Epidemiological Studies Depression Scale; DHQ = Driving Habits Ques- tionnaire; AHEAD = Asset and Health Dynamics Among the Oldest Old; CAS-IB = Consumer Assessment Study Interview Battery; EPESE = Established Populations for Epidemiologic Studies for the Elderly; ECA = Baltimore Epidemiologic Catchment Area Study; SPPARCS = Study of Physical Performance and Age-Related Changes in Sonomans; ALSA = Australian Longitudinal Study of Aging. 336 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS Table 2. Variables Measured in Studies Evaluating Driving Cessation and Health-Related Outcomes Author, Year Exposure and Covariates Assessed Outcomes Measured Al-Hassani et al. 2014 Driving cessation, age, sex, marital status, education, self- Depressive symptoms (Geriatric Depression Scale), rated health perceived control, self-reported health, life satisfaction (Likert scale) Choi et al. 2014 Driving cessation, baseline cognitive function, health Cognitive function (Health and Retirement Study cognitive status, age, sex, race, marital status, education battery) Curl et al. 2013 Driving cessation, sex, race, marital status, self-rated Productive engagement and social engagement health status Edwards et al. 2009a Driving cessation, baseline depressive symptoms, general Depressive symptoms (CES-D), self-rated health (Likert health, self-rated health, physical performance scale), physical performance (Turn 360 test), general health and functioning (SF-36) Edwards et al. 2009b Driving cessation, age, health, visual acuity, baseline Three-year mortality risk depressive symptoms, baseline cognitive function Fonda et al. 2001 Driving cessation, spouse’s driving status, age, race, sex, Depressive symptoms (CES-D) education, geographical location, baseline health, physical and cognitive functioning Freeman et al. 2006 Driving cessation, baseline health, cognitive function, Long-term care entry (interviewer-administered depressive symptoms, demographic characteristics questionnaire) Liddle et al. 2012 Driving cessation, health, ADLs, sex, age, living situation Functional status (physical self-maintenance scale, IADL scale), life satisfaction (Life Satisfaction Index), role participation (role checklist), time use (semistructured interview) Mann et al. 2005 Driving cessation, age, race, sex, health status Self-rated health status (OARS physical health scale), functional status (OARS IADL scale, Sickness Impact Profile, Functional Independence Measure), mental status (Mini-Mental State Examination) Marottoli et al. 1997 Driving cessation, health status, ADLs, age, sex, education, Depressive symptoms (CES-D) marital status, housing type Marottoli et al. 2000 Driving cessation, health status, ADLs, age, sex, education, Self-reported out-of-home activity levels (home interviews) marital status, housing type Mezuk et al. 2008 Driving cessation, age, race, education, self-rated health, Social network characteristics; friends and relatives (Likert cognitive function scale) O’Connor et al. 2013 Driving cessation, age, sex, race, education, health status, Self-rated health (Likert scale), physical performance (Turn self-rated health, physical performance, geographic 360 test), general health and functioning (SF-36) location, Ragland et al. 2005 Driving cessation, health status age, sex, education, Depressive symptoms (CES-D) marital status, cognitive function, baseline depression status Siren et al. 2004 Driving cessation, physical health, psychological well- Self-rated health (self-report), life satisfaction (Satisfaction being, marital status Life Scale) Windsor et al. 2007 Driving cessation, health and sensory function, age, sex, Depressive symptoms (CES-D), self-rated health and education, marital status, income, perceived control, sensory function (Likert scale), perceived control baseline depressive symptoms (Expectancy of Control subscale of the Desired Control 40,41 Measure ) CES-D = Center for Epidemiologic Studies Depression Scale; SF-36 = Medical Outcomes Study 36-item Short Form Survey; ADLs = activities of daily liv- ing; IADL = instrumental activity of daily living; OARS = Older Americans Resources and Services. A Finnish study found that drivers were more likely gitudinal studies even after adjusting for sociodemographic to assess their health as good (59.4%) than ex-drivers factors and baseline health. Although one study reported (42.5%), and another study found that former drivers a 6.7-point decline in the physical functioning domain and had poorer overall health than current drivers, but because a 12-point decline in the physical role domain of the SF- both of these studies were cross-sectional, it is possible that 36, they examined a small sample of ex-drivers (n = 37) in former drivers stopped driving because of poor health. a cohort of 690 older adults. Physical Health Social Health 7,14,20,32,33 Of the five studies that found declines in physi- Social health refers to the capacity to interact in society, 7,20,33 cal functioning, three were cross-sectional, making it which can be measured according to social engagement, difficult to discern temporality, but these studies showed social contacts, and satisfaction with social roles and social 7,14,20,32,34,35 that former drivers had less participation in outside activi- support. Decline in social health after driving ties and lower productivity in daily life activities than cur- cessation appeared greater in women than in men. The rent drivers (Table 3). The association between driving reported declines in social health were not as rapid as 14,35 34 cessation and poor physical functioning was strong in lon- those in physical health. For example, one study JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 337 Table 3. Categorical Health Outcomes Associated with Driving Cessation for the 16 Studies Poorer Less Lower Out- Greater Greater Less Functional Greater Productive Poorer Greater of-Home Dependency Greater Risk Depressive Social Status (Role Cognitive Engagement General Risk of Activity and Loss of Entry into Author, Year Symptoms Engagement Playing) Decline (e.g., Work) Health Mortality Level of Control Long-Term Care Al-Hassani et al. 2014 ++ + Choi et al. 2014 + Curl et al. 2013 + Edwards et al. 2009a  ++ Edwards et al. 2009b + Fonda et al. 2001 + Freeman et al. 2006 + Liddle et al. 2012 ++ + Mann et al. 2005 ++ + Marottoli et al. 1997 + Marottoli et al. 2000 + Mezuk et al. 2008 O’Connor et al. 2013 ++ + + Ragland et al. 2005 + Siren et al. 2004 ++ Windsor et al. 2007 + + Studies, n 6 6 5 2 2 4 2 1 2 1 += Significant association;  = No significant association. 338 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS reported that, over a 13-year period, driving cessation was 3-year mortality, with nondrivers four to six times as associated with a 51% reduction in the size of social net- likely to die as drivers after adjusting for baseline psycho- works of friends and relatives, which was not mediated by logical and general health, sensory function, and cognitive the availability of or access to alternative transport. In abilities. The other study found that 5-year mortality risk addition, support from family and friends remained for nondrivers was 68% higher than in drivers. The stron- unchanged. Former drivers were likely to spend less time ger association reported in the first study may be due in in social activities and more time in solitary leisure or to part to the fact that its study subjects were less healthy 7,20 32 abandon previous social activities. than those in the latter. Cognitive Decline Depressive Symptoms 34 2,4,6,7,14 One longitudinal study reported that former drivers had Five cohort studies that examined the effect of driv- poorer cognitive abilities as measured according to the ing cessation on depressive symptoms in older adults were Mini-Mental State Examination than current drivers. Simi- included in a meta-analysis. Four of the studies reported sig- larly, another study found that former drivers had faster nificantly greater depressive symptoms in ex-drivers after cognitive decline over a 10-year period than active drivers adjustment for potential confounding factors. Effect esti- even after controlling for baseline cognitive function and mates did not show significant heterogeneity (Q = 3.266, general health. Current drivers were also healthier and had df = 4, P = .51; I = 0.000), indicating that the studies were better cognitive function than former drivers in a cross- fairly homogenous, so a fixed-effects model was used. Over- sectional study. all, driving cessation almost doubled the risk of greater depressive symptoms in older adults (summary OR = 1.91, Entry into Long-Term Care 95% CI = 1.61–2.27) (Figure 2). A funnel plot for the five studies did not indicate any major publication bias because The only study to evaluate entry into LTC reported that the summary OR was near the estimated effects from the former drivers were nearly five times (hazards ratio two largest studies. A cross-sectional study that used a dif- (HR) = 4.85, 95% confidence interval (CI) = 3.26–7.21) ferent measure for depression also found that greater depres- as likely as current drivers to be admitted to LTC facilities sive symptoms were associated with driving cessation. (e.g., nursing home, assisted living community, retirement home). Even after adjusting for marital status or co-resi- dence, the authors found a strong association between DISCUSSION driving cessation and LTC entry. Having no other driver Driving cessation in older adults is associated with a vari- in the house was independently associated with LTC entry ety of adverse health outcomes, particularly greater depres- (HR = 1.72, 95% CI = 1.15–2.57). sive symptoms. These findings are generally consistent with a previous review but update and expand the find- Risk of Mortality ings of that review with more than 10 additional years of There was a general agreement between the two stud- empirical research. Evidence of the association between 32,36 ies that exclusively examined the relationship between driving cessation and depression is robust and compelling. driving cessation and risk of mortality. One of these stud- Depressive symptoms were measured using the Center for ies found that driving cessation was a strong predictor of Epidemiologic Studies Depression Scale in all five cohort Figure 2. Forest plot, summary odds ratios (ORs), and 95% confidence intervals (CIs) of depressive symptoms associated with driving cessation. The size of each square is proportional to the relative weight that each study contributed to the summary OR. The diamond indicates the summary OR. Horizontal bars indicate the 95% CIs. Heterogeneity: Q statistic: 3.266, df = 4, P = .51, I = 0.000. JAGS FEBRUARY 2016–VOL. 64, NO. 2 HEALTH CONSEQUENCES OF DRIVING CESSATION 339 studies included in the meta-analysis. Moreover, these five adults may combine errands such as a trip to the drug studies were of high quality, as indicated by NOS scores. store with seeing a friend. Although declines in social 4 35 With the exception of one study, the underlying popula- activities may be gradual, they have been found to tions studied were nationally representative samples of the strongly mediate the association between driving cessation U.S. population. Because of the integral role that driving and mortality over time. plays in personal identity and independence, driving cessa- Exdrivers tend to have poorer cognitive abilities than tion may lead to psychological reactions. The perceived current drivers. Although most studies have shown that loss of control that accompanies driving cessation may declines in cognitive abilities contribute to driving cessa- partly explain the association between driving cessation tion, there is a paucity of studies focusing on the effect of and greater depressive symptoms. Not much is known driving cessation on cognitive abilities. Findings from one about the extent to which existing transition services and study indicate a possible bidirectional association between programs contribute to the maintenance of control beliefs driving status and cognitive abilities. and social functioning, but studies have found that avail- Factors that are likely to precipitate mortality are ability and access of alternative transport may not mitigate also likely to affect driving status, making it difficult to 2,34 the observed risk of increased depressive symptoms. establish a causal relationship between driving cessation 32,36 Given the observational nature of the included studies, the and mortality, but the two studies included in this possibility that driving cessation and depression are both review adjusted for baseline covariates that could con- consequences of some other common factor (e.g., declining found the association between driving cessation and mor- health) cannot be completely excluded. Nevertheless, addi- tality. Both studies indicate that driving cessation is a tional research may identify effective interventions that strong risk marker for mortality, possibly by worsening can avoid the worsening of depressive symptoms associ- the diminishing functional capabilities of the normal ated with driving cessation. aging process. Prior research reported conflicting findings on the The aforementioned adverse health consequences effect of driving cessation on general health. Although notwithstanding, reducing or ceasing driving in older some researchers found nondrivers to have more medical adults may have safety benefits. One study reported a conditions and poorer health than drivers, others have 45% reduction in the annual rate of crash injury in medi- 22,38 reported the opposite. There is growing evidence that cally unfit drivers after they received warnings from their driving cessation may exacerbate decline in general physicians. health. The prospective nature of the study on health tra- Although this review provides an up-to-date synthe- jectories, adjusting for baseline covariates, offers com- sis of the research literature on driving cessation and pelling evidence of this effect. The conflicting evidence in health outcomes, it has several notable limitations. With the literature might be explained in part by the fact that the exception of one study, the studies examining the healthier people adapt better to driving cessation than effect of driving cessation on depressive symptoms those in poorer health. Additional large, prospective included a self-report depression scale rather than a clin- studies controlling for location and medical conditions are ical diagnosis and thus were able to examine changes required to further establish the effect of driving cessation only on the scale and not in the proportion of partici- on health. pants classified as clinically depressed. In addition, the Based on the current findings, driving cessation may assessments of other health outcomes varied substantially hasten declines in physical and social health in older across the studies reviewed. The use of standardized adults. Older ex-drivers tend to have markedly fewer out- measures could allow for quantitative synthesis to obtain 14,32 of-home activities as they substitute indoor activities for robust estimates of effect size. Two studies used outside activities. Although older adults tend to find sub- data from the same project, but the respective study stitute activities to do around the home, those activities samples did not overlap. Finally, this review was limited may not benefit physical functioning as much as produc- to studies published in English and excluded qualitative tive work or volunteerism outside the home does. The studies, which can provide rich and deep—although not health implications of markedly poorer physical function- generalizable—information about the effects of driving ing are profound in terms of worsening of underlying cessation. Additional longitudinal studies using standard- physical and emotional problems, deconditioning, and ized measures of health outcomes are needed to better need for support with IADLs. As older adults transition to understand the effects of driving cessation on health and stopping driving, programs should be in place to facilitate well-being in older adults, particularly as to how these continued physical and social activities. effects may differ according to geographic location and Although there were discrepancies in the assessment of other driver characteristics. social functioning after driving cessation, the findings are generally consistent. In some qualitative studies, older ex- CONCLUSIONS drivers mentioned loss of spontaneity and the increasing 5,39 need to plan things ahead of time, which can limit There is mounting evidence that driving cessation in older adults may contribute to a variety of health problems. Of opportunities for out-of-home social engagement and activities. Loss of social functioning appears to affect special note is the apparent effect of driving cessation on women more than men, but women who voluntarily cease self-reported depressive symptoms. Pooled data from five driving seem prepared to adapt to a nondriving lifestyle, studies indicate that driving cessation nearly doubles the risk of greater depressive symptoms in older adults. The whereas those who were forced to stop had a more diffi- strength of the association between driving cessation and cult transition. Because of lifestyle changes, many older 340 CHIHURI ET AL. FEBRUARY 2016–VOL. 64, NO. 2 JAGS 9. Colby S, Ortman J. The Baby Boom Cohort in the United States: 2012 to self-reported depressive symptoms is generally consistent 2060. Population Estimates and Projections. Washington, DC: U.S. Census across studies. This finding may be generalizable to the Bureau, 2014. older adult population in the United States because the 10. United States Department of Transportation. FHWA: Highway Finance underlying population in four of the five studies came from Data Collection. Our National Highways. Washington, DC: Office of Highway Policy Information, 2011. nationally representative samples in the United States, and 11. Frey EH. Baby boomers and the new demographics of American’s seniors. the fifth came from a fairly comparable Western Aus- J Am Soc Aging 2010;34:28–37. tralian population. This review also sheds light on other 12. Foley D, Heimovitz H, Guralnik J et al. Driving life expectancy of persons health outcomes of driving cessation, including declines in aged 70 years and older in the United States. 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Predicting episodic memory performance of very old men and women: Contributions from age, depression,

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