"Is It Time to Stop Driving?": A Randomized Clinical Trial of an Online Decision Aid for Older Drivers

Marian E. Betz MD, MPH; Linda L. Hill MD, MPH; Nicole R. Fowler PhD, MHSA; Carolyn DiGuiseppi MD, MPH, PhD; S. Duke Han PhD; Rachel L. Johnson MS; Lauren Meador MPH; Faris Omeragic BS; Ryan A. Peterson PhD; Daniel D. Matlock MD, MPH

Disclosures

J Am Geriatr Soc. 2022;70(7):1987-1996. 

In This Article

Abstract and Introduction

Abstract

Background: Many older adults face the difficult decision of when to stop driving. We sought to test whether an online driving decision aid (DDA) would improve decision quality.

Methods: This prospective two-arm randomized trial enrolled English-speaking licensed drivers (age ≥70 years) without significant cognitive impairment but with ≥1 diagnosis associated with increased likelihood of driving cessation; all participants received primary care in clinics associated with study sites in three states. The intervention was the online Healthwise® DDA for older adults addressing "Is it time to stop driving?"; control was web-based information for older drivers only. The primary outcome was decision conflict as estimated by the Decisional Conflict Scale (DCS; lower scores indicate higher quality). Secondary outcomes were knowledge and decision self-efficacy about driving decisions. We examined postrandomization differences in primary and secondary outcomes by study arm using generalized linear mixed-effects models with adjustment for site and prerandomization scores.

Results: Among 301 participants (mean age: 77.1 years), 51.2% identified as female and the majority as non-Hispanic (99.0%) and white (95.3%); 98.0% lived in an urban area. Participant characteristics were similar by study arm but differed across sites. Intervention participants had a lower mean DCS score (12.3 DDA vs 15.2 control; adjusted mean ratio [AMR] 0.76, 95%CI 0.61–0.95; p = 0.017). Intervention participants had higher mean knowledge scores (88.9 DDA vs. 79.9 control; OR 1.13, 95%CI 1.01–1.27, p = 0.038); there was no difference between groups in self-efficacy scores. The DDA had high acceptability; 86.9% of those who viewed it said they would recommend it to others in similar situations.

Conclusions: The online Healthwise® DDA decreased decision conflict and increased knowledge in this sample of English-speaking, older adults without significant cognitive impairment, although most chose to continue driving. Use of such resources in clinical or community settings may support older adults as they transition from driving to other forms of mobility.

Trial registration: ClinicalTrials.gov identifier "Advancing Understanding of Transportation Options (AUTO)" NCT04141891.

Introduction

The decision to reduce or cease driving is often difficult and stressful for older adults, their families, and their healthcare providers. There are over 45 million licensed older drivers in the United States,[1] yet older adults generally outlive safe driving ability by 7–10 years.[2] As a result, many older adults and their family members are faced with the decision of if and when to stop driving, and how to stay mobile afterward. Driving has a clear relationship to health and perceived independence and well-being. Although crash risk rises with age,[3] driving and maintaining independence are closely linked, and driving cessation can negatively impact a person's health and psychosocial well-being.[3–6]

Decision-making about driving cessation is complicated by the nature of driving risk (impacted by myriad cognitive and physical conditions[7,8]), varying support for individuals after driving retirement (including emotional support and usable alternative transportation), and strong emotions about driving. Older adults want to maintain control of driving decisions and have time to prepare for mobility transitions.[9–11] Family members want to discuss driving with their loved ones and are often uncertain of how and when to do so, especially since these discussions are not routine in primary care.[9,12,13] The challenge of how to support older adults making decisions about driving[14–16] gains urgency with the aging population and a growing number of older adults living with physical and cognitive impairment.

Although informational websites and self-assessment tools exist, a key knowledge gap has been how to help older drivers actually make decisions about their driving in a way that is individualized and supports autonomy. In clinical medicine, decision aids are used to increase patient knowledge and decision quality.[17] An existing web-accessible driving decision aid (DDA)[18] meets international decision aid standards[19] but has not yet been tested for efficacy.

The Advancing Understanding of Transportation Options (AUTO)[20] study is a multisite, two-armed randomized controlled trial testing the impact of a DDA on older adults' decisions about changes in driving behaviors and cessation. AUTO was designed to enroll 300 community-dwelling older drivers, each with a study partner identified by each driver. Dyads were randomized to view a DDA or control (web-based information only[21]), and the trial seeks to examine arm differences on decision conflict, knowledge, and self-efficacy, hypothesizing that DDA participants will have higher quality decisions (as approximated by lower internal conflict, higher knowledge, and higher self-efficacy).[22]

processing....