Parkinson disease and driving An evidence-based review

From the Departments of Aging and Geriatric Research (A.M.C.) and Occupational Therapy (A.M.C., S.C.)
Neurology (Impact Factor: 8.3). 11/2012; 79(20):2067-2074. DOI: 10.1212/WNL.0b013e3182749e95
Source: PubMed

ABSTRACT The growing literature on driving in Parkinson disease (PD) has shown that driving is impaired in PD compared to healthy comparison drivers. PD is a complex neurodegenerative disorder leading to motor, cognitive, and visual impairments, all of which can affect fitness to drive. In this review, we examined studies of driving performance (on-road tests and simulators) in PD for outcome measures and their predictors. We searched through various databases and found 25 (of 99) primary studies, all published in English. Using the American Academy of Neurology criteria, a study class of evidence was assigned (I-IV, I indicating the highest level of evidence) and recommendations were made (Level A: predictive or not; B: probably predictive or not; C: possibly predictive or not; U: no recommendations). From available Class II and III studies, we identified various cognitive, visual, and motor measures that met different levels of evidence (usually Level B or C) with respect to predicting on-road and simulated driving performance. Class I studies reporting Level A recommendations for definitive predictors of driving performance in drivers with PD are needed by policy makers and clinicians to develop evidence-based guidelines.

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Available from: Alexander M Crizzle, Aug 11, 2015
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    • "In addition, we were unable to collect information on why falls occurred (i.e., due to freezing of gait), when these occurred (i.e., at night), or whether they occurred in the " on " of " off " medication state. Falls are more likely to occur during the wearing off phase (Albanese, 2007), and there is some evidence that the UPDRS motor scores in the " off " (versus the " on " ) state are a stronger predictor of driving performance (Crizzle et al. 2012b). For the PD sample as a whole, lower balance confidence (ABC) scores were significantly related to poorer contrast sensitivity, greater LED levels, and self-reported avoidance of driving in challenging situations. "
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    ABSTRACT: Aims: Factors related to fall risk (balance confidence, motor, visual, and cognitive deficits) may also affect the driving practices of people with Parkinson's disease (PD). The purpose of this study was to explore these potential associations. Methods: A sample of 11 self-reported fallers (mean age 72.3 ± 6.0 years; 55% men) and 16 non-fallers (mean age 71.1 ± 7.2 years; 100% men) were assessed on a battery of clinical measures and brake reaction and response time. Electronic devices were installed in vehicles to examine naturalistic driving practices. Results: In the sample overall, lower balance confidence scores were associated with worse contrast sensitivity, higher levodopa equivalency dosage, and more reported driving avoidance. Fallers had significantly lower balance confidence (p < 0.01), more episodes of hard braking (p < 0.05), and drove at slower speeds (km/hour) on most roadways (p < 0.05). Conclusions: Researchers and clinicians should consider mobility problems, particularly recurrent falls and balance confidence, which may influence driving practices.
    Physical & Occupational Therapy in Geriatrics 12/2014; 33(1). DOI:10.3109/02703181.2014.991057
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    • "This was an unexpected result given that cognitive dysfunction has been implicated as contributing to impaired driving ability in PD patients. Prior research has demonstrated that certain cognitive tests such as the ReyeOsterrieth Complex Figure Test (ROCF), Trails B, Trails B-A, and functional reach may be predictive of impaired driving performance in PD [1]. Although we did not have these specific detailed cognitive tests to analyze in our cohort, our study found no significant difference in MOCA scores, nor a significant difference in proportion of drivers with MoCA scores in the MCI range between the safe and risky groups, supporting our observation that neocortical cholinergic uptake is not associated with risky driving behavior. "
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    ABSTRACT: It is unknown whether driving difficulty in Parkinson disease (PD) is attributable to nigrostriatal dopaminergic or extranigral non-dopaminergic neurodegeneration. To investigate in vivo imaging differences in dopaminergic and cholinergic innervation between PD patients with and without a history of risky driving. Thirty non-demented PD subjects (10 women/20 men) completed a driving survey. These subjects had previously undergone (+)-[(11)C] dihydrotetrabenazine vesicular monoamine transporter 2 and [(11)C] methyl-4-piperidinyl propionate acetylcholinesterase PET imaging. Acetylcholinesterase PET imaging assesses cholinergic terminal integrity with cortical uptake largely reflecting basal forebrain and thalamic uptake principally reflecting pedunculopontine nucleus integrity. Eight of thirty subjects reported a history of risky driving (been pulled over, had a traffic citation, or been in an accident since PD onset) while 22 had no such history (safe drivers). There was no difference in striatal dihydrotetrabenazine vesicular monoamine transporter uptake between risky and safe drivers. There was significantly less thalamic acetylcholinesterase activity in the risky drivers compared to safe drivers (0.0513 ± 0.006 vs. 0.0570 ± 0.006, p = 0.022) but no difference in neocortical acetylcholinesterase activity. Using multivariable logistic regression, decreased thalamic acetylcholinesterase activity remained an independent predictor of risky driving in PD even after controlling for age and disease duration. Risky driving is related to pedunculopontine nucleus-thalamic but not neocortical cholinergic denervation or nigrostriatal dopaminergic denervation in PD. This suggests that degeneration of the pedunculopontine nucleus, a brainstem center responsible for postural and gait control, plays a role in the ability of PD patients to drive.
    Parkinsonism & Related Disorders 09/2013; 20(1). DOI:10.1016/j.parkreldis.2013.08.021 · 4.13 Impact Factor
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    • "However, due to the categorical nature of the scale, findings are difficult to interpret, particularly as our cohort only ranged from state 2 to 3 although subjects with MHY scores of ≥2.5 were likely to fail the road test than those categorized as stage 2. Although the UPDRS is considered the gold standard of PD assessment for movement disorder specialists/neurologists, the application in isolation to predict pass/fail on-road outcomes performs poorly, consistent with findings of a recent evidence based review [26]. Visual-cognitive deficits (e.g., visuoperceptual , spatial, attentional, information processing speed) are critical to driving impairment [6, 8, 27–31] "
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    ABSTRACT: Background: The primary influence of motor symptoms on driving performance remains unclear due to the inconsistent use of various motor rating scales used in prior studies. Objective: This study aimed to determine which of three measures utilized in PD, the Unified Parkinson's Disease Rating Scale (UPDRS) motor section; the Modified Hoehn and Yahr; and the Rapid Paced Walk Test would best predict pass/fail outcomes on a road test in a sample of PD drivers. Methods: All participants (N = 55; 79% men) completed a road test. Receiver Operating Characteristics were then contrasted for all subjects based on assessments from all three disease severity indices. MMSE scores were then modelled with significant disease severity measures (if any) to determine if the predictive accuracy could be improved. Results: The Rapid Paced Walk Test and the Modified Hoehn & Yahr both predicted pass/fail outcomes on the road test (Area under the curve of 0.73 and 0.82, respectively). UPDRS motor scores, however, did not predict safe driving. When optimal cut-off points on the Modified Hoehn & Yahr (≥2.5) and Rapid Paced Walk Test (>6.22 seconds) were modelled with MMSE scores indicative of mild cognitive impairment (<27), the model accurately classified 92% and 100% as failing the road test, respectively. Conclusion: Although the Rapid Paced Walk Test had a slight advantage in differentiating between pass/fail outcomes compared to the Modified Hoehn & Yahr, both tests alone cannot be used in isolation to predict driving safety. Predictive accuracy can be improved using both select cut-off points on the Modified Hoehn & Yahr and Rapid Paced Walk test with MMSE scores in PD drivers. Though these findings are useful, an on-road test is still the gold standard, and screening should always be followed by formal testing.
    01/2013; 3(2):153-60. DOI:10.3233/JPD-120152
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