R E S E A R C H A R T I C L E
Open Access
Are interventions effective at improving
driving in older drivers?: A systematic
review
H. I. Castellucci
1, G. Bravo
2, P. M. Arezes
3and M. Lavallière
4,5,6,7*Abstract
Background: With the aging of the population, the number of older drivers is on the rise. This poses significant challenges for public health initiatives, as older drivers have a relatively higher risk for collisions. While many studies focus on developing screening tools to identify medically at-risk drivers, little research has been done to develop training programs or interventions to promote, maintain or enhance driving-related abilities among healthy individuals. The purpose of this systematic review is to synopsize the current literature on interventions that are tailored to improve driving in older healthy individuals by working on components of safe driving such as: self-awareness, knowledge, behaviour, skills and/or reducing crash/collision rates in healthy older drivers.
Methods: Relevant databases such as Scopus and PubMed databases were selected and searched for primary articles published in between January 2007 and December 2017. Articles were identified using MeSH search terms: (“safety” OR “education” OR “training” OR “driving” OR “simulator” OR “program” OR “countermeasures”) AND (“older drivers” OR “senior drivers” OR “aged drivers” OR “elderly drivers”). All retrieved abstracts were reviewed, and full texts printed if deemed relevant.
Results: Twenty-five (25) articles were classified according to: 1) Classroom settings; 2) Computer-based training for cognitive or visual processing; 3) Physical training; 4) In-simulator training; 5) On-road training; and 6) Mixed interventions. Results show that different types of approaches have been successful in improving specific driving skills and/or behaviours. However, there are clear discrepancies on how driving performance/behaviours are evaluated between studies, both in terms of methods or dependent variables, it is therefore difficult to make direct comparisons between these studies.
Conclusions: This review identified strong study projects, effective at improving older drivers’ performance and thus allowed to highlight potential interventions that can be used to maintain or improve older drivers’ safety behind the wheel. There is a need to further test these interventions by combining them and determining their effectiveness at improving driving performance.
Keywords: Elderly drivers, Road safety, Prevention, Collisions
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* Correspondence:martin_lavalliere@uqac.ca
4Module de Kinésiologie, Département des Sciences de la Santé, Université du Québec à Chicoutimi (UQAC), Saguenay, QC, Canada
5Laboratoire de recherche biomécanique & neurophysiologique en réadaptation neuro-musculo-squelettique - Lab BioNR, UQAC, Saguenay, QC, Canada
Background
The number of older drivers is rapidly rising due to the aging population [1–4]. It is projected that, by 2030, 20% of the population will be 65 years or older [5]. In Canada, it is expected that, by 2026, 1 driver out of 5 will be 65 years or older [6]. With increasingly active life-styles, seniors are expected to rely even more on their vehicles, taking more trips, driving further distances, and keeping their licenses longer than prior generations [7]. In fact, it is anticipated that a large proportion of both men and women will continue driving well into their 80’s [8]. For example, a majority of Canadian seniors hold a valid driver’s license (4.7 million in 2017. repre-senting 75% of all seniors) [9]. These trends pose signifi-cant public health concerns, as older drivers are disproportionately involved in collisions [9] causing ser-ious injury and death, when exposure (kilometres driven) is taken into account [10].
The higher crash rates in older adults may be due to age-related medical conditions. For example, seniors may develop vision impairment [11, 12], mild cognitive impairment, early dementia, Parkinson’s disease and other neurodegenerative disorders, or may have suffered a stroke. All these conditions produce symptoms that impair the skills that are required to drive safely. Many studies show that these conditions lead to worse driving performances both on-road [13, 14] and in-simulator evaluations [15] compared to the general older adult population. Despite these numerous health conditions associated with aging that might negatively impact driv-ing performance, the proportion of older drivers who are considered healthy still represents the largest segment of these drivers. Therefore, there is a need to assess inter-ventions that are tailored for them.
Multiple assessment tools are available for use within clinical settings to screen for at-risk drivers. Although many assessments/tools are quick and easy to adminis-ter, a screening battery has not yet been developed [16, 17]. The potential to detect unsafe drivers versus suc-cessfully identifying safe drivers is an important consid-eration, particularly as removing one’s license can have negative consequences [18,19]. Prior studies have found that driving cessation is associated with increased de-pression, social isolation, institutionalization and even early mortality [20, 21]. A recent survey conducted by Vrkljan et al. [22] showed inconsistency in practice among evaluations in a sample of driver assessment cen-tres for medical fitness to drive (n = 47). Their results highlight the necessity of evidence-based guidelines for the training and assessment of at-risk drivers.
While licensing authorities must consider public safety when delivering driver’s licenses, it is important to help seniors drive for as long as possible to facilitate their au-tonomy and independence. This is particularly the case
since there are few programs to help seniors adjust to non-driving.
Alternatively, interventions aimed at improving or maintaining driving skills offer new opportunities to help seniors drive safer, longer. Several studies have examined the impact of workbooks, seminars, and cognitive, simu-lator or on-road training on driving performance in older adults in general, and in those with various med-ical conditions. The purpose of this systematic review is to synopsize the current literature on interventions that are tailored to improve driving: Self-awareness, know-ledge, behaviour, skills and/or reducing of the number of collisions in healthy older drivers.
Methods
A systematic literature review (SLR) methodology [23] was used to synopsize the current literature on interven-tions that are tailored to improve older individuals’ driv-ing. This methodology is scientifically transparent, replicable, and useful to generate an in-depth analysis of the scientific literature [24]. An initial exploratory review was produced prior to conduct the full SLR [25]. This method allows to elucidate common knowledge of the topic, to identify if the proposed SLR fits the existing knowledge in the area, to determine the key concepts and to refine the research question. Also, this SLR followed a five-step approach proposed by Denyer and Tranfield [25]: 1) Question formulation; 2) Locating studies; 3) Study selection and evaluation; 4) Analysis and synthesis; and 5) Reporting and using the results. Based on witch, a review protocol was used regarding the formulation of the research question, on the selec-tion of scientific databases and search terms, and on the inclusion and exclusion criteria for searching and analys-ing retrieved publications.
Step 1: question formulation
A PICO framework (Population, Intervention, Control, Outcomes) was used to generate the research question of this study (Step 1). This approach allows for a more systematic approach regarding the identification of rele-vant information and its understanding by using these four categories [24,26]. Therefore, the research question formulated for this SLR was: In healthy older drivers (P), which type of intervention program (I), education, computer-based, physical training, on-road, simulator-based or mixed program (C) improved driving: Self-awareness, knowledge, behaviour, skills and/or crash rates (O)?
Step 2: locating studies
Based on the research question defined in Step 1, search strings to be used and appropriate bibliographic data-bases were defined in Step 2. Scopus and PubMed
databases were used as they encompass a wide array of scientific areas as well as the most relevant peer-reviewed publications [27]. Articles were identified using MeSH search terms and strings (in English only): (“safety” OR “education” OR “training” OR “driving” OR “simulator” OR “program” OR “countermeasures”) AND (“older drivers” OR “senior drivers” OR “aged drivers” OR “elderly drivers”). The EndNote version X9.2 man-agement software package was used to manage all the information.
Step 3: study selection and evaluation
To select the most relevant scientific articles to include in the review, the inclusion and exclusion criteria were defined in Step 3. The following key inclusion criteria were defined prior to the search:
Original articles written in English and published in peer-reviewed journals;
Published or in press between January 2007 and December 2017.
Articles were excluded if the sample presented drivers with specific health conditions (e.g.
traumatic brain injury, vision impairment associated with specific pathologies, stroke or Parkinson’s Disease).
Titles and abstracts of papers were scanned independ-ently by three of the authors to identify relevant articles to retrieve for full text analysis. In cases where the pa-pers seemed potentially eligible, but no abstract was available, the full text of the paper was retrieved. Dis-agreements between authors led to a deeper joint ana-lysis of the paper; and a decision was then made regarding its inclusion. Full texts were independently reviewed for inclusion by the same three authors.
The literature search purposely only included studies between 2007 and 2017, since previous systematic re-views on the topic had already been conducted [28,29]. These reviews cover researches completed prior to 2008, and despite being well-conducted systematic reviews, more recent studies on different interventions to im-prove older drivers’ performance have been conducted but not yet been synthesized. To our knowledge, there is no more recent review in the literature, despite the need for guiding evidence-based practices.
Step 4: analysis and synthesis
Step 4 consisted in analysing, extracting and managing papers’ information to identify and highlight key compo-nents of the research conducted and its results. Primary studies meeting the inclusion criteria and reported in the included reviews were identified, and the corre-sponding data was extracted using a standardized data
extraction form. The Quality Assessment Tool set known as “QualSyst tools” was selected as it allows ap-praisal of quality while assessing potential bias over a wide variety of research designs, from experimental to observational [30]. Furthermore, this set of tools has one version for quantitative studies and another one for qualitative studies, and in this review, the first one was used. The quantitative version consists in a checklist of 14 questions, with possible answers of: yes, no, partial or not applicable. The score for a“yes” answer is 2 points, for a“partial” answer 1 point, and for “no” 0 points. The sum of all answers is then calculated from the corre-sponding points and divided by the total of applicable responses.
The QualSyst was used by three of the authors to evaluate internal and external validity of the considered studies. The QualSyst tool was originally created as a threshold allowing a study to be included in a review through a cut-off point (0.55 to 0.75) [30]. In this review, the QualSyst cut-off score of 0.55 was chosen to capture 75% of the articles initially deemed as relevant for the re-view, as well as to ensure the inclusion of several de-scriptive articles containing valuable data [31]. More specifically, papers with a score higher than 0.8 were classified as having a strong methodology (> 0.8), be-tween 0.79 and 0.71 as being good, and adequate if the score was between 0.7–0.55, or limited and therefore ex-cluded if the score was lower than 0.55 [32,33].
By using an approach adapted from Sackett et al. [24], identified papers were also categorized using a standard-ized value system to grade biomedical practices accord-ing to the followaccord-ing system:
Level I: Systematic reviews, meta-analyses, random-ized controlled trials
Level II: Two groups, nonrandomized studies (e.g., cohort, case control)
Level III: One group, nonrandomized (e.g., before and after, pre-test and post-test)
Level IV: Descriptive studies including analysis of outcomes (e.g., single-subject design, case series)
Level V: Case reports and expert opinions including narrative literature reviews and consensus
statements.
Using such an approach while conducting a review also provides a scheme of references for the clini-cians interested in using such methods/approaches in their practicum. Evidence-based practices are built on the assumption that scientific evidence of the ef-fectiveness of an intervention can be deemed more or less strong and valid according to a hierarchy of research designs, the assessment of the quality of the research, or both.
Step 5: reporting and using the results
For Step 5, the results were grouped (Tables1,2,3,4,5, 6, 7 and 8) according to the specific type of programs (independent variables) used by Golisz [59], who consid-ered 5 different options such as: (1) education-based training programs, (2) computer-based training, (3) physical training, (4) simulator-based training, and (5) route-based or actual driving training. Moreover, an-other independent variable was considered in the current study (6 - Mixed programs) since there were many investigations that used two types of interventions, therefore making it difficult to differentiate which one of the variables is responsible for the obtained results. It is noteworthy that the route-based or actual driving train-ing (5) alone was not used in any of the studies evalu-ated and is therefore not presented in the tables.
The dependent variables were categorized according to the methods used to collect them (Table 1): Tests/ questionnaires, on-road evaluations, simulator and the combination of all. Also, the dependant variables were grouped to infer on the impact of the given program: Self-awareness and/or knowledge, behaviour, skills and crash rates (Tables2,3,4,5,6,7and8).
Self-awareness/Knowledge: Self-awareness of one’s ability to drive and of their capacities and/or limitations to do so safely is mainly evaluated by conducting inter-views or via questionnaire. As for knowledge, it is often associated with traffic regulations and laws, as well as the effect of health and other factors on driving.
Behaviour: The drivers’ behaviour is documented as moment of the day, roads used, driven speed, or what has been described by Michon [60] in his model of driv-ing as strategic and tactical levels.
Skills: Described as the operational level of Michon’s model [60], skills are linked with direct control of the vehicle as well as with visual searches surrounding a manoeuvre.
Crash rates (or collisions/accidents): Either collected as self-reported value by participants or by cross-referencing available databases, crash rates (ex. Colli-sions/accidents per distance driven or per year) are used as a predictor of an intervention’s effectiveness.
Results
Figure 1 shows the results of the search strategy using PRISMA. An initial number of 1510 papers was identi-fied through search of databases (SCOPUS: 934 and Pubmed: 576), from which 484 duplicates were removed. After screening the remaining 1026 title, abstract and keywords of each article, 36 papers were identified as be-ing potentially relevant. Followbe-ing a complete review of the corresponding full-texts, 29 papers were then se-lected based on the previously mentioned inclusion cri-teria. Seven (7) papers were not considered due to different situations [61–67], for example: the objective of the paper by Joanisse et al. [61] was to report the find-ings from an evaluability assessment of the 55 alive ma-ture driver-refresher course offered by the Canada Safety Council. Another example is the study by Musselwhite [63] where different issues were addressed through an expert group opinion identifying age related physio-logical and cognitive changes that may be involved in collisions. Finally, after applying the QualSyst [30], 4 pa-pers were removed due to the methodology quality. Thus, 25 papers were included in the final review.
Table 1 shows the summary of studies reviewed. It
should be noted that none of the reviewed studies con-sidered route-based or actual driving training as a pure independent variable. Also, it can be seen that 8 of the 25 studies evaluated a combination of more than one type of intervention (Mixed approach), followed by computer-based and education interventions with 7 and 6 studies, respectively. On the other hand, interventions with less studies in this review are those based on phys-ical training and simulator-based training, with 4 and 2 studies each. For more specific information on studies identified in this literature review, detailed descriptions of protocols can be found in Tables4,5,6,7and8.
Tests/questionnaires were used more frequently to evaluate programs, secondly, on-road evaluations and the combination of these two approaches and thirdly, in-simulator alone or combined with on-road evaluation (Table1).
Table 2 presents the principal dependant variables used to infer on the impact of the given program: Self-Table 1 Summary of the reviewed studies
Type of Programs Method used to collect the dependent variables
On-road (OR) Simulator (S) Test/Questionnaire (TQ) OR/TQ S/TQ OR/S Total
Education 1 0 4 1 0 0 6 Computer based 1 1 4 0 1 0 7 Physical training 2 0 0 0 0 0 2 Simulator-based training 0 2 0 0 0 0 2 Mixed 1 0 0 4 0 3 8 Total 5 3 8 5 1 3 25
Awareness/Knowledge (SAK), Behaviour (B), Skills (S) and Crash Rates (CR). Although 25 studies were reviewed, the number of dependent variables was 28 as three of the studies presented more than 1 dependent variable [35, 52, 53]. The most studied dependent vari-able was Skills, tested 12 times, followed by studies that considered Behaviour, tested 10 times.
Before presenting the summary of the results (Table3) and the synthesis of reviewed studies (Tables 4, 5, 6, 7 and 8), it is important to highlight that the effect of the independent variable was classified as (+) when the ef-fect resulted in a significant improvement in the dependent variable, (−) when the effect was significantly negative or no change was observed in the dependent variable and (+/−) when the obtained results were not clear (i.e. non-significant effect or a combination of sig-nificantly positive and negative effects on driving).
Overall results show that 60% of reviewed studies pre-sented positive (+) results, 24% prepre-sented negative (−), and the remaining 16% of the studies showed unclear re-sults (+/−). For example, from Table 4, the study by Coxon et al. [34] presented unclear overall results (+/−) since self-regulatory driving practices generally showed positive results, but a negative result in the distance driven per week, the restriction of driving space, the use of alternate transportation and community participation 12-months + post-intervention.
Regarding independent variables, the highest overall positive results are for physical training (Table 6) and
mixed programs (Table 8) with values of 100 and 88%, respectively. Finally, the lowest overall positive results can be observed when the reviewed studies considered education (43%) and computer-based programs (33%).
In all reviewed studies, primary research approaches were randomized controlled trial (RCT), observed in 17 studies, followed by a non-randomized controlled study (NRCT) and a cohort study used 4 and 3 times respect-ively. Also, only 1 study presented a pre-test and post-test approach. Finally, regarding sample size, studies evaluated ranged from 11 to 4880 drivers.
Education-based training programs
Education-based training programs were quite variable in terms of their duration (Table 4), some of them last-ing from 1 day up to a full month, the number of classes ranging between 1 and 4. Programs were developed mainly in classroom format. The follow-up evaluation from the intervention was also very variable, going from immediately to 2, 3, 6, and up to 12 months post-intervention. Four (4) of the studies were conducted using a RCT (Level 1) while the remaining 2 used a retro-cohort design (Level 3).
Regarding the dependent variables, 5 of the reviewed studies used questionnaires/tests to evaluate the pro-grams with self-reported driving knowledge, driving be-haviours, and driving habits, among others. Drivers reported changing their driving habits following the pro-gram and add increased knowledge of road safety facts, Table 2 Summary of the dependent variables considered in the reviewed studies
Dependent variables
Type of Programs Self-Awareness and/or Knowledge (SA/K) Behavior (B) Skills (S) Crash Rates (CR) Total
Education 2 4 0 1 7 Computer based 0 2 4 1 7 Physical training 0 0 2 0 2 Simulator-based training 0 0 2 0 2 Mixed 2 4 4 0 10 Total 4 10 12 2 28
Each study may have had more than one type of dependent variable, explaining why the totals add up to more than 25
Table 3 Summary of the results
Dependent variables
Type of Programs Self-Awareness and/or Knowledge (SA/K) Behavior (B) Skills (S) Crash Rates (CR) Total
(+) (−) (+/−) (+) (−) (+/−) (+) (−) (+/−) (+) (−) (+/−) (+) (−) (+/−) Education 2 0 0 1 2 1 0 0 0 0 1 0 3 3 1 Computer based 0 0 0 1 1 0 3 1 0 0 0 1 4 2 1 Physical training 0 0 0 0 0 0 2 0 0 0 0 0 2 0 0 Simulator-based training 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 Mixed 2 0 0 4 0 0 3 1 0 0 0 0 9 1 0 Total 4 0 0 6 3 1 9 3 0 0 1 1 19 7 2
Table 4 Synthesis of intervention studies involving education-based training programs Autho rs Numb er (n), Age (yr) Count ry (c) R.D. O bjective Study descrip tion Dep endent Vari able Rele vant resul ts QS Coxon et al., [ 34 ] n = 366 yr = be tween 75 and 94 years old. c = Aus tralia RCT To ascertain whe ther a safe -trans portation progr am can chang e driv ing exp osure while mai ntain ing com mun ity particip ation of older driv ers Participants were random ized in 2 groups: -Intervention group (n: 19 0): They had to partic ipate in tw o session s held 1 month apart. The sessio n was delivered by an occup ation al therapist face to face an d laste d 120 and 45 min , the first and second sessio n, respe ctively -Cont rol group (n: 190): Did not rece ive any educ ation. Befor e the random izat ion all the particip ants performed the basel ine asses sment and self-reported que s-tionna ires. Also , the driving expo sure was measu re over the 12 mont hs of study throu gh an in vehicl e monito r-ing de vice. (B) Drivi ng exp osure measure over the 12-m onth study period with an in-ve hicle monito ring de vice (B): Driving space and use of alternate transport ation we re measu red using a que stionnaire. (B): Depres sive symp toms were measu red using the Geria tric Dep ression Scale. B( − ): An education progr am doe s not translate to sign ificant differ ences in the dista nce driven pe r w e ek, the restriction of driving spa ce, the use of alternate trans portation and the com munit y partic ipation afte r 12-mo nth po st interve ntion. Also , there was no dif-fere nce betwee n the control and interve ntion group in proporti on of partic ipants with tw o or more de-press ive symp toms at 12 mont hs. B (+) : Participants in the intervent ion group w e re more like ly to be close r to adopting se lf-regulatory driv ing pract ices at 12 month s than control group. The odds of the particip ants in the interven tion group b e ing in a highe r b e havioral prof ile we re 1.6 time s greater than thos e in the con-trol group. 0,89
Nasvadi and Vavr
ik, [ 35 ] n = 139 (was cons idered phase 2) yr= be tween 55 and 94 years old. c = Can ada Retro- Coh ort D etermi ne if the crash rate of agi ng driv ers can be mi tigated by post -lice nse driv er education The particip ants we re divided in 2 group: -Drivers who atten ded the 55 ali ve/ mature driv ing course s b e tween Janu ary 1, 20 00 and Ju ly 31 , 2003 (n: ns). -Drivers who did not atte nd the educ ational program (n: ns). Then we re compared the cra shes rates afte r the date of atte ndanc e at the course , until Decemb er 31, 2003 (CR): Crashes an d viola tions were obt ained from Insuranc e Corporatio n o f British Colu mbia. CR (− ): Older men and wom en who atte nded the 55 Alive/Mature Drivi ng cou rse had a 1.5 times greater odds of being involved in a cra sh than their match ed controls . The se results we re mar ginally sign ificant (p = .078) . For wo men separately, there was no differ ence betwee n subje cts and contro ls for the num ber of post-c ours e crashes, re-gard less of age cate gory . Howe ver, for me n, driv ers aged 75 years an d older who atte nde d 5 5 Alive/Mature Drivi ng we re 3.8 times more likely to be involved in a cra sh (p = .0 50). 0,81 Nasvadi, [36 ] n = 367 yr = be tween 55 and 94 years old. c = Can ada Retro- Coh ort Exa min e long-te rm le arning out -com es of a sample o f olde r driv ers wh o attende d a mature driv er edu-cation progr am. The cohort cons iste d of driv ers aged 55 years and olde r wh o attende d the 55 alive/mature driving course. All particip ants we re surveye d by telepho ne. (SA/ K) and (B ): The sur vey cont ained ope n-end ed and cl osed questions and aske d respon dents to recall what they had learn ed in the course, and how their driving behavior had chang ed becau se of atten ding. SA/K (+) B (+): Three qua rters of partic ipants sai d they changed the ir driv ing habits as a result of atte nding the cou rse (55 alive/ mature) including: inc reased aware ness and vis ual skills; chang es in attitude; im proved spee d and spa ce mar gins ; avoid ance of hazards; usin g more caut ion; obe ying road rul es; and improve d vehi cle mane uvers. Men we re more likely to 0,79
Table 4 Synthesis of intervention studies involving education-based training programs (Continued) Autho rs Numb er (n), Age (yr) Count ry (c) R.D. O bjective Study descrip tion Dep endent Vari able Rele vant resul ts QS repo rt their driving skills had im proved since taki ng the cou rse, and older men rep orted sig nificantly highe r me an comfo rt scores with their driving. Jone s et al., [ 37 ] n =5 8 yr = ave rage age 70.9 years old (ag es N/S). c = USA RCT D escribe driv ing exper ience s and ha bits of a comm unity sample of olde r driv ers (60+ years) an d to de term ine whe ther the progr am red uces these olde r adu lts ’driving ris k exposu res. Participants were random ized in 2 groups: -Intervention group (n: 33 ): 4 weeks of train ing in a cl assroom setting with 2 h of training per week. The 4 sessio ns inc lude: roadw ise revi ew, road smart, safer driv ing and being medw ise to stay ro adwise medi cation. -Cont rol group (n:25): Did not rece ive training The bot h group compl eted the basel ine questionna ire and afte r the 4 weeks complet ed the questionna ire again. (B): Driving habit risk exp osure were div ide in two type s -Hig her driv ing risk exposu re: defi ned as frequ ency of driving furt her than 10 mi les from hom e, afte r dark, betwee n 5 pm an d 7 pm, and on inters tates. -Lowe r driv ing ris k exposu re: defined as frequ ency of driving less than 2 mile s from home and be fore 9 am. (B): They als o asked for driv ing exper ience B( − ): There were no st atistical differ ences in lower and higher driv ing risk exp osure whe n com paring the interven tion and cont rol group. 0,79 Gaines et al., [ 38 ] n = 195 yr = be tween 79 and 84 years old c= N M RCT Ass ess the process and sho rt-term eff ects of the CarFit progr am. Participants were random ized in 2 groups: -CarFit group (n: 83): the interve ntion was carried out in one day throu gh an indi vidual app ointme nt with the com munity ’s CarFit even t coord inator. Each CarF it asses sment req uired app roximat ely 15 mi n for compl etion. The refore , the total time could be 15 0 mi n. -Com parison group (n: 112): Did not rece ive training All the particip ants answered the driving questionna ire in the bas eline and six month s afte r the CarF it interve ntion. (B): A driv ing quest ionnaire bas ed in 3 part s was app lied: -Driving Ac tivity: a highe r score indi cates gre ater driving activity. -Com fortable Drivin g: a lowe r sc ore indi cates gre ater comfo rt during the driv ing activ ities. -Driving Be haviors: a lowe r sc ore indi cates saf er driving behaviors . B( − ): There was no statist ically sign ificant diff erence betwee n having a CarF it interven tion or not rece iving training after the six-mont h post CarFit interve ntion in driv ing beh aviors. 0,75 Jone s et al., [ 39 ] n =4 4 yr = ave rage age 79 ye ars old (ages N/S). c = USA RCT Co mpare the im pact of a mu lti-se ssion interac tive, expert-l ed ver-sion of the trai ning progr am (Se -nio rs on the MOV E – Ve rsion-A) to a se lf-guided and less reso urce inten-siv e version of the program (Sen iors on the Move – Versi on-B) on olde r driv ers ’know le dge an d be havior pe rtaining to driv ing. Participants were random ized in 2 groups: -SOM-A (n: 20): Co nsisted in the fou r sessio ns ut ilized in the Jones et al., 2011 and the CarFit asses sment . -SOM-B (n: 24 ): Con sisted in a self-guide d and less inten sive version of the SOM-A. The part icipants had to assist to a one sessio n an d tw o op-tiona l (one was in class an d the othe r the CarF it ass essm ent) At the beginn ing of each se ssion the (SA/ K): Self-re port ed driving know-ledge 15 item s we re develo ped by the auth ors to assess specific de tails taught during the session s. SA/K (+): The y foun d sign ificant differ ences in SOM-A group be-tw een the basel ine and the first fol -low up in the knowle dge of the prope r pla cement of the head re-straint , the time che cking tire pre s-sur e, mu scle relaxe rs do not affect driv ing and the defin ition of mod er-ate drinki ng for older adults. Bu t this sign ificant diff erence with the follow up tw o was only with the it em of de finition of drinki ng for olde r 0,68
Table 4 Synthesis of intervention studies involving education-based training programs (Continued) Autho rs Numb er (n), Age (yr) Count ry (c) R.D. O bjective Study descrip tion Dep endent Vari able Rele vant resul ts QS groups compl eted the bas eline questionna ire, the n immedi ately after the com pletion of the progr ams and finally afte r 6 mon ths after the bas eline. adu lts. For the othe r hand, the SOM -B de mons trated a significan t differ -ence betw een follow up two on know ledge abou t mu scle relaxers. SA/K (+/ − ): Comparing the mean total know ledge scores bas eline and im mediately afte r the com pletion of the train ing betw een the groups they found that the progr am with 4 obli gatory se ssions was signific ant greater than the self-gu ided pro -gram wit h only one req uired se ssion. Howe ver, this differenc e was not sig-nific ant afte r 6 mont hs.
Table 5 Synthesis of intervention studies involving computer-based training Autho rs Numb er (n), Age (yr) Country (c) R.D. Objec tive Stud y desc ription Depend ent Variabl e Relevant results QS Edward s et al., [ 40 ] n = 500 yr = ave rage age 74 and 75 years old (ages N/S). c = USA and UK Cohort The curre nt an alyses were cond ucted to exa mine whe ther compl eting this spee d o f processing training reg imen de lays driv ing cess ation. The coho rt was forme d by part icipants from 2 different study. The interve ntion was based in 10 spee d of proces sing training session s le d by a trainer in which the sub jects prac ticed com puterized exe rcises of vis ual atten tion aimed at enhanc ing the spee d and accu racy of visual pe rformanc e. The session s laste d 1 h, tw ice a week for 5 weeks. The ass essm ent carried out at bas eline, imme diately post training, an d was rep eated 3 years afte r train ing. (B): D riving status an d the num ber of days pe r w e e k driven was evaluated with the Mobili ty Drivi ng H abits Quest ionnaire. -Far visual acu ity was eva luated with a st andard letter chart. -Ment al status was ass essed with the Mini-M ental Stat e Exa minatio n. B (+): Sp eed of proces sing training particip ation was prot ective agai nst driving ce ssation, main ly in thos e drivers who drove more often an d those with better vis ion. Thu s, the particip ants who compl eted the training we re 40% less likely to cease driving acr oss the sub sequent 3 years as compared with cont rols 0,86 Ball et al. , [ 41 ] n = 908 yr = betw een 65 and 91 years old. c = USA RCT To test the effect s of cog nitive train ing on subse quent mot or vehicle col lision (MVC) involvement of olde r driv ers. Partic ipants we re random ized in 4 groups: -Con trol group (n:298 ): No train ing -Mem ory training (n: 103): Based in mne monic strat egies. -Re asoning train ing (n: 133): Bas ed in st rategies for fin ding the pattern in a le tter or word se ries an d ident ifying the next it em in the serie s. -Sp eed of processing training (n: 12 9): bas ed in practice of visual attenti on skil ls and the ability to ident ify and loc ate vis ual info rmation quickly in inc reasing ly demand ing vis ual dis plays. The se ssions were le d by train ers, cond ucted in groups of 2– 4 part icipants dur ing app rox. 70 min se ssions over a period of 5 to 6 we eks. In each interve ntion cond ition , 10 training sessions were car ried out twice a we ek ov er a 5-we ek pe riod Partic ipants com pleted ass essm ents at bas eline, imme diately fol lowing, an d ann ually at 1, 2, 3, an d 5 years . (CR): The prim ary outcom e was state-recorded moto r vehi cle col lision (MVC) obt ained from the Depart-ments of Motor Vehicle s in the states of Alabama, Indi ana, Mar yland, an d Penn sylvania. The variable w e re: Total col lisions, at-fault collisions, p e rson-t ime (in years ), person-m iles, at-fau lt cra shes/ye ar, at-fault crashes/mile rate ratio s. Mileage — The num ber of miles driv en per week was rep orted by part ici-pants on the Mob ility Drivi ng Habits Quest ionnaire and was used to calc u-late the de pende nt variable of inter-est, rate of MVCs pe r pe rson mile driven CR (− ): The part icipants wh o carried out the memor y train ing do not show a sign ificant ass ociatio n in the reduction of rate of at fault MVC per year CR (+): The part icipants unde r spe ed processing training an d reaso ning training exp erience d a sign ificantly lower rate of at fault MVC per year of driving exp osur e or per person mile driven. 0,86 Horsw ill et al., [ 42 ] n =7 5 yr = betw een65 and 89 years old. c = Australia RCT Exa mine the longer-t erm ef-fec ts of hazard percept ion. Partic ipants we re random ized in 3 groups: -Tra ining with out booste r (n: 26 ): pe rforme d the haz ard pe rception train ing that cons isted in an instructional video followe d b y video-bas ed exercis es. -Tra ining with boo ster (n: 25): After (S): Simp le spati al RT test: the particip ants must tou ch as qui ckly as possible 15 high cont rast rectangles that appeared one after anothe r o n the compu ter screen at random intervals.(S): Haz ard perce ption tests: 4 hazard perception test s per particip ant we re gen erated from a S (+): The part icipants that car ried out the training responded 0.81 s fast er than bas eline com pared with those in the pla cebo condit ion. Thi s differenc e it was mai ntained afte r one and thre e mont hs of followi ng with 0,67 s an d 0,45 s fast er, respectively. S (+): The part icipants wh o we re 0,79
Table 5 Synthesis of intervention studies involving computer-based training (Co ntinued) Autho rs Numb er (n), Age (yr) Country (c) R.D. Objec tive Stud y desc ription Depend ent Variabl e Relevant results QS one mont h of rece ive the same train ing of the group without boo ster the y receive d 22 min of add itional train ing vid eo. -Pl acebo (n: 24 ): they had a pla cebo interve ntion watchin g ano ther video with clips of a driv ing instructor dis cussing aspects o f safe driving. All the groups pe rforme d the haz ard pe rception test in the first session prior to the train ing and then afte r one and three-mont h po st interve ntion. pool of 153 vid eos filmed from the driver ’s perspective. under interven tion had a sig nificant immedi ate effect of trai ning on hazard perception S (+/ − ): The ha zard pe rception training wit h bo oster did not show a significan t differ ence relative to baseline than trai ning with out booste r bas ed on the ha zard perception test sco res. Edward s et al., [ 43 ] n = 500 yr = ave rage age 72.08, 74.13 and 74.52 years old (ages N/S). c= U K RCT To exami ne how cog nitive spee d o f processing training affects driving mob ility acr oss a 3-year period among older driv ers. Bas ed upon their UFOV test pe rformanc e the particip ants we re ran domized in 2 groups: -Cogni tive speed of proc essing train ing (n: 66): the tasks in the com puter involved ident ified and loc alize visual and audit ory targets. -Com pute r cont act internet training (n: 68): particip ants rece ived instructions on compu ter hardw are, how to use a mou se, how to use and e-m ail and how to access and use we b pag es. The interve ntion had 10 se ssions, 60 mi n in dur ation , guided by a trai ner an d involving 1– 3 particip ants per class . O nce finalized the training follow up intervi ew s occurred within 3 years +/ − 3 mon ths of the part icipants las t ass essment . (B): D riving behaviors was asses sed with the Mobili ty Que stionnaire: -Driving expo sure: Total num be r o f challen ging cond itions encount ered while driving-Drivin g spa ce: Exten t into envi ronme nt driven-Drivi ng diffi-culty 3 (Alone , Lane an d chang es): Left-han d: Rating of difficulty whil e driving in each situa tion; 1 = no diffi-culty to 4 = extre me difficul ty.-Driving difficul ty 5 (R ush hour, Hig h traffic, Night , Rain and Mergi ng into traffic): Rating of difficulty whil e driving in each situati on; 1 = no difficul ty to 4 = extreme diff iculty. B (+): The part icipants that did not receive the spee d of proces sing training exp erience d st eeper decline in driv ing mob ility across the 3-y ear period rel ative to the reference group as indicated by inc reased driv ing diffi-culty and decreased driv ing expo sure and spa ce. B( − ): The part icipants that com plet ed the speed of proc essing train ing experie nced increased driv ing difficulty acro ss time whe n driving alone, making lane chang es , and making left-h and tu rns acr oss oncom -ing traffic than did the referenc e group (drivin g diffic ulty three-item compos ite). B( − ): The part icipants that we re trained did not differ acr oss time from the reference group in driving exposu re, driv ing spa ce, or the degree of driving difficul ty as indicated by the five-item compos ite 0,79 Cuene n et al., [ 44 ] n =5 6 yr = ave rage age 70.84, 69.84 and 73.06 years old (ages N/S). c = Belg ium and Holla nd RCT The pur pose of the pre sent study was to invest igate the effec t of a compu terized WM train ing on asp ects of older driv ers ’cog nitive abi lity and driv ing abi lity. Partic ipants we re random ized in 2 groups an d the cont rol group was col lected: -Ada ptati ve Training Group (n: 19): the diff iculty level of the trai ning was aut omatically adjuste d o n a trial-b y-trial basis. -Non Adap tative Training Group (n: 19 ): the diffic ulty level of the train ing was not adj usted -Con trol Group (n:18) : No Tra ining The tw o-training interve ntion group (S): Thre e Cogni tive me asures were evaluated: -Working memor y -Atten tion -Inhib ition (S): Six spec ific driving measures w e re eva luated: -Driving spee d (km /h) -SDLP (m) -Gap accept ance (s) -Com plete st ops at st op sign s -Giving right of way -Crash es (number) S (+): The part icipants unde r compu ter train ing achi eved a significan t differ ence for wo rking memor y and the driving measure of giving right of way. In particular, particip ants who not we re unde r training ha d lowe r work ing me mory capacity and gave le ss right of way than the othe r two training groups. However, the re was an impro vemen t in the adap tive train ing group in cognit ive ability, smaller in the non-0,71
Table 5 Synthesis of intervention studies involving computer-based training (Co ntinued) Autho rs Numb er (n), Age (yr) Country (c) R.D. Objec tive Stud y desc ription Depend ent Variabl e Relevant results QS cons iste d in working memor y train-ing based in 3 subtasks: visuo-spatial tas k, a backward digit span tas k and a le tter spa n task . The training was con-duct ed at home , on a PC, via the intern et with a total numbe r of ses-sions betwee n 20 an d 25. Af ter the trai ning the part icipants de velope d the post-t est that was the sam e pre-test an d cons isted in cog ni-ti ve tasks and driv ing in a simulat or scenario. adaptive training group and only minim al in the no-training cont rol group support ed for work ing memor y. S( − ): The eff ects of the training did not achi eve a stati stically significan t differenc e for the cog nitive abi lities of attenti on and inhibit ion. S (+): The driv ing abi lities such as driving spe ed and com plete stops at stop signs achi eved only mar ginally a significan t effect . Howe ver, the other driving me asures such as SDL P, gap acceptan ce, giving right of way, and crashes did not find st atistically significan t differ ence. Cassavaugh and Kramer, [ 45 ] n =2 1 yr = ave rage age 71.7 years old (ages N/S). c= USA
Pre- Post test
The pre sent st udy ’s main obje ctive was to inve stigate whe ther training in lab oratory task s woul d trans fer to driv ing performance in olde r adu lts. All the part icipants we re unde r the sam e compu ter-ba sed training. The interve ntion consiste d in 8-train ing sessi on lasted 90 mi n and car ried out in diff erent days. The pro-gram ha d differ ent task s (attent ion, vis uo-spat ial working memor y, man-ual cont rol and dua l task s). The ass essm ent consiste d in two initial driving in simul ator and two fin al post-interve ntion driving sim ula-tor session , ident ical to the first. (S): Re sponse accuracy and res ponse time were measured in the sele ctive atten tion and N-bac k tasks. Root mean square track ing error and ti me-on-target we re analyz ed for the track -ing task . -Tracking task -Visual selective atte ntion task -Visual –spati al N-bac k task -Dual task s (S): Drivi ng Si mulato r -Lane posi tion and followi ng distance were ass esse d in terms of roo t mean square error.-Res ponse time to le ad-vehicle brake even ts was measu red in millise conds. S (+): The part icipants wh o we re under a com puter-based training achieved improve ments in single an d dual cog nitive tas ks. These im prove-ments we re translate to an im prove-ment in driving simulat or performance acr oss the cou rse of the study 0,69 Johnst on et al., [ 46 ] n =5 3 yr = ave rage age 68.83 years old (ages N/S). c = Canad a NRCT The curre nt st udy ass essed the eff ectiven ess of Drive Sharp in trai ning olde r driv ers in a naturalistic class setting The part icipants we re div ided in 2 groups: -Con trol group (n:18) -Ex perim ental group (n:24) The interve ntion was the Drivesharp cou rse that lasted 5 we eks with 2 se ssions for week and each sessio n was led by a facilitat or with a dur ation of 60 min . This course was de velope d in a cl assroo m envi ronme nt on indi vidual de sktop com puter with 3 gam es that inc orporat es divided attenti on and mu ltiple obje ct, intend ed to enlarge the UFOV and train s spee d of proc essing . (S): A brief version of the Hazard Percep tion Test was utilized (S): Tra ils A and B: were ut ilized to measure the proces sing speed, working memor y, and exe cutive control. S( − ): Af ter the five weeks of training the analysis of pe rformanc e data did not reveal ed any significan t benefit s to the Drivesharp course . 0,68
Table 5 Synthesis of intervention studies involving computer-based training (Co ntinued) Autho rs Numb er (n), Age (yr) Country (c) R.D. Objec tive Stud y desc ription Depend ent Variabl e Relevant results QS All part icipants com pleted trails that ass ess vis ual searc h, memor y, and atte ntion and a short vers ion of the Haz ard Perc eptio n Test in the pre -test ing. After the 5 five we eks of train ing the part icipants atte nde d the post -testing se ssion that was the sam e pre-testing with only one diff er-enc e that the exper iment al group com pleted a usa bility questionna ire.
Table 6 Synthesis of intervention studies involving physical training Autho rs Number (n), Age (yr) Co untry (c) R.D. Objec tive Study descrip tion D epend ent Variabl e Re levant res ults QS Maro ttoli et al., [ 47 ] n = 178 yr = average age 77.4 and 77 .2 years old (ages N/S). c = USA RCT To de termine whethe r a multic ompo nent physical cond itioning progr am targeted to axial and extre mity flex ibility, coord ination, an d spee d of movem ent cou ld improve driv ing performance amon g olde r driv ers. The particip ants were random ized in 2 groups -Cont rol group (n: 90 ): the y receive d mont hly in-ho me educa-tion mod ules revi ewing general safe ty issue s abou t home safety, fall prevention, and vehicl e care. -Intervention group (n: 88):1 2 weeks of dai ly trai ning of 15 min at home particip ants. The participan ts receive d a manu al with image s and instructions . Also , they had a weekly visit by a physical the rapist to review the exerc ises. All the particip ants performed the basel ine asses sment and then the chang e in on-road driving perform-ance (primary out come) at 3 mont hs was measured. (S) : Change in on-road driv ing pe r-form ance at 3 month s relative to bas eline. (S) : Sec ondary out comes were the driv ing eva luators overall rati ng an d num be r o f critical errors at 3 mont hs S (+): The partic ipants afte r the 12 we eks of daily training at home in the intervent ion group mai ntained the driving pe rformanc e mean while in the cont rol group they decl ined. Inte rvention group mad e 27.1% fewe r critical errors than control gro up during on-road asses sment 0,89 Marme leira et al., [ 48 ] n =2 6 yr = betw een 55 and 78 years old. c = Portug al RCT The main aim of this res earch was to study the effect s o f a similar exerc ise progr am on the spee d of behavior of older adu lts dur ing on the ro ad driving. The particip ants were random ized in 2 groups: -Cont rol group (n:13): Did not receive inte rvention -Exercise group (n: 13): Was bas ed in an exe rcises progr am of 8 weeks with 3 days pe r we ek wit h a se ssion of 60 min. All the particip ants performed the on-ro ad bas eline ass essment an d after 8 weeks carried out the post-interven tion ass essment . (S) : Brake Re sponse Time Task: The part icipants had to brake as quickly as possible whe never the leading car ’s rear brake lights were activated. (S) : Perip heral Resp onse Time Tas k: The participan ts had to react by de press ing with the ir left thumb a mi croswitch attach ed to the left sid e of the st eering whe el. (S) : Choic e Resp onse Time Tas k: The part icipants were inst ructed to fol low the le ading car and react as qui ckly as possible to eithe r using the brake or depre ssing the mi croswitch on the steering whe el. The leading car ’s rear brake ligh ts we re activ ated. (S): Dual-Task Co ndi-ti on: The participan ts had to brake as fast as possible wh en the le ading car ’s rear brake lights were activated an d mu st realize a menta l-cal culation task . S (+): The partic ipants unde r the exe rcise group showe d a signific ant im prove ment for the simple, two choi ce and peripheral reaction time tas ks an d in the dual task cond ition. More over, a compos ite sc ore refle cting all react ion time me asurem ents sho wed a sign ificant im prove ment. 0,79
Table 7 Synthesis of intervention studies involving simulator-based training Authors Number (n), Age (yr) Country (c) R.D. Objective Study description Dependent Variable Relevant results QS Marchal- Crespo et al., [ 49 ] n = 32. yr = between 65 and 92 years old. c = USA RCT One goal of the present study was, therefore, to determine if the guidance-related learning enhancement persists at a long-term (1 week later) retention test. Evaluated 4 groups two mainly group divided by age and then every group was randomly assigned in guidance and no guidance: -Guidance group-young (n:15): Drove 15 times with haptic guidance and 5 without. -Guidance group-old (n: 17): Drove 15 times with haptic guidance and 5 without. -No guidance group-young (n: 15): Drove the circuit 20 times without ro-botic guidance. -No guidance group-old (n:14): Drove the circuit 20 times without robotic guidance The intervention consisted in 3 experimental session on different days. In the first and third session were carried out tests. The second session participants performed the training. (S): The tracking error: defined as the mean of the absolute value between the center of the simulated wheelchair and the black line, was measured (S): Trajectories followed. (S):Long-term reduction in steering performance. (S): Performance (error reduction). S( − ): Training with guidance significantly improved long-term retention of the task only for younger drivers. Furthermore, improved long-term retention more for initially less skilled drivers and finally im-proved learning of the steering task in curves, whereas it did not affect learning during straight lines. S( − ): Older drivers did not find significant difference in training with guidance or without. S( − ): There was an effect of age on driving performance and retention. The older drivers have a worse performance and also learned more slowly and forgot the learned task. 0,75 Rogé et al., [ 50 ] n =3 1 yr = between 63 and 78 years old. c = France RCT Our aim in this study was to test the two following hypotheses: that specific training given during simulated driving would improve elderly drivers ’useful visual field; and that the training given would allow them to detect more easily vulnerable road users than untrained elderly drivers during simulated driving. The 31 participants were divide in 2 groups: -Experimental (n: 15): training in simulator to increase the useful visual field. -Control (n: 16): driving in the simulator maintaining a constant distance between the vehicle in front. The interventions were based in two visits to the lab separated with 12 days on average. The entire two sessions lasted 5 h and 4 h and 15 min to the experimental and control group respectively. (S): Useful visual field size: Was estimated during driving. Participants had to detect a change in color (central signal) of a disc which appeared briefly and intermittently on the rear window of the vehicle they were following. 22 central signals appeared during the test. They also had to detect 48 peripheral signals which appeared briefly at 3 eccentricities on the road over 8 different meridians.(S): Visibility distance of vulnerable road users S (+): There was a significant effect in the useful visual field size, were untrained participants detected a lower number of signals in the central task compared to the trained group. Also, in the peripheral task the experimental group detected a greater number of signals than untrained participants (49,48% vs 27.93%) when this test was administered at the end of the experiment. S (+): The training would allow elderly drivers to improve their ability to detect vulnerable road users while driving. Visibility distance for vulnerable road users was greater in the experimental group than in the control group and the visibility distance was greater in session 2 than in session 1. Also, the type of vulnerable road user also had a significant effect on visibility distance which was greater for pedestrians than for two-wheeled motorized vehicles, were the trained group was better to de-tect pedestrians in the road environment 0,68
Table 8 Synthesis of intervention studies involving mixed training Autho rs Nu mber (n), Age (yr) Coun try (c) R. D. O bjective Stud y descrip tion Dep endent Vari able Relevant results QS Porter , [ 51 ] n =5 4 yr = average age 77 .6, 77.1 and 73.6 ye ars old. c = Canad a RCT The pur pose of this study was to exa min e an alternate form of driver train ing by utiliz ing vid eo an d glob al posi tionin g system (GP S) techno logy, in combi nation with a class room-b ased education progr am. The partic ipants we re random ized in 3 groups: -Cla ssroom educ ation (n: 18): 55 Alive Mature Drivin g progr am, 2 sessi ons of 4 h. -Vide o (n: 17): rece ived video and GPS feedback + cl assroom educ ation. The particip ant watche d the vid eo of the ir own pre -test drive with the driv ing instructor and were giv en very specific instructions on how to improve the ir own driv ing -Cont rol (n:19): Not specifie d The on-road test we re pe rformed in the pre and post. (S): Driving Test (errors ): Partic ipants drove a 26 km in a st andard ized all test we re performed with a dig ital vid eo came ra an d the n were watchi ng to sco re the driving errors. S( − ): Partic ipants that car ried out the 55 Ali ve Matu re Drivi ng progr am did not sign ificantly change from pre-to post-t estin g. S (+/ − ): Partic ipants in the video group and GPS feedback significan tly reduced their driv ing errors after the progr am. In this group 9 of 17 sub jects im proved, whereas onl y 4 of 18 im proved in the Education group, an d just 1 o f 19 im proved in the Contr ol group. 0,96 Maro ttoli et al., [ 52 ] n =1 2 6 yr = average age 80 .4 and 79.7 years old (ages N/S). c = USA RCT Thi s study was de signed to de term ine whe ther an ed ucat ion progr am consisting of classro om an d on-road train ing cou ld enhanc e driv ing pe rformanc e. The partic ipants we re random ized in 2 groups: -Cla ssroom + On Road driving train ing (n: 69): This group receive d 8 h of class room and 2 h of on road train ing. -Cont rol (n: 57 ): Thi s group rece ive mod ules direc ted at vehicle, home and enviro nmenta l safe ty. Bot h gro ups pe rforme d the ir train ing at 8 weeks and finally ha d driv ing and know ledge test. (S): Driving Perfo rmance : The road test was bas ed on the Con nectic ut Dep artmen t of Moto r Ve hicles test and asses sed a wide range of driv ing abilitie s. (SA/ K): Kn owledg e Test: 20 ro ad know ledge questions from the AAA Driver Im provement. Prog ram and eight road sig n que stions used in our earlier studies. (SA/ K): Interve ntion Participant Perc eptio ns: the particip ants were aske d if they like d the progr am adhe rence . S (+): The progr am bas ed in a classroo m educ ation plus on road driving sho w som e im provements in the driving performance com paring to a control group. After 8 w e eks of training the trai ning group was 2.87 points high er than the control group in the road test sco re. SA/K (+) : Moreo ver, the re we re differenc e in knowle dge test score after 8 we eks, 3.45 points higher in the interven tion than in the cont rol group. O verall, the particip ants said that they like this type of progr am and fou nd it be neficial. 0,89 Bédard et al., [ 53 ] n=7 5 yr = betw een 65 an d 87 years old. c = Canad a RCT if the com bination of an in-clas s ed ucation progr am with on-road ed ucation woul d le ad to improve -me nts in olde r driv ers ’know le dge of safe driving practices an d on-road driv ing eva luations. Participant s w e re random ized in 2 groups -Int ervention group (n: 38): rece ived the 55-Al ive/Mat ure driving pro-gram , as we ll as 2 se ssions of 40-m in on ro ad pract ice. -Cont rol group (n:37) : The proc edure of this study was the initial on road driv ing eva luation. 4– 8 weeks after compl eting the train ing were performed the second on ro ad driving eva luation. (B): Road eva luation: The on-road eva luation las ted app roxim ately 35 min cons iste d of vary ing type s of roadw ays and speeds an d le ft and right turns at cont rolled and unco n-trolle d inters ectio ns. -Start ing/stopping/bac king -Signal violati on/right of way/ inat tention -Mov ing in roadw ay. -Passi ng/spe ed and tu rning (SA/ K): The know ledge was eva luated with a quest ionnaire that cons ists of 15 mu ltiple-choice questions B (+): O n the other hand, the on-road eva luation results sug gest im-provements on som e aspects o f safe driving such as movin g in the roadw ay. SA/K (+) : This study reveal ed a significan t improve ment after the education and on road pract ice, with an increase in the know ledge test from 61% of quest ions corr ectly answere d at bas eline to 81% at follow-up. 0,89 Hay et al., [ 54 ] n =6 7 yr = average age 75 years old (ages NR CT Comp are the eff ectiven ess of two train ing progr ams: pure cog nitive train ing and the same cognit ive The partic ipants we re divide d in 2 groups -Cogni tive trai ning (C T, n:4 0): had a (The cog nitive pe rformanc e was eva luated with the: (S): Trail Maki ng Test (A and B): S (+): Bot h group of train ing shows improve ment; a diminuti on in the numbe r o f perseveration s in the 0,82
Table 8 Synthesis of intervention studies involving mixed training (Continued) Autho rs Nu mber (n), Age (yr) Coun try (c) R. D. O bjective Stud y descrip tion Dep endent Vari able Relevant results QS N/ S). c = France train ing cou pled with thre e driving simul ator train ing sessi ons, bot h progr ams be ing add ressed to olde r driv ers presen ting a cog nitive se lf-ass essment bias. dur ation of 35 h for 12 we eks and was com posed of 20 cogn itive exerc ises with 15 difficul ty le vels each, focused on: atte ntion, memor y, visuosp atial abilities, exec utive functions -Cogni tive trai ning + driv ing simul ator (CT + DS, n: 27): Was the sam e training plus 1 h of simul ated driv ing, 3 sessio ns of 20 min . The eva luations car ried out were before an d afte r train ing trou gh the cog nitive eva luation an d on ro ad eva luation. asses sed processing speed, exec utive function, and vis ual scann ing abi lity and invo lved tw o parts. (S): Digit Substitutio n Symbol Test: asses sed psycho motor proces sing spee d. (S): The speed of proc essing and visual attenti on was eva luated with the Usef ul of Fi eld of View.(S): The on-road driv ing eva luation was bas ed on two differ ent, but eq uiva-lent road trips combi ned urb an, sub-urb an d rural circ uits and a se ction of ring road/h ighway. Also , there we re two grid, the first, ass essed eleve n dim ension s of driv ing. The second grid was com pleted in real time dur ing the trip by the exper i-men ter se ated be hind the driv er. TMT, an inc rease in the num ber of correct sy mbols for the DSST , short er interval prese ntation of the target to which they react ed (visual atten tion), participan ts anticipat ed the traffic and the envi ronme ntal chang es better and driving performance . S (+): Partic ipants from the CT group tended to make more planning errors than part icipants from the CT + D S group, regardless of the time of eva luation S (+/ − ): The driv ing simul ator experie nce did not inf luenc e the drivers ’behavior on the road. The participan ts from the CT + D S group did not make significan tly fewer driving errors than thos e from the CT group. The refore , the add ition of driving in a simulat or to the cognit ive program led to a deterioration in spee d adap tation and car cont rol handlin g performance s, whereas the pur e C T led to an improve ment of these driving pe rformanc es. Casut t et al., [ 55 ] n =9 1 yr = betw een 62 an d 87 years old. c = Switzerland RCT NM The partic ipants we re random ized in 3 groups: -Simu lator Training Group (n: 39): A train ing sessio n took 40 min . The goal of this training approach was to increase the menta l work load of corr ect driving in a realis tic mu ltitasking driv ing se tting. -Cogni tive Tra ining Grou p (n: 26): The goal of this training approach was to increase specific driv ing releva nt cog nitive fun ctions . Each of the 10 training sessio ns was com posed of 10 min intr insic alertness training, fol lowed by 10 min of phasic ale rtness train ing and 20 mi n o f vig ilance training. -Cont rol Group (n: 26 ): No training. The study desig n was a pre-post de-sign . Durin g the pre -posttes t were cond ucted the cogn itive and on road tests. The exper iment al groups betw een the pre-po st te sts (S): During the on-ro ad test driv ing asses sment the instructors made note s in the evaluation she et but only eva luati ng cog nitive asp ects of driv ing beh avior. Drivin g perform-ance was me asured usin g driving er-rors, top spe ed, me an spe ed, lane accu racy, lane variability, and reac-tion ti me to haz ardous event s. (S): Cogniti ve test battery eva luate d: Reac tion test , Cogni trone test, dete rmination test, pe ripheral percept ion test, adap tive tachis toscop ic traffic perception test and adapti ve matrices test . S (+): The driv ing simul ator-training group showe d an improve men t in on-road driving performance com -pared to the atte ntion-training group and both train ing groups in-creased cog nitive pe rformanc e com-pared to the contro l group. 0,82
Table 8 Synthesis of intervention studies involving mixed training (Continued) Autho rs Nu mber (n), Age (yr) Coun try (c) R. D. O bjective Stud y descrip tion Dep endent Vari able Relevant results QS performed the training. Rom oser, [ 56 ] n=2 1 yr = “active learning gro up ” age ran ge = 73 –82, avg. = 77.4, SD = 3.47 “cont rol group ” age range = 72 –81; avg. = 76.5, SD = 3. 20 c = USA NR CT Det ermine the long-t erm effect s of activ e train ing on olde r driv ers ’sc an-nin g in intersect ions. Participant s who partic ipated in the study o f Rom ose r and Fishe r (200 9) we re recru ited. -Acti ve learning group (n: 11): Receiv ed cust omized feedback from a replay of his own simulat or and field drives eva luati ons. -Cont rol group (n:10) : Receiv ed no train ing All partic ipants pe rformed 6 indi vidual sessi ons and the train ing sessi on was the num ber 4, the other sessi ons we re de signated to the pre and post evaluations (simulator an d on ro ad). (B): Videos showi ng the individ ual inters ection mane uvers of the particip ants we re analyz ed to dete rmine if the driv er made a corr ect second ary look at the inters ection . The main out come is percen tage of second ary looks, defi ned as the num ber of inters ection s whe re the driv er took a prope r second ary loo k divided by the total numbe r of inters ections the driv er navig ated, was calc ulated for B (+): The 20 09 st udy, older drivers in the activ e learn ing group took second ary looks in 46 .3% of intersect ions prior to activ e train ing in a simulat or and in 79.6 % of intersect ions. Two years later, the same activ e learn ing group driv ers continu ed to exec ute se cond ary looks in inters ection s 72.7 % of the time a res ult that was still significan tly highe r than their 2009 pretraining performance . The 6.9% decrease was not statist ically significan t B (+): O lder driv ers in the cont rol group who rece ived no training in 2009 took second ary look s in 40.7% of inters ections during the first field drive an d in 38.5% of inte rsections 6 to 8 weeks later. Two years lat er, these same control group drivers took second ary look s in 42.9% of intersect ions again, no statistically significan t chang e in pe rformanc e. 0,82 Rom oser and Fishe r, [ 57 ] n=5 4 yr = betw een 70 an d 89 years old (ra nge = 70 to 88; sam ple mean = 77 .54; sample ST D = 4.55) c = USA NR CT Det ermine whe ther older drivers loo ked less oft en for pot ential thre ats while tu rning than youn ger driv ers and to compare the eff ective ness of active and pas sive train ing on olde r driv ers ’ pe rformanc e and evaluation of the ir driv ing skil ls in inte rsections . Participant s w e re divided into thre e age groups (70 –74 ; 75 –79; 80 –89), then each group were ass igned to one of the next 3 gro ups: -Acti ve learning group (n: 18): Receiv ed cust omized feedback from a replay of his own simulat or and field drives eva luati ons. -Passi ve learn ing group (n: 18): Receiv ed a tradition al lecture-style train ing sessio n consisting of powe r point s slide s, te xts, figu res and anim ations. -Cont rol group (n: 18): Receiv ed no train ing All partic ipants pe rformed 6 indi vidual sessi ons and the train ing sessi on was the num ber 4, the other sessi ons we re de signated to the pre and post evaluations (simulator an d on ro ad). (B): Videos showi ng the individ ual inters ection mane uvers of the particip ants we re analyz ed to dete rmine if the driv er made a corr ect second ary look at the inters ection . The main out come is percen tage of second ary looks, defi ned as the num ber of inters ection s whe re the driv er took a prope r second ary loo k divided by the total numbe r of inters ections the driv er navig ated, was calc ulated for B (+): The part icipants in the activ e learning group increase their second ary looks more than the double that they took before training an d ten ded to rate this training to be more eff ective. Between the activ e an d pas sive groups there was a sign ificant differenc e, as was that be tween the active an d cont rol groups in their second ary looks. Fi nally, there were significan t differ ences betw een active an d pas sive groups an d betwee n active an d cont rol groups but not betw een the passive and control groups. 0,81 Lavallière et al., [ 58 ] n =2 2 yr = betw een 65 NR CT If simul ator training, cou pled wit h vid eo-base d feed back can mod ify The partic ipants we re random ized in 2 groups (B): All drivers drove 12 km in the same vehicle on the same open B (+): The part icipants in the feedback group after the training 0,75
Table 8 Synthesis of intervention studies involving mixed training (Continued) Autho rs Nu mber (n), Age (yr) Coun try (c) R. D. O bjective Stud y descrip tion Dep endent Vari able Relevant results QS an d 85 years old. c = Canad a vis ual searc h behaviors of older driv ers while changing lanes (Feed -bac k drivers). -Fee dback group (n:10 ) -Cont rol group (n:12) Then part icipated in 5 sessio ns, whe re the first and last se ssion inc luded the on road and in simul ator asses sment s. The 3 sessi ons be tween the pre -post tests we re the same for both groups with the ge neral driver refre she r cou rse (base d on the 55 -alive driv er safe ty) and driving simulat or training. The only one diff erence was that the feedback group rece ived driv ing spec ific feedback. road circuit for bot h the pre and post-t raining se ssions. For each on-road lane chang e, 20 s of data were extrac ted from the records; 15 s prior to the initial displacement of the ve-hicle tow ards the targ et lane and 5 s afte r this initial displ acem ent. The principal out comes we re: -Frequen cy of vis ual inspect ions dur ing lane chang es -Tem poral insp ection of the blind spot. increased the frequ ency of verification of the blin d spot increasing from 32,3% be fore the intervent ion to a 64,9% po st intervent ion. Add itionall y, the re was an inc rease of visual insp ection s occurring prior to the onset of the lane chang es (after the train ing, 96% of the verif ications occurred prior to the onset of the lane chang es).
but the impact of the intervention faded over time [39]. Only one study used on-road data, measured through collisions and violations of traffic regulations. The remaining study used a mix of questionnaires and moni-toring of driving. For the study that evaluated implica-tions in collision [36], drivers who participated in the program add 1.5-time greater odds of being involved in a crash than their matched controls.
Computer-based training
Table 5 presents reviewed papers regarding computer-based training. Four (4) of the studies were conducted using a RCT (Level 1), 1 used a non-RCT 2-group approach (Level 2), 1 a pre/post-test intervention (Level 3) and 1 a cohort design (Level 3). The most studied dependent variable was assessed through questionnaires/tests (3 of 7 studies). It is also import-ant to acknowledge that 3 of the studies additionally used the on-road assessment or simulator driving for evaluation purposes. Despite differences in the form of their interventions, 4 out of the 7 reviewed studies presented computer-based training based on 10 clas-ses. Follow-up of these studies varied between imme-diate evaluations, up to 1 to 5 years post-intervention. This later evaluation of the program’s impact was based on crash rates [41]. Two (2) studies assessed
behaviours with mixed results on reported outcome, some factors improving such as less driving cessation over 3 years [40] while other specific manoeuvres de-teriorated [43]. Speed of processing training showed a positive impact on reducing driving cessation and lowering at fault motor vehicle collisions, as well as improving reaction time [42, 45].
Physical training
Only 2 studies used physical training to improve driving skills. Both used a RCT (Level 1), 1 using an evalu-ation scheme similar to an instructor looking at a driver’s overall performance [47] while the second study used different types of evaluations more associ-ated with processing and movement time, such as brake reaction time and peripheral response time tasks [48]. Both programs showed relatively similar active time for the older drivers, Marottoli et al.’s program lasting 21 h [47] and Marmeleira et al.’s pro-gram 24 h [48]. The 2 interventions showed a positive impact on driving performance by either maintaining driving capacity after 12 weeks or even improving scores of reaction time measurements. However, it is not possible to identify if there was any issue with adherence to training in these 2 studies.
