A Three-Tiered Comprehensive Driving Evaluation Integrating a Driving Simulator Test for Drivers with Borderline Cognitive Fitness-to-Drive: Proof of Concept.

Comprehensive driving evaluations for older adults with cognitive impairment are time-consuming, expensive, and involve risk. To minimize these challenges, we evaluated a three-tiered driving evaluation process incorporating cognitive tests (Step 1), a driving simulator test (Step 2), and a road test (Step 3). Participants in this study were referred to a driving assessment center for concerns about cognitive fitness-to-drive. Each participant completed all three evaluation steps. Their fitness-to-drive was determined independently by an occupational therapist and an experienced driving evaluator with a driver instructor background. Our main objective was to examine the agreement between the occupational therapist's determination of fitness-to-drive after each step and the driving evaluator's determination of fitness-to-drive after the road test. As a secondary objective, the occupational therapist's confidence in their determinations was also examined. Results showed agreement for 38.8% of participants after Step 1, 46.5% after Step 2, and 92.3% after Step 3. The mean occupational therapist's confidence rating in their determination (scale of 0 to 100; higher is better) was 36.15 after Step 1, 49.54 after Step 2, and 90.54 after Step 3. All drivers deemed to have passed the evaluation had been identified as such after the driving simulator test. These results suggest that the best agreement between the occupational therapist and the driving evaluator was reached after the final step. However, the results also indicate that for some participants, a road test may not be required following a driving simulator test. Eliminating the road test in some instances may create efficiencies and reduce cost and risk while maintaining accurate determinations of fitness-to-drive.