Rashid, Roshe
(2020)
Predicting fitness to drive of people with dementia in Iraq.
PhD thesis, University of Nottingham.
Abstract
Dementia causes progressive loss of cognitive capacities including memory, orientation, information processing, comprehension, insight and judgment. Thus, it leads to an impairment in activities of daily living and social functioning. Dementia affects driving performance and safety. People with dementia need to consider giving up their driving privileges at some point during the illness progression. However, driving cessation can result in loss of independence, mobility and social integration. Assessment of fitness to drive in drivers with dementia is important in maintaining patients’ rights and public safety. Cognitive tests are frequently used to inform recommendations on fitness to drive in people with dementia.
There is no evidence from the literature to indicate whether the prevalence of dementia in Iraq and its neighbouring countries is different to the rest of the world. Similarly, the issue of driving and dementia remains an unexplored area of research in the Arab world. Lack of guidelines on driving regulations in people with long term condition such as dementia remains undiscussed and unpublished given the highly volatile political environment in the region. Subsequently, clinicians are left to make their own decisions on driving fitness which is understandably relevant to the patient’s quality of life and overall prognosis. Therefore, to assist clinicians both locally and internationally in the decision-making process, this thesis has attempted to fill the gap in the literature and explore the measures which can improve clinicians’ prediction of fitness to drive. This should improve the overall accuracy of such predictions through the implementation and integration of a cognitive test battery in the process of driving assessment in people with dementia in Iraq. This approach was taken in view of the lack of an on-road assessment (gold standard) facility in the region.
The Nottingham Assessment for Drivers with Dementia (NADD) was selected for this purpose. The NADD was developed at the University of Nottingham as part of a research program on the effects of cognitive impairment on driving abilities. It involves a collection of cognitive tests used to predict safe driving in people with dementia. It was validated on an independent sample of drivers with dementia in the UK, where 79% of participants were correctly classified as safe or unsafe to drive by the cognitive tests. The on-road assessment–considered the ‘gold standard’ of driving ability–was the criterion against which NADD performance was compared. To address the main objectives of predicting fitness to drive in people with dementia in Iraq, this thesis comprises two studies:
(Study 1)
Aim: To assess the strength of association between cognitive tests and on-road driving ability in people with dementia
Method: A systematic review of 30 studies and meta-analysis of 16 studies was conducted.
Results: The review showed positive association between the on-road driving performance of people with dementia when a cognitive assessment battery was used instead of a single cognitive measure. The meta-analysis showed an overall weak to moderate (0.3 to 0.4) relationship between all cognitive measures and on-road driving for all cognitive domains except language for people with mild dementia: mental and cognitive status r = 429, 95% CI: 0.285 to 0.554, attention and concentration r = .39, 95% CI: 0.246 to 0.332, executive function r = .310, 95% CI: 0.188 to 0.423, visuospatial r = .354, 95% CI: 0.250 to 0.450, memory r = .336, 95% CI: 0.187 to 0.470, language r = .432, 95% CI: -0.0601 to 0.755.
Conclusion: A composite cognitive battery is likely to be better than testing single cognitive domains when assessing fitness to drive in patients with dementia.
(Study 2)
Primary aim: To translate a composite cognitive test battery in the form of the NADD into Kurdish and then validate it in a sample of 67 participants recruited from both governmental and private psychiatric clinics from both the cities of Erbil and Sulaymaniyah from the northern region of Iraq (Kurdistan).
Secondary aims:
• To evaluate the accuracy of Iraqi psychiatrists’ opinion in determining fitness to drive in people with dementia in Iraq.
• To evaluate the role of in-clinic assessments, MMSE, and EADL in determining fitness to drive in people with dementia in Iraq.
• To describe common driving errors made during the on-road assessment by all participants in the validation study, which included drivers with a complaint of memory impairment (CMI) n=25, mild cognitive impairment (MCI) n=26, and participants with moderate dementia n=16 in Iraq.
Method: Sixty-seven participants were assessed on the NADD, MMSE and EADL. Then, Fitness to drive was tested on public roads in Iraq (on-road assessment) to differentiate safe and unsafe drivers. Driving errors were noted for all participants during the assessment by both the investigator and the driving instructors.
Results: The NADD was a good predictor of ‘on road’ performance with an overall predictive accuracy of 70.15 % with an Area Under the Curve (AUC = .780, SE = 0.062, p < .001). The NADD was better at identifying unsafe drivers (sensitivity 71.11%) than safe drivers (specificity 68.18%). Psychiatrists in Iraq were unable to predict either the NADD pass or fail or the on-road driving outcomes, with a total of 28 misclassified on the NADD and 26 participants misclassified on the on-road assessment. The addition of further in-clinic assessments in the form of the MMSE and EADL added value in making better predictions on driving safety with the MMSE (AUC = .854, p <0.05). Drivers with dementia performed worse and made more driving errors during the on-road assessment.
Conclusion: Cognitive assessment battery in form of the NADD with clear cutoffs has clinical utility in assessing fitness to drive and their integration into current clinical practice in Iraq is recommended. The results are generalisable to all countries with limited resources for establishing specialist on-road driving assessment centres.
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