School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE WORKSHEET

Name: Ryan Hua and Jessica Scott

Date: 10/08/14

Focus Question: Are driving simulators effective in predicting cognitive performance in older adults?

Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Inclusion Criteria
Written in English
Older Adults
Driving Simulators
Published within ten years
Exclusion Criteria
Teens with cognitive impairments
Published earlier than 2000
Qualitative studies

Author/
Year
Vance, D.,
Fazeli, P.,
Ball, D.,
Slater, L.,
& Ross, L.
(2014).

Study Objectives

Level/Design/ Subjects

To examine driving
simulator
performance in an
older sample of
adults with HIV.

Level IV
Descriptive crosssectional pilot study
26 participants who met
the criteria were
explained the details of
study and signed a
consent form.

Intervention and
Outcome Measures
Intervention:
Pilot study lasted for 2.5
hours
Participants were
administered a
demographic, mental and
physical health
instruments, a driving
questionnaire, cognitive
assessment, and driving

Results

Study Limitations

Older age was

associated with
slower (lowest)
divided-attention
reaction time and
average dividedattention.

Small sample size

Higher income was

associated with
slower (lowest)

Lack of younger
HIV infected group
or an uninfected
comparison group

Implications for OT
Clinical and communitybased practice of OT:
Results indicate that older
age is associated with
slower divided attention
and reaction time.
Program development:
Because useful field of
vision (UFOV)
performance is the single
best predictor of passing or

Age was 40 + years

simulator tests.

gross reaction time.

65% of the participants

were male

Outcome Measures:
A comprehensive
cognitive battery is
covering a range of
cognitive domains
(memory, speed of
processing, and
psychomotor), and
everyday functioning
measures including two
PC-based driving
simulations.

Drug use was

associated with
lower (faster)
average gross
reaction time.

Participants had been

diagnosed with HIV for
an average of nearly 16
years
All participants were
required to have a
current drivers license,
and have been
currently treated at a
university- affiliated
HIV clinic
Participants performed
a medical chart
extraction to gather
most current CD4+ Tlymphocyte cell counts
and HIV plasma viral
loads.

Better complex
reaction time
performance and
better memory
performance
Hopkins Verbal
Learning TestRevised (HVLT-R)
were associated
with better driving
simulator
performance via
lower percent of
drive time spent
outside the lane.
Better letter
comparison
performance was
associated with
better driving
simulator
performance
through lower
percentage of drive
time spent over the
speed limit.
Better executive
performance (Trails
B) was associated
with faster average

failing an on the road

driving assessment, it is
important to examine how
this cognitive ability can
be improved in this
population
Societal needs:
Results showed that
increased age and poorer
UFOV performances were
found to be related to
slower reaction times in the
driving simulator.
Healthcare delivery and
health policy:
Results indicated that when
working with older adults
with HIV, therapist must be
aware of the prevalence of
cognitive deficits in this
population that can affect
everyday functioning,
including driving, which
could threaten their safety
and the safety of others.
Education and Training of
OT students:
Occupational therapist
performing the intervention
should be trained with the
driving simulator prior to
administering.
Refinement, revision, and
advancement of factual
knowledge or theory:
UFOV performance is the

divided-attention
reaction time.

single best predictor of

passing or failing an on the
road driving assessment
beyond vision and other
cognitive measures in older
adults. It is important to
examine how this cognitive
ability can be improved in
this population.

More miles were

driven in a 7-day
week was
associated with
higher income,
fewer medications
taken, worse UFOV
performance,
slower (lowest)
gross reaction time,
and higher number
of pedestrians hit in
the driving
simulator.

More accidents in
the previous two
years were
associated with
slower (lowest)
gross reaction time
and higher total
number of
collisions in the
driving simulator.
Lee, H.,
Lee, A.,
Cameron,
D., & LiTsang, C.
(2003).

To measure the
performance of
older drivers using
an interactive PCbased driving
simulator and to
determine which
measures were
associated with the
occurrence of motor
vehicle crash.

Level II
Retrospective cohort
study
129 retired drivers
volunteered
Age ranged between 60
and 88 years (mean 73).

Intervention:
30 min initial interview
and 45 min simulateddriving session.
The focus of this study
was on older adults and if
driving simulators could
be used to identify the
risk of motor vehicle
crashes.

The results
indicated that there
was a negative
correlation between
each criterion and
age, meaning that
simulated-driving
performance
worsens with
increasing age.

A small sample size

A non- randomized
control group
Difficulty in
implementing on the
road validation of
the driving
simulator due to
ethical and practical

Clinical and communitybased practice of OT:

Results indicate that
individuals with inflated
risk of vehicle crashes
could be identified using
the PC-based interactive
driving simulator.
PC based simulators are
sufficiently affordable to

22% of the drivers were

female
Required to hold a valid
driving license with no
obvious visual deficits
such as cataract or
glaucoma.
Completed once for the
participants and was
carried out in a clinic.

The laboratory technician

received an operating
manual and was adopted
to ensure uniformity and
consistency of the data
collection.

Additionally, the
results stated that
cognitive skills,
such as, working
memory, ability to
make rapid
decisions, judgment
under time pressure,
and confidence in
driving at a high
speed were
associated with
crash.

Outcome Measures:
Vehicle speed, indicator
usage, lane position, and
stopping distance were
captured by the PC-based
STISM Driving
Simulator.

Overall the results

were significant due
to a p value of .001.
Multiple outcomes
were taken into
account in the
statistical analysis.

The following were also

measured.
Rules
compliance
Traffic sign
compliance
Driving speed
Use of indicator
Road use
obligation
Decision and
judgment
Working
memory
Two
simultaneous
tasks
Speed

Majority of the
participants seldom
used the rear mirror
of the simulator
during the
assessment.

Laboratory technician,
who was blinded to the
driving history
assessment, carried out
the study.

9% of the
participants reported
simulator sickness.

constraints.

be used as a screening tool.

A selection bias in
this study

Program development:
The current license
renewals in the United
States are inadequate in
assessing driving
competency and safety.
Therefore, an
understanding of the
factors that influence the
older drivers risk of a
vehicle crash is important.

Small size of the

monitor display

Societal needs:
Older drivers have a higher
crash involvement on a
per-mile basis compared
with younger age groups.
Therapists need to develop
an appropriate evaluation
method to identify those
who are at higher risk for a
crash and provide
intervention as early as
possible.
Healthcare delivery and
health policy:
This study demonstrated
that an ecological driving
simulator approach to
screen out problematic or
unsafe older drivers need
to be undertaken before a
road test is considered.
Education and training of
OT students:
Occupational therapist

compliance
Divided
attention

performing the intervention

should be trained with the
driving simulator prior to
administering.
Refinement, revision, and
advancement of factual
knowledge or theory:
Prospective studies need to
be undertaken to determine
whether the driving
simulator can predict
future crash occurrences

Casutt, G.,
Theill, N.,
Martin, M.,
Keller, M.,
& Jncke,
L. (2014).

To determine if
driving simulator
training will
improve cognitive
performance and on
the road driving
compared to a nontraining control
group.

Level III
Three groups (a driving
simulator training
group, an attention
training group, and a
control group
Pre/post design
91 participants with
valid drivers license
started the study
14 dropped out during
data collection
77 participants (55 men
and 22 women)
Age ranged between 62
and 87 (mean age 72)
The driving simulator

The study was over a

span of seven weeks.

The results
indicated that
driving simulator
performance is
statistically
predicted (50% of
explained variance)
by performance
measures obtained
during on-road
driving and
cognitive testing
independent from
age. The multiple
outcomes taken into
account were
chronological age,
mileage, and sex.

The first and seventh

week the participants
were tested on the on the
road and cognitive
assessment. The second,

Older drivers differ

from young drivers
in terms of
cognitive, motor,
sensory functions

Intervention:
In the pre and posttest
sessions all participants
conducted cognitive and
on the road tests
Between the pre and
posttests measurements,
the participants
performed either the
training regimes/or
waited for the posttest.
Data acquisition took 25
months

The absence of a
further active
control group to
control for simple
activity (even being
unrelated to
driving).

Clinical and communitybased practice of OT:

Results concluded that
those who had driving
simulator training showed
improvements in on the
road driving performance.

Simulator Sickness
(SS) is still a
problem for some
subjects practicing
with the driving
simulator

Program development:
There is evidence that
driving performance
declines and crash risk
increases with increasing
age. Many driving errors
result as a consequence of
the reduction in cognitive
performance, which should
be improved by training
and practice.

Training intensity
and duration are
issues that will have
impacts on training
results

Societal needs:
Cognitive training regimes
in older adults have
consistently demonstrated

group, who had 31

participants. The
cognitive training group
who had 23
participants. The last
group was a control
group who had the
remaining 23
participants.

fourth, and sixth weeks

the participants were on
the driving simulator.
Outcome Measures:
On the road test &
driving assessment,
Cognitive assessment and
driving Simulator
assessment were
assessed.

but also in terms of

driving experience,
driving strategies,
and mileage.
The study included
that driving
simulator
performance is
strongly related to
on the road driving
performance
(although to a lesser
degree) to cognitive
performance.
The close relation
between on the road
performance and
performance in a
simulator test
qualifies
sophisticated
driving simulator
tests for usage in
evaluating
performance in
older participants.
Participants in the
driving simulator
training group
improved their onroad driving
performance
compared to
attention training
group.

improvements in trained
cognitive tasks. There is
evidence that training of
particular cognitive
functions can exert
beneficial effects on
driving behavior.
Healthcare delivery and
health policy:
Driving simulator training
offers the potential to
enhance driving skills in
older adults. The driving
simulator also seems to be
a more powerful program
for increasing older
drivers safety on the road.
Education and training of
OT students:
Occupational therapist
performing the
intervention should be
trained with the driving
simulator prior to
administering
Refinement, revision, and
advancement of factual
knowledge or theory:
Further studies have to be
conducted disentangling
the different cognitive
processes benefiting most
from the driving simulator
training. Different samples
of older drivers (i.e. at risk
drivers with mild or
advanced cognitive

problems) will benefit

from the driving simulator
and/or attention training.
Horberry,
T.,
Anderson,
J., Regan,
M., Triggs,
T., &
Brown, J.
(2006).

To measure the
relative effects of invehicle distraction
and highway visual
clutter, and to
measured the
possible effects of
distraction in a
sophisticated driving
simulator.

Level II
31 participants were in
this study
Ten were younger
drivers (aged under 25
years, mean age 21
years),
11 were mid-age
drivers
(aged 3045, mean age
37 years)
Ten were older drivers
(aged 6075 years,
mean age 66 years).
Participants were given
a simple or complex
highway environment.
Distractors were
billboards and
advertisements.
Other distractors were
buildings, oncoming
vehicles and other
highway furniture.

Intervention:
Participants were
introduced to the driving
simulator and the
relevant functions of the
vehicle.

Minimum speeds
were higher in the
presence of the two
most severe hazards
when participants
were distracted.

The participants took part

in a practice trial for
approximately 5 minutes
to familiarize them with
the simulator vehicle and
experimental tasks.

Older drivers drove

slower than younger
drivers.

The participants went

through six experimental
drives.
Participants were
instructed to drive as they
normally would and obey
the road rules.
Participants were
instructed to drive as
closely as possible to the
indicated speed limits
and to avoid collisions
with other vehicles or
pedestrians.
Each drive consisted of
six minutes of driving
with approximately a
three-minute rest breaks
between each drive.

Performing an
additional in-vehicle
task (such as tuning
the radio or
conducting a
conversation) whilst
driving can degrade
driving performance
in some driving
situations.
Older adults were
more responsive to
hazards because
they slowed to
lower minimum
speeds.
Older adults slow
down and give
themselves an
increased margin for
error because they
know they cannot
respond to hazards

Tasks found to be
relatively more
distracting
The laboratory may
not compromise
safety in the real
world if they are
performed
infrequently or in
low demand
situations.

Clinical and communitybased practice of OT:

Resulted indicated that invehicle tasks impaired
several aspects of driving
performance for older
drivers.
Program development:
The study indicated that
older drivers drove slower
than younger drivers,
which implied that they
had difficulty performing
when there was a
distraction and
compensated by slowing
their speed.
Societal needs:
The implications of these
results state that there is a
need to inform the public
of the potential dangers of
performing everyday tasks
while driving, which may
have a greater detrimental
effect on safety than
engaging in a mobile
telephone discussion.
Healthcare delivery and
health policy:
This study utilized a
driving simulator in order
to measure the possible

Outcome Measures:
Data were analyzed for
mean speed and deviation
from the posted speed
limit.

as quickly.

effects of distraction,
which included overall
driving performance,
responses to hazards, and
perceived mental
workload.
Education and training of
OT students:
Occupational therapist
performing the
intervention should be
trained with the driving
simulator prior to
administering

Fofanova,
J., &
Vollrath,
M. (2011).

To examine the
effect of age on
driving
performance, as well
as the compensation

Level II
Two groups
There were ten

Intervention:
The participants of this
study were instructed to
participate in a driving
task and a secondary

The study
concluded that the
age effect in dualtask cost is larger
than the general

The steering while

in the Lane Change
Task (LCT) is
smaller than the
normal one.

Refinement, revision, and

advancement of factual
knowledge or theory:
This study adds to the
weight of scientific
evidence of previous
research that performing
in-vehicle tasks while
driving has a detrimental
effect on driving
performance and that these
effects are relatively stable
across different driver age
groups and different
environments. The role of
exposure to distraction in
defining overall crash risk
is an important area for
future research.
Clinical and communitybased practice of OT:
Overall, driving
performance of older
drivers was worse in all

strategies of older
adults under
distraction.

participants
The mean age was 68.4
years.
The other group that
was tested in this study
was ten middle-aged
drivers with a mean age
of 38.6.

task.
After the secondary task,
the participants were
asked to rate their driving
performance, their
perceived workload, as
well as their perceived
distraction.
Outcome Measures
The participants engaged
in a practice session of
LCT (two baseline tracks
of just driving), a
baseline of the secondary
task, and an experimental
drive accompanied by the
two secondary tasks with
and without a time
pressure.
Driving
performance
Perceived
workload
Perceived
distraction

ageing effect
presented in a single
performance.
The results stated
that driving
performance
decreases with age.
The p value for this
intervention
p<0.031, meaning
that age
significantly affects
driving
performance.
The first was the
task, which had a p
value of p<0.001
and the next was
interaction, which
had a p value of
p<.006.

A small screen is
placed in front of
the steering wheel,
which makes it less
realistic.
There was a
selection bias,
because the
participants were
close friends with
the researchers.

conditions as compared to
younger drivers.
Program development:
The number of older
drivers in the world is
raising increasingly, which
leads to an increasing
concern about traffic
safety as aging is
associated with
psychophysiological
changes, which can
decrease driving ability. A
field study to which older
drivers are willing to
engage in potentially
distracting activities while
driving is largely
unexplored. This
knowledge enables the
therapist to examine where
the problems of older
drivers with regard to
distraction are found.
Societal needs:
Older drivers reluctance to
engage in distracting tasks
while driving may be a
process of self-regulation
Healthcare delivery and
health policy:
This study utilized a
driving simulator in order
to analyze driving
performance.
Education and training of

OT students:
Occupational therapist
performing intervention
should be trained with the
driving simulator prior to
administering
Refinement, revision, and
advancement of factual
knowledge or theory:
Trends and patterns
associated with distraction
while driving should
contribute to further
research.

Reference List:
Casutt, G., Theill, N., Martin, M., Keller, M., & Jncke, L. (2014). The Drive-wise project: Driving simulator training increases real driving performance in
healthy older drivers. Frontiers in Aging Neuroscience, 6(85), 1-14. doi: 10.3389/fnagi.2014.00085
Fofanova, J., & Vollrath, M. (2011). Distraction while driving: The case of older drivers. Transportation Research Part F: Traffic Psychology and Behaviour,
14(6), 638-648. doi: http://dx.doi.org/10.1016/j.trf.2011.08.005
Horberry, T., Anderson, J., Regan, M., Triggs, T., & Brown, J. (2006). Driver distraction: The effects of concurrent in-vehicle tasks, road environment
complexity and age on driving performance. Accident Analysis and Prevention 38(1), 185-191. doi: 10.1016/j.aap.2005.09.007
Lee, H., Lee, A., Cameron, D., & Li-Tsang, C. (2003). Using a driving simulator to identify older drivers at inflated risk of motor vehicle crashes. Journal of
Safety Research, 34(34), 453-459. doi: 10.1016/j.jsr.2003.09.007
Vance, D., Fazeli, P., Ball, D., Slater, L., & Ross, L. (2014). Cognitive functioning and driving simulator performance in middle-aged and older adults with HIV.
Journal of the Association of Nurses in Aids Care, 25(2), e11-e26. doi: 10.1016/j.jana.2013.12.001

10