The value of using the Addenbrookes Cognitive Exam-III and the Rookwood Driving Battery to aid fitness-to-drive decisions with people who have dementia or mild cognitive impairment

Abstract

Introduction:

Further evidence is required to support the use of a combination of a generalist cognitive screen Addenbrookes Cognitive Exam-III and a specialist neuropsychological driving screen Rookwood Driving Battery to aid occupational therapists in making fitness-to-drive decisions for people with dementia.

Method:

An exploratory retrospective study was completed for drivers with dementia or mild cognitive impairment living within Scotland. Data were extracted from patient notes of drivers referred to occupational therapy, who had an ACE-III and RDB completed within a 6-month timeframe.

Results:

The study sample included 98 participants. A significant negative correlation was identified between both assessments. Lower cut-off scores were identified on the ACE-III below which no participant scored Rookwood Driving Battery <6 (Addenbrookes Cognitive Exam-III cut-off = 65), or the upper Rookwood Driving Battery pass of ⩽10 (Addenbrookes Cognitive Exam-III cut-off = 54). A small subset of participants (n = 14) sat the on-road test. No participant passed on-road with a score >7 on the Rookwood Driving Battery.

Conclusion:

The ACE-III is a useful guide for referral to occupational therapy for assessment using the Rookwood Driving Battery and subsequent fitness-to-drive decisions for people with dementia.

Keywords

dementia driving Addenbrookes Rookwood retrospective

Introduction

Dementia is the name for a group of symptoms that affect a person’s memory, thinking, cognition, language, behaviour and social abilities. Internationally, more than 55 million people live with dementia (World Health Organization, 2023). It is projected that more than 1 million people will have dementia in the United Kingdom (UK) by 2025 (Alzheimer’s Society 2021). In Scotland, more than 90,000 people are living with dementia, the majority of whom have Alzheimer’s disease (AD; Alzheimer Scotland, 2023). Dementia is progressive, and people diagnosed with mild cognitive impairment (MCI) may later develop dementia.

Following a diagnosis of dementia or MCI, a concern many people have is their safety to drive a vehicle. Whilst it is well documented that drivers with moderate to severe dementia should not be driving, drivers with MCI or mild dementia often retain the skills to continue to drive (Allan et al., 2016; Dickerson, 2014; Lee and Molnar, 2017). Difficulties are highlighted as a change in tactical-level driving skills: perception; judgement; attention and divided attention; split-second decision making; praxis; and comprehension. Legally, a driver must be able to drive their car independently (Alzheimer Scotland 2016). Wheatley et al. (2014) argue that strategies such as having someone acting as a co-pilot do not reduce risk, because there is often insufficient time for the driver to process information and make a tactical-level response to an identified hazard. A decision to stop driving needs to be supportive, evidence based and made at the right time with the person, for the right reasons.

Internationally, there are many different methods used to obtain evidence for driving cessation (Lee and Molnar, 2017; Unsworth et al., 2012), including a full interview and a variety of assessment formats. The ultimate goal is to enable safe drivers to retain their licence, whilst supporting those at risk to stop driving (Byszewski et al., 2013). If someone is assessed as safe, this is a recognition of acceptable risk rather than a guarantee that they will not be involved in a crash (Ferrah et al., 2016).

In 2018, a consensus was achieved by 145 multidisciplinary staff, representing 6 countries, creating 23 non-prescriptive driving and dementia guidelines. Using a combination of ADAPTE and DELPHI methodology, the premise was to support creation of national guidelines by individual countries. (Rapoport et al., 2018). America described eight consensus statements following a review of the underpinning literature, with strength of evidence graded at three levels: strong, suggestive and clinical judgement (Wheatley et al., 2014). Carmody (2012) reports six key points as guidelines in his position paper for Australia and New Zealand. In the UK, the Driver and Vehicle Licensing Agency (DVLA) guidelines are available for specific medical conditions including dementia and MCI.

Qualitatively, decisions about the timing of stopping driving can be very be difficult for drivers with dementia, families and professionals. Driving is an instrumental activity of daily living, necessary for maintaining independence and freedom. It facilitates engagement in roles, employment, community engagement and social inclusion (Dickerson, 2014; Harries and Unsworth, 2013). It is recognised as a major contributor to quality of life for older adults with or without dementia (Byszewski et al., 2010). Therefore, the decision is not simply based on cognitive ability but on a complex interplay of social, emotional, environmental and occupational factors. A qualitative meta-synthesis of 9 studies, with a combined total of 492 participants, identified several negative consequences arising from driving cessation, including social isolation; mental ill-health; loss of identity and self-esteem; and increased caregiver burden. The meta-synthesis highlighted the need for better communication between people with dementia and professionals, more sensitive advanced planning conversations around driving, and greater person-centred, collaborative decision making (Sanford et al., 2020).

Bringing an occupational lens and specialist assessment skills, literature identifies occupational therapists as first-line providers for determining fitness-to-drive, and driving assessments are rightly placed within their remit (Harries and Unsworth, 2013; Wheatley et al., 2014). UK occupational therapists can legally make fitness-to-drive decisions (Royal College of Occupational Therapists, 2023) assisting people to make the best decision, at the right time. Putting people through unnecessary assessments at the wrong time can be distressing and it places demand on occupational therapy resources. Miss-timed or inappropriate assessment could break down the relationship between the person and their therapist or family if the outcome is difficult (Sanford et al., 2020). Occupational therapists can support a person and their family through the assessment process and after driving cessation; find new transportation options that continue to enable the person’s participation in meaningful occupations.

Based on the authors’ experience in delivering occupational therapy input for driving assessment, the research team identified that their service had a steady annual increase over the past 13 years in referral rates for objective evidence to support fitness-to-drive decisions. The death of a pedestrian caused by a driver with dementia mounting the pavement in 2012 was a pivotal moment for local clinical practice, resulting in conversations about driving becoming an integral part of memory screening and a risk-averse approach by some psychiatrists. Some referrals appeared inappropriate leading to debate with referrers, as occupational therapists sought to act as advocates for the person being referred (e.g. a driver scored ACE-III 35/100 and had post-it notes on the dashboard explaining how to start the car). There was risk of harm through unnecessary assessment and therefore, a need to generate clear local practice guidelines that were evidence based and promoted a rights-based approach in conjunction with the best use of service resources.

The initial question was whether the person’s generalist cognitive screen score could be used as a reliable guide for the timing of referral in conjunction with circumstantial evidence. Completion of a literature review in 2018 led the team to research this hypothesis.

The study presented in this paper aimed to identify any correlation between the person’s score on the generalist cognitive screen used – The Addenbrookes Cognitive Exam-III (ACE-III; Hodges and Larner, 2017), and the person’s subsequent score on the specialist neuropsychological driving screen used locally by occupational therapists – The Rookwood Driving Battery (RDB; McKenna, 2009). If correlation was established, ACE-III score parameters would be sought to guide evidence supporting referral for RDB completion, with the aim to create local guidelines and reduce the risk of premature driving cessation or harm through unnecessary assessment.

A small retrospective audit completed in Dublin in 2016, with 21 participants, explored any possible predictive correlation between the older Addenbrooke’s Cognitive Examination-Revised (ACE-R) and the RDB. Presented orally, the findings indicated the potential for a correlation and the ability to identify an average ACE-R score for each RDB score domain. The recommendation was for research with a larger sample group (Davis, 2016).

Methods

Study design

The study evolved due to a combination of increased occupational therapy resource demand, and the need to find evidence justifying the management of inappropriate referrals. An exploratory trial using retrospective data collected in routine clinical practice was used to determine the value of using the ACE-III and the RDB to aid fitness-to-drive decisions for people with dementia or MCI.

Data collection involving retrospective review of patient notes was completed from January 2020 to April 2021, using information routinely recorded throughout 2015–2019. There was no direct contact with participants and clinical practice was not impacted. The data collection time frame was extended from 12 to 16 months due to impact of the COVID-19 pandemic. The data were extracted from the patient’s electronic record and paper case notes before being reviewed by a research assistant and checked for accuracy. The data collected were:

• Sex

• Age

• Diagnosis (dementia type/MCI)

• Addenbrookes Cognitive Exam-III (ACE-III) score

• Rookwood Driving Battery (RDB) score

• Fitness-to-drive decision

• On-road test result

Setting

Scotland’s population covers urban, rural, island and highland geography. There are 20 medical driver assessment centres in the UK, however, only one in Scotland (Edinburgh). This leads to inequity and potential injustice for people living in rural communities or islands, with risk of premature driving cessation leading to occupational deprivation, and reduced quality of life for drivers with dementia. It is unrealistic to refer all drivers with dementia for the on-road test due to the burden on that service. Thus, there is a need to ensure referrals for the on-road test are evidence-based and follow a rights-based approach. This has resulted in increased demand for occupational therapy resources to complete specialist assessments. Previously, fitness-to-drive decisions were made by doctors or optometrists. However, in 2022, UK law changed allowing more health professionals including specialist nurses, allied health professionals and occupational therapists to complete DVLA medical fitness-to-drive questionnaires (UK Government, 2022).

The local Psychiatry of Old Age Occupational Therapy Team provides assessment and interventions for older adults with a mental illness or dementia/MCI, in community and inpatient settings throughout the fourth largest county in Scotland. This county is situated centrally with a mix of urban, rural and highland geography. Average life expectancy is slightly above the national average for Scotland across all age groups and sex.

Participants – inclusion criteria

The study sample group (n = 98), comprised drivers with dementia or MCI. Participants had Alzheimer’s disease (AD, n = 33), vascular dementia (VD, n = 28), mixed dementia (MIX, n = 16), mild cognitive impairment (MCI, n = 20) or other non-specified dementia (OTH, n = 1). The study sample included all patients referred to occupational therapy for cognitive driving assessment between January 2015 and December 2019. Due to the deteriorating nature of disease progression, data was included from participants who completed both assessments within a timeframe of 6 months. This was to minimise the risk of discrepancies in levels of cognition.

Study hypothesis

A higher score on the ACE-III indicates better cognition, whereas a higher score on the RDB indicates poorer cognition. Therefore, the study hypothesis was that there would be a negative correlation between the ACE-III and the RDB scores. The null hypothesis was that there would be no correlation and therefore, no evidence base to guide referral timing.

Study objectives

Primary objective

To identify the upper and lower score cut-offs on the ACE-III, between which a referral to occupational therapy for specialist assessment using the RDB is justified.

Secondary objectives

To explore the impact of any variables such as sex, age or type of dementia on either assessment.

To identify if there is a cut-off score on the RDB above which consistently results in a fail on-road for people with dementia or MCI.

Assessment tools

1. The Addenbrookes Cognitive Exam-III (ACE-III) is available free with no copyright restrictions for use within clinical practice and research. The ACE-III has been developed from the original ACE created in Cambridge in the 1990s, then revised (ACE-R) to facilitate cross-cultural usage and improve sensitivity, resulting in the ACE-III version in 2012. It is used internationally as described by Bruno and Schurmann Vignana (2019) in their critical review.

The ACE-III is used locally within the study setting and covers five cognitive domains: attention; memory; fluency; language; and visuospatial skills. An individual’s academic ability must be considered during testing (Hodges and Larner, 2017). The test is normally completed within 15–20 minutes. Scored out of 100, a lower score indicates cognitive decline. The cut-off for dementia is between 82 and 88; with a score below 86 generally used to inform the need for further investigation. Potts et al. (2022) describe the ACE-III as a reliable tool for discriminating between dementia, MCI and controls, however, it is less reliable in discriminating between dementia types.

2. The Rookwood Driving Battery (RDB) is a simple office-based standardised screen for the core neuropsychological skills needed for driving, designed specifically to assess fitness-to-drive in the neurological population. Developed at the Rookwood Hospital in Wales between 1989 and 2006, it underwent a series of validation studies against on-road driving performance (McKenna, 2009). It is published by Pearson, for use by occupational therapists and clinical psychologists.

The RDB assesses core cognitive skills for safe driving, identified as visual perception; attention; praxis; and executive function. There is also a test of comprehension. Physical power, fine motor coordination, or skills where compensatory techniques may support safe driving, are not tested (McKenna, 2009).

The RDB comprises 12 sub-tests and is scored out of 22. A higher score indicates a poor performance with a score >10 classed as a fail (90% chance of failing on-road), and scores between 6 and 10 represent an increasing risk of failure where on-road testing is indicated. It is not age specific and is indicated for a variety of neurological conditions, including traumatic brain injury, stroke, dementia, Parkinson’s disease and multiple sclerosis (McKenna, 2009).

Statistical analysis

Statistical analyses were carried out in R (version 4.0.5; R Core Team, 2021). The relationship between the scores on the two tests; ACE-III and RDB, was analysed using General Linear Modelling (GLM). As a statistically significant negative correlation was found, binomial logistic regression was performed to establish an upper and lower cut-off point on the ACE-III score at which a pass or fail on the RDB was recorded. Due to the debate around which score cut-off on the RDB is reliable for the dementia population (⩽10, and <6 for those with dementia) this analysis was performed for both cut-off points (McKenna and Bell, 2007; Vella and Lincoln, 2014). A significant result was taken as p < 0.05. In an additional analysis, demographic variables such as age, sex and dementia type were included in the GLM to establish any impact on the relationship between the ACE-III and RDB score.

Ethics and consent

All data used were anonymised after quality control checks were completed prior to export for statistical analysis. Participant consent was not required as there was no direct contact with any participant. The study was granted proportionate ethical approval in December 2019.

Results and findings

Demographic data

There were 98 participants in this study. The age range was 63–94 years with a mean age of 79.5 years, 90% of participants were over 70 years. Demographic data is reported in Supplemental Table 1. No participants with Frontotemporal Dementia or Dementia with Lewy Bodies were included in the data. This may have been due to factors within the presentation of these dementias impacting driving at an earlier stage, resulting in an easier decision around driving cessation for the responsible clinician. These findings are backed up by Toepper et al. (2019) in their systematic review of 53 dementia driving assessment papers, including 19 additional references specific to clinical features of dementia syndromes highlighting the impact of other non-cognitive factors on driving fitness in the earlier stages of disease progression for people with ‘non- Alzheimer dementias’.

Identifying any correlation between the ACE-III and the RDB

A statistically negative correlation was identified between the scores on the two assessments (F_(1,96) = 33.26, p < 0.001). As the ACE-III score decreases, the RDB score increases (see Figure 1). As a negative correlation was found, further analysis of the data was possible.

Impact of confounding variables

In this analysis, confounding variables such as age, sex, and diagnosis were present. These variables were included in the GLM looking at the relationship between the ACE-III and RDB scores. The analysis showed no significant impact of age (p = 0.135), and sex (p = 0.611) on the test scores. There was found to be an effect of diagnoses MCI (p = 0.00162) and VD (p = 0.03428) on the relationship between scores. All other diagnoses present in this analysis were found to be not significant (AD, MIX, Other, p > 0.05), (See Supplemental Figure 1). Further analysis of the impact of the diagnosis on both the ACE-III and RDB assessments was done using GLM analysis. Individuals diagnosed with MCI scored significantly higher on the ACE-III assessment (F_{(4, 93)} = 2.744, p = 0.00464) in comparison to the other diagnoses. The significance of diagnosis VD on the ACE-III score is lost in this further analysis with the removal of other variables from the model. There was no impact of any diagnoses on the RDB score found (F _{(4, 93)} = 1.065, p > 0.05).

Using Logistic regression to identify upper and lower score cut-offs on the ACE-III for a pass/fail on the RDB

The upper score cut-off for a pass in the RDB is classed as ⩽10. Any person scoring above this has a 90% chance of failing on-road (McKenna, 2009). However, more recent research and debate indicate that this cut-off may not be reliable for people over 70 years old (Rees et al., 2008), or those with dementia. Some participants with dementia scored a ‘pass’ between 6 and 10 on the RDB, however, subsequently failed the on-road test, suggesting that the lower cut-off score <6 is a more accurate predictor of pass/fail on-road for this group. (McKenna and Bell, 2007; Vella and Lincoln, 2014). Therefore, analyses in this study were completed for both RDB score cut-off points to explore this further.

Binomial logistic regression was performed to determine the relationship between the ACE-III score and participants who passed or failed on the RDB, with the pass RDB score cut-off at ⩽10. This analysis showed this relationship to be significant (p = 0.000729). A lower ACE-III cut-off score was identified as 54 (see Figure 2, red line) below which no participant achieved a pass, scoring ⩽10 on the RDB. The majority of participants who failed the RDB (score 11–22) scored 34–80 on the ACE-III. However, one participant scored highly on both the ACE-III and the RDB (ACE-III score: 82, RDB score: 17) which was unexpected, thus a reliable upper ACE-III cut-off score was not identified. An RDB pass of ⩽10 was achieved by participants scoring 54 or above on the ACE-III (Figure 2).

Similarly, a binomial GLM was performed to determine this relationship, with the pass RDB score being changed to <6. This analysis showed this relationship to be significant (p = 0.001894). A lower ACE-III cut-off score was identified as 65 (see Figure 3, red line) below which no participant achieved a pass on the RDB. The majority of participants who scored 6 or above on the RDB, scored between 34 and 88 on the ACE-III. Similarly to the previous analysis, a small number (3) of participants scored highly on both the ACE-III and the RDB which was unexpected, thus a reliable upper ACE-III cut-off score was not identified.

Decision after RDB result and on-road data

Following the ACE-III and RDB assessments, 17 participants continued driving with a planned 12-month review, (RDB score 3–5), 35 participants were referred for the on-road test (RDB score 5–14), and 46 stopped driving (RDB score 9–22). Although the decision was made to refer 35 participants for the on-road test, only 14 went on to sit an on-road test within the data collection timeframe (16 months, see limitations in discussion; More demographic data is included in Supplemental Table 2).

Due to the small on-road sample subset (n = 14), reliable statistical analysis was not possible, however, we can report interesting trends. In this on-road sample subset (n = 14), no participant passed on-road with a score greater than 7 on the RDB, and 90% of those who failed, scored between the RDB 6–10 parameter. Figure 4, shows that 4 participants passed on-road with (RDB range 5–7) and 10 participants failed (RDB range 6–12).

Discussion and implications

This paper reports the results of a retrospective analysis of routinely collected clinical data and is the first RDB dementia-specific study (including MCI data) published to date. To summarise the key findings, the results have confirmed a significant negative correlation between the ACE-III and RBD scores, justifying using a combination of both screens within clinical practice. The results identified a lower cut-off ACE-III score of 65 to inform the timing and use of the RDB within the dementia population. Furthermore, the data from the on-road subset suggests a lower cut-off RDB pass score of <6 as more reliable for this group, although this subset is too small (n = 14) for any reliable analysis to be completed, and any conclusions to be made. The subsequent discussion situates these four key findings within existing literature and clinical practice.

Establishing a correlation confirms using a combination of both the ACE-III and RDB in clinical practice

Using a combination of both tools brings both generalist cognitive and driving specific information to the assessment process, informing accurate, evidence based, objective outcomes and decision making with the person and their family. Other authors also suggest that the use of a combination of assessment tools represents best practice clinically (Allan et al., 2016; Lee and Molnar, 2017).

Previous research about the use of a generalist cognitive screen such as the ACE-III alone reflects poor correlation with on-road driving (Bennett et al., 2016; Hollis et al., 2015; Rees et al. 2008). Our study results support this, with a few participants performing outside the correlation, scoring unexpectedly highly on both assessments (Figures 2 and 3) These participants’ ACE-III scores alone did not reflect actual RDB performance, indicating unreliability if ACE-III is taken as a single basis for decision making. The ACE-III is impacted by premorbid intelligence or academic achievement (Hodges and Larner, 2017), however, the RDB is not (McKenna, 2009). These participants may have higher intelligence, scoring well on the ACE-III, however, the extent of their cognitive change was picked up by the more sensitive RDB.

The purpose of the RDB is to assist in identifying the likelihood of passing or failing the on-road test. It is not designed as a standalone assessment, and the results should be considered in conjunction with other evidence (McKenna, 2009). McKenna et al. (2004) argue that standardised office-based testing using a specific neuropsychological battery of tests such as the RDB is more objective and reliable than an on-road test due to the potential of the subjectivity of different on-road examiners.

The RDB is becoming more popular nationally and is recognised as a useful tool, however, dementia-specific data is limited. Initial RDB studies had limited numbers of drivers with dementia – just 12.5% of the sample group (McKenna, 2009; Vella and Lincoln, 2014). Various studies have shown that the RDB is better at predicting a fail or identifying drivers who are at risk on-road, than predicting drivers who are likely to pass on-road (Mckenna et al., 2004; McKenna and Bell, 2007). Debate regarding older drivers aged >70 years, as well as those drivers with dementia, has centred on the lack of evidenced-based data, with additional debate about which RDB score is an accurate cut-off for this group. Considering this debate, we could hypothesise that finding an ACE-III cut-off score below which no participant scored RDB pass <6 is justified within the dementia population.

Identifying ACE-III cut-off score which justifies use of the RDB

Establishing the correlation allowed further development of data analysis to explore ACE-III score parameters justifying the use of the RDB. For both RDB pass score cut-off points of ⩽10 and <6, logistic regression highlighted lower cut-off ACE-III scores below which consistently resulted in an RDB fail, however, there was no ability to identify a higher cut-off ACE-III score that consistently produced an RDB pass. For the higher RDB pass cut-off ⩽10 the ACE-III cut-off score was 54 (Figure 2). For the lower RDB score domain <6 this cut-off ACE-III score was 65 (Figure 3).

If we consider McKenna and Bell (2007) and Vella and Lincoln’s (2014) research, about a reliable RDB cut-off <6, then we could suggest that any ACE-III score <65 is a realistic reason not to pursue further assessment with drivers in the dementia population. However, this needs to be considered on an individual basis in conjunction with all other evidence and there may be occasions where drivers scoring ACE-III 54–64 are screened using the RDB. Dementia-specific guidelines published in New Zealand (Fisher and Thomson, 2014) used the ACE-III score to guide disease progression and identify guidelines for each dementia stage. Moderate dementia was classed as ACE-III score 35–64 with specific driving guidance ‘must stop driving’. This matched our study results identifying that no participant scoring ACE-III <65, achieved <6 for the lower RDB pass domain.

In clinical practice, a driver may wish to complete both the RDB and on-road test, even if results point towards the likelihood of failing. This is generally at the driver’s request as an on-road test result is more easily understood than table-top tests (Lanceley, 2015) and reflects a rights-based approach. However, we must continue to support referrers to make confident decisions around driving cessation where it is obvious that the person should not be driving, without the need for further assessment through a combination of local and national resources (Fisher and Thomson, 2014).

On-road data supporting use of the <6 RDB pass cut-off for drivers with dementia

Of the 14 participants who sat the on-road test, 4 passed, and 10 failed (see Figure 4.). It can be observed that the 4 participants who passed, scored ⩽7 on the RDB. Due to the small number of participants in this data subset (n = 14), no robust conclusions can be made. A larger sample group would be required to test the reliability of using the <6 RDB cut-off within the dementia population, and is an area for future study.

Allen et al. (2016) reviewed clinical guidelines available and emphasised the importance of decision making encompassing all factors available and not based entirely on a score. It is essential that this approach is used with all drivers, but especially for those scoring a borderline score, for example, 5, 6 or 7 on the RDB. This factor has been reflected in the preliminary work to develop local guidelines (Supplemental Table 4.).

The Impact of variables was minimal

Our results show that there was no impact of age or sex in this analysis. There are varying levels of correlation between diagnoses (see Supplemental Figure 1). In particular, our results indicated an effect of diagnoses of MCI and VD on the correlation. During analysis of the effects of diagnoses on the individual assessment scores, those diagnosed with MCI scored significantly higher on the ACE-III. This result is expected (Potts et al., 2022) and is not impacted by a lower cut-off score. Subsequent analysis found no significance of other diagnoses (VD, AD, MIX, OTH) on the ACE-III score, with no significance of any diagnosis on the RDB score. Therefore, the lower cut-off ACE-III scores were established for the study sample as a whole.

Limitations

The study sample (n = 98) is the largest RDB dementia-specific study to date, however, it comprised more male participants than females: 61 males and 37 females. This was similar for the on-road data subset (n = 14) comprising: 11 males and 3 females. Liddle and McKenna (2003) discuss the historical nature of driving as being a predominately male occupation which may explain this trend. We could also surmise that females may be less inclined to participate in an assessment process and simply choose to stop driving. However, there is no data to confirm this idea. It is also worth noting that no females passed the on-road test, which may be an interesting area for further research.

Time between assessments was not measured as a variable in this study. The study sample comprised only those participants with both assessments completed within the 6 months agreed on inclusion timeframe to minimise the risk of discrepancies in the levels of cognition measured. However, there is still a risk of disease progression within this 6-month period. The effect of time between assessments and subsequent results should be included in future studies.

Of the 35 participants referred for the on-road test, data were only available for 14 participants during the data collection phase, restricting the ability to perform robust statistical analysis. Possible reasons for this difference in number:

• Death of participant

• Disease progression during wait time

• Missed appointment

• Participant chose to surrender licence

• On-road tests were not completed during the data collection timeframe due to the COVID-19 Pandemic.

Future research

• Research with a larger sample of on-road data in conjunction with the RDB score could provide further evidence of the impact of any dementia or cognitive impairment on the lower cut-off score of <6 and the pass/fail outcome of the on-road test.

• Analysis of different dementia types may be of interest and inclusion of time as a variable.

Conclusion

This study has demonstrated a significant relationship between the ACE-III and the RDB; as the ACE-III score decreases, the RDB score increases. A cut-off score of 54 on the ACE-III was established at which no participant passed scoring ⩽10 on the RDB, and a cut-off score of 65 on the ACE-III was established at which no participant passed, scoring <6 on the RDB. A pass score of <6 appears more reliable than the RDB score of ⩽10 for dementia/MCI. This highlights the usefulness of using a combination of both tools to inform a rights-based approach to assessment and fitness-to-drive decision making.

The results will be used to create local referral guidelines, in conjunction with previous research, about the timing of referral to occupational therapy for specialist assessment using the RDB, and when to refer for an on-road medical driving assessment, so that drivers with dementia will be referred to occupational therapy at the right time and for the right reasons. Provisional ideas for developing local guidelines based on the findings of this study are included in Tables 3 and 4 in the Supplemental File. This study adds more evidence about the use of the RDB within the dementia population and is useful wherever the RDB is used in clinical practice.

Key findings

For drivers with dementia scoring >65 on the ACE-III, completion of the RDB is recommended.

A pass RDB score <6 appears more reliable than an RDB pass ⩽10 within the dementia population.

What the study has added

An ACE-III result can indicate use of the RDB to aid fitness-to-drive assessments within the dementia population and a combination of ACE-III and RDB results can inform a decision to refer for the on-road test.

Supplemental Material

sj-docx-1-bjo-10.1177_03080226241299594 – Supplemental material for The value of using the Addenbrookes Cognitive Exam-III and the Rookwood Driving Battery to aid fitness-to-drive decisions with people who have dementia or mild cognitive impairment

Supplemental material, sj-docx-1-bjo-10.1177_03080226241299594 for The value of using the Addenbrookes Cognitive Exam-III and the Rookwood Driving Battery to aid fitness-to-drive decisions with people who have dementia or mild cognitive impairment by Hazel R Douglas, Jenna P Breckenridge, Jane Foster, Rebekah P Douglas, Aileen C Gemmell and Emma LH Arblaster in British Journal of Occupational Therapy

Footnotes

Acknowledgements

The authors would like to thank everyone involved in this study: Tia Dixon – Team line manager for her support throughout the whole process, Petra Rauchhaus – Clinical Trials Statistician, University of Dundee for assisting with the study protocol, and Paul Swinton – Statistician from Robert Gordon University Aberdeen for checking the accuracy of the analysis.

Ethics approval

The study was reviewed and approved by the North West Greater Manchester Research Ethics Committee (Reference 19/NW/0755 date of approval 02.12.2019).

Sponsor reference number 3-038-19

REC reference: 19/NW/0755

IRAS project ID: 271319

Research Registry: 5306

Consent

Consent from individual subjects was not required as the study design involved only retrospective access to patient records.

Patient and public involvement

During the development, progress and reporting of the submitted research, patient and public involvement in the research was not included at any stage.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study received grant funding of £5000 from the Constance Owen’s Trust in the form of the Royal College of Occupational Therapists Early Researcher Award for 2020. These monies enabled employment of a part-time research assistant for 12 months as part of the data collection phase of the study.

Contributorship

HRD, JF, and JPB developed the study. JF and ACG collected the data. ELHA monitored the data collection. RPD completed the statistical analysis. HRD, JPB and RPD drafted the manuscript. All authors have contributed to the study and have approved the final version of the manuscript.

ORCID iD

Hazel R Douglas

Supplemental material

Supplemental material for this article is available online.

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