Abstract
Systematic reviews of literature relevant to driving and community mobility for older adults are important to the practice of occupational therapy. We describe the four questions that served as the focus for the systematic reviews of the effectiveness of occupational therapy assessments and interventions for driving and community mobility for older adults. We include the background for the reviews; the process followed for each question, including search terms and search strategy; the databases searched; and the methods used to summarize and critically appraise the literature. The final number of articles included in each systematic review, a summary of the themes of the results, the strengths and limitations of the findings, and the implications for practice, education, and research are presented.
Keywords
Since 1998, the American Occupational Therapy Association (AOTA) has instituted a series of evidence-based practice projects to assist members with meeting the challenge of finding and reviewing the literature to identify evidence and, in turn, use this evidence to inform practice (Lieberman & Scheer, 2002). Following the evidence-based philosophy of Sackett, Rosenberg, Muir Gray, Haynes, and Richardson (1996), AOTA’s projects are based on the principle that the evidence-based practice of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research.
A major focus of AOTA’s evidence-based practice projects is an ongoing program of systematic reviews of the multidisciplinary scientific literature, using focused questions and standardized procedures to identify practice-relevant evidence and discuss its implications for practice, education, and research. Systematic reviews of driving and community mobility strengthen current knowledge of the efficacy of practices used by occupational therapy practitioners working in the area of driving and community mobility for older adults.
Background
In the 2010 Census (U.S. Census Bureau, 2012), it was reported that the number of older adults in the United States totaled 40.3 million, representing 13% of the population. According to the National Highway Traffic Safety Administration (2010), the number of licensed older drivers in 2008 was 32 million, a 20% increase from 1999, representing 15% of all licensed drivers (compared with 14% in 1999).
Driving and community mobility are important instrumental activities of daily living as identified by the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014). Community mobility can be defined as “moving around in the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other public transportation systems” (AOTA, 2014, p. S19). For older adults, driving represents not only a means of transportation but also independence, self-reliance, and the ability to participate in other meaningful occupations (Oxley & Whelan, 2008).
Overall, older adults are at higher risk for crashes (Fildes, 2008). However, evidence has indicated that older adults who drive a limited number of miles per year account for the high crash rates (Langford, Methorst, & Hakamies-Blomqvist, 2006). According to Anstey, Wood, Lord, and Walker (2005), some cognitive, sensory, and physical changes, such as changes in visual attention, memory, and reaction time that take place during aging, may affect driving performance of older adults and contribute to crash risk. In addition, medical conditions such as dementia, cardiovascular disease, sleep apnea, schizophrenia, and Parkinson’s disease may affect fitness to drive and may slightly or moderately increase crash risk (Crizzle, Classen, & Uc, 2012; Marshall, 2008).
An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of an occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both. AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This model standardizes and ranks the value of scientific evidence for biomedical practice using the following grading system adapted from Sackett et al. (1996):
Level I: Systematic reviews, meta-analyses, randomized controlled trials
Level II: Two groups, nonrandomized studies (e.g., cohort, case control)
Level III: One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV: Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V: Case reports and expert opinion that include narrative literature reviews and consensus statements.
The systematic reviews on driving and community mobility for older adults were supported by AOTA as part of the Evidence-Based Practice Project and are based on the need for occupational therapy practitioners to have access to the results of the latest and best available literature to support intervention within the scope of occupational therapy practice. AOTA is committed to supporting the role of occupational therapy in this important area of practice. Previous systematic reviews of the focused questions targeting aspects of intervention were completed for the 1985–2004 time frame. The current systematic reviews were updated for the period 2005–April 2011, except for the new assessment question, which covered the period of 1990–April 2011.
The four focused questions developed for the updated reviews were based on the search strategy of the earlier reviews. These questions were reviewed by review authors, an advisory group of experts in the field, AOTA staff, and the consultant to the AOTA Evidence-Based Practice Project.
The following three focused questions served as the basis for the systematic reviews of occupational therapy interventions and assessments for driving and community mobility for older adults:
What is the evidence supporting the use of clinical assessments (e.g., vision, cognition, physical function) and performance-based assessments (e.g., behind the wheel, simulated) for determining driving safety or competence and driving cessation for older adults?
What is the evidence for the effectiveness of interventions to address cognitive and visual function, motor function, driving skills, self-regulation and self-awareness, and the role of passengers and family involvement in the driving ability, performance, and safety of older adults?
What is the evidence for the effect of policy and community mobility programs (e.g., alternative transportation, walkable communities, education, driving cessation programs, and pedestrian programs) on the performance and participation of older adults?
In addition to the systematic reviews based on these three questions, a fourth systematic review was completed for a focused question on interventions related to vehicle-related modifications. The methodology for this question is incorporated in this article; the results for this question are reported in the Occupational Therapy Practice Guidelines for Driving and Community Mobility for Older Adults (Stav, in press), and a summary of the evidence is available as a Critically Appraised Topic in the Evidence-Based Practice and Research section of the AOTA website (http://www.aota.org/Practice/Productive-Aging/Evidence-based.aspx).
Method
Search terms for the systematic reviews were developed by the methodology consultant to the AOTA Evidence-Based Practice Project and AOTA staff in consultation with the authors of each question and were reviewed by the advisory group. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. Table 1 lists the search terms related to population and intervention included in each systematic review. A medical research librarian with experience in completing systematic review searches conducted all searches and confirmed and improved the search strategies.
Search Strategy for the Systematic Reviews on Occupational Therapy and Driving and Community Mobility for Older Adults
Note. Search terms with an asterisk were searched only with senior driver, aged driver, older driver, and elderly driver (not with aging and elderly).
Databases and sites searched included Medline, PsycINFO, CINAHL, AgeLine, Ergonomics Abstracts, Transportation Research International Documentation, IEEE Xplore, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews and the Campbell Collaboration, were included in the search. These databases are peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct systematic reviews of selected clinical questions and topics. Moreover, reference lists from articles included in the systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.
Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature incorporated into a review. The reviews for all four questions were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were studies related to older adult driving and within the scope of practice of occupational therapy. The literature included in the reviews was published between 2005 and April 2011. The earlier reviews included studies published between 1985 and 2004. The assessment studies examined were published between 1990 and April 2011 and assessed predictive or concurrent validity. They also included at least some assessments commonly used by occupational therapists. The reviews excluded data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations, and theses. Studies included in the reviews are Level I, II, and III evidence. Level IV and V evidence was included only when higher-level evidence on a given topic was not found.
A total of 5,797 citations and abstracts were included in the reviews. The question on assessment included 1,743 references; person interventions, 1,609; car interventions, 735; and policy and community mobility interventions, 1,710 references. The first author of this article completed the first step of eliminating references on the basis of citation and abstract. For the majority of the projects, the systematic reviews were carried out as academic partnerships in which academic faculty worked with graduate students to carry out the reviews. Review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the reviews on the basis of predetermined inclusion and exclusion criteria.
A total of 135 articles were included in the final review. Table 2 presents the number and levels of evidence for articles included for each review question. The teams working on each focused question reviewed the articles according to their quality (scientific rigor and lack of bias) and levels of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article and an appraisal of the strengths and weaknesses of the study on the basis of design and methodology. AOTA staff and the Evidence-Based Practice Project consultant reviewed the evidence tables to ensure quality control.
Number of Articles in Each Review at Each Level of Evidence
Summary of Themes in the Reviews
The results of the systematic reviews published in this issue of the American Journal of Occupational Therapy provide guidance for occupational therapy practitioners working with older adults on driving and community mobility. By reviewing the scientific literature and appraising and synthesizing specific studies, the authors have been able to provide guidance on critical practice questions.
In the area of assessments, evidence was found for the use of single assessments and batteries of assessments. Research in the area of driving assessments was conducted with both healthy older drivers and those with functional deficits from a specific condition associated with aging.
The evidence for interventions focusing on the older driver was grouped under the following themes: educational interventions, interventions addressing cognitive–perceptual skills, interventions addressing physical fitness, simulator training to address driving skills, and behind-the-wheel training to address driving skills. The systematic review on policy and community mobility found evidence grouped under the following themes: licensure policy, driving cessation programs, community mobility, and walkable communities.
Strengths and Limitations of the Reviews and Implications for Occupational Therapy Practice, Research, and Education
The three systematic reviews presented in this issue (Dickerson, Meuel, Ridenour, & Cooper, 2014; Golisz, 2014; Stav, 2014, in press) have several strengths and include many aspects of driving and community mobility for older adults. The updated reviews include 135 articles, 55 of which were dedicated to intervention studies. Three-fourths of those intervention studies provided Level I and Level II evidence, indicating that the evidence is of high quality. The reviews also involved systematic methodologies and incorporated quality control measures.
The limitations of the systematic reviews are based on the design and methods of individual studies and include limited reporting of a training program, limited follow-up, small sample sizes, high dropout rates, and lack of a control group or randomization in several of the studies. In addition, a variety of assessments and outcomes were used, making it difficult to group the intervention and assessment studies together. Please refer to the individual systematic reviews for more complete information on the results, interpretation of findings, limitations, and implications for practice (Dickerson et al., 2014; Golisz, 2014; Stav, 2014, in press).
These systematic reviews provide summaries of the best scientific literature to answer the focused questions. The results described here can be directly integrated into clinical practice by combining the scientific evidence with clinical expertise and client preferences. In addition, this information may be used when advocating for occupational therapy services to a payer or regulator or providing information and support to a client and family member at any point during the intervention process.
In the future, researchers should build on the existing studies discussed in the systematic reviews included in this issue. Clearly, more work is needed to definitively answer the four questions that served as the basis for these systematic reviews. The future of occupational therapy is based on all occupational therapy practitioners developing a firm grasp on the best available evidence. This agenda is also clear for academic programs training the next generation of occupational therapy practitioners. Educators need to be aware of these systematic reviews and present this multifaceted information to students rather than focus on a favored type of intervention. In addition, the evidence should not be presented in a one-size-fits-all framework but should be discussed from a client-centered and occupation-based perspective as described in the Framework (AOTA, 2014).