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Matthew Rizzo, MD; Stephen Reinach, MS; Daniel McGehee, MS; Jeffrey Dawson, ScD

Arch Neurol. 1997;54(5):545-551.

Abstract
Background
Alzheimer disease (AD) is the most common cause of dementia and can impair cognitive abilities crucial to the task of driving. Rational decisions about whether such impaired individuals should continue to drive require objective assessments of driver performance.

Objective
To measure relevant performance factors using high-fidelity driving simulation.

Design
We examined the effect of AD on driver collision avoidance using the Iowa Driving Simulator, which provided a high-fidelity, closely controlled environment in which to observe serious errors by at-risk drivers. We determined how such unsafe events are predicted by visual and cognitive factors sensitive to decline in aging and AD.

Setting
The University of Iowa Hospitals and Clinics, Iowa City, and the Iowa Driving Simulator.

Participants
Thirty-nine licensed drivers: 21 with AD and 18 controls without dementia.

Main Outcome Measures
We determined the number of crashes and related performance errors and analyzed how these occurrences were predicted by visual and cognitive factors.

Results
Six participants (29%) with AD experienced crashes vs 0 of 18 control participants (P=.022). Drivers with AD were more than twice as likely to experience close calls (P=.042). Plots of critical control factors in the moments preceding a crash revealed patterns of driver inattention and error. Strong predictors of crashes included visuospatial impairment, reduction in the useful field of view, and reduced perception of 3-dimensional structure-from-motion.

Conclusions
High-fidelity driving simulation provides a unique new source of performance parameters to standardize the assessment of driver fitness. Detailed observations of crashes and other safety errors provide unbiased evidence to aid in the difficult clinical decision of whether older or medically impaired individuals should continue to drive. The findings are complementary to evidence currently being gathered using techniques from epidemiology and cognitive neuroscience.

Author Affiliations
From the Colleges of Medicine (Drs Rizzo and Dawson) and Engineering (Dr Rizzo and Messrs Reinach and McGehee) and the Public Policy Center (Dr Rizzo and Mr McGehee), University of Iowa, Iowa City.

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