Decision Making Among Older Adults: the AUTO study

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7. PROJECT SUMMARY Decisions about driving cessation are emotionally difficult for older adults, their family members, and their providers – and they are also ubiquitous and of critical importance. Cognitive impairment – including from Alzheimer’s disease in its earliest stages – complicates driving decisions and has been linked to both driving risk and the need for eventual driving cessation. Issues with driving may be an early-warning sign of cognitive impairment associated with Alzheimer’s disease and related dementia, when persons may still have decision-making capacity. Prior work shows that older adults want to make decisions about driving themselves, and they want time to prepare for transitions especially because driving cessation can lead to decreased independence and mobility and, consequently, poor psychosocial outcomes such as depression and isolation. An existing web-based driving decision aid (DDA) offers the potential to educate older adults, help them clarify their values and understand their options, and make the decision that is right for them. This R01 proposal builds on preliminary work aligned with the NIH Stage Model for Behavioral Intervention Development (Stage II efficacy testing of a previously developed intervention) and is responsive to the FOA’s call for translational work to leverage cognitive, emotional and motivational strengths to facilitate optimal decision-making. Over a five-year period, our multi-disciplinary, established study team aims to (1) test the efficacy of the DDA in improving decision quality, (2) determine the DDA’s effects in specific subpopulations of older adults, including individuals with early Alzheimer’s disease and/or mild cognitive impairment, and (3) identify the best settings for future DDA use. Our underlying hypotheses are that the DDA will help older adults, including those with Alzheimer’s disease-related cognitive impairment, make high-quality decisions (i.e., informed and in line with their values), which will mitigate the negative psychosocial impacts of driving cessation, and that optimal DDA effects will be found in certain populations in certain settings. We will first test the DDA’s efficacy in a three-site, two-armed randomized controlled trial of older drivers (n=300, ≥70 years), as compared to a web-based control (basic information about driving without guided decision-making). Older driver enrollment will be complemented by enrollment of one “family member” (relative or trusted friend) per driver. The primary trial outcome (immediate) will be self-rating of decision quality (Aim 1a). We will also test the DDA’s longitudinal effects on psychosocial outcomes (Aim 1b) and driving behaviors (Aim 1c) at 12 and 24 months. We will next use the trial data for stratified analyses of the DDA’s effect on decision quality in subpopulations defined by cognitive function – including individuals with early-stage Alzheimer’s disease (Aim 2a), decisional capacity (Aim 2b), and attitudinal readiness to stop driving (Aim 2c). In Aim 3, we will use questionnaires and qualitative interviews to examine DDA acceptability and preferred timing and setting for use. Key stakeholders will include older drivers, family members (or trusted friends), healthcare providers caring for older adults – including those who provide services for persons with Alzheimer’s disease and related dementia, and leaders in older driver research and policy. The roles of family members and healthcare providers in supporting drivers gain additional importance in the context of concerns about cognitive or decisional capacity, including in Alzheimer’s disease and mild cognitive impairment, highlighting the need for inclusion of their perspectives in research. The proposed research fills a critical need for usable tools to help older adults safely retire from driving while maintaining independence, mobility and well-being. The planned analyses will allow tailoring and dissemination to older drivers with dementia and their families; this may include dissemination through healthcare settings with targeted guidance to clinicians about when in the course of Alzheimer’s disease to use the decision aid or public-facing resources. The aging of the population lends urgency to these issues, and our proposed work will provide the scientific foundation for future implementation of an effective, patient-centered driving decision aid in real-world settings. Understanding how, with whom, and when to use a driving decision aid offers the potential to significantly improve the independence, health, and well-being of millions of older adults.