Archives of Clinical Neuropsychology

20 (2005) 217–228

The relationship of neuropsychological functioning to

driving competence in older persons with
early cognitive decline
William M. Whelihana,b∗,1 , Margaret A. DiCarloa,b , Robert H. Paula
a
Brown University School of Medicine, RI, USA
b
Roger Williams Medical Center—Psychiatry, 50 Maude Street, Providence, RI 02908, USA

Accepted 8 July 2004

Abstract

The study focused on the role of traditional and computer-administered visual attention and executive
measures in the prediction of driving competence in older individuals with early-stage cognitive decline.
A group of 23 patients with questionable dementia by Clinical Dementia Rating (CDR = 0.5) was
evaluated with a group of 23 age-matched controls. For the patient group, correlational analyses revealed
that road-test performance was significantly related to a number of executive and visual attention
measures but not to other neuropsychological measures. For the control group, road-test performance
was only significantly related to age. A hierarchical regression procedure was utilized to further explore
the contribution of specific executive and visual attention measures and 46% of the variance in road-test
performance was attributable to these measures for the patient group. A discriminant function analysis
utilizing executive and visual attention measures for the entire group of participants classified those who
passed and failed the road test with 80% accuracy. Neuropsychological executive and visual attention
measures may play a useful role in determining competence to drive in older individuals with early-stage
cognitive decline.
© 2004 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.

Keywords: Driving; Executive functioning; Computerized assessment; Competence; Elderly; Mild cognitive im-
pairment

∗
Corresponding author. Tel.: +1 401 456 2201; fax: +1 401 247 2582.
E-mail address: wwhel@brown.edu (W.M. Whelihana,b ).
1
Roger Williams Medical Center—Psychiatry, 825 Chalkstone Ave., Providence, RI 02908.

0887-6177/$ – see front matter © 2004 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.acn.2004.07.002
218 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

1. Background

Elderly drivers are at higher risk than all other age groups for motor vehicle accidents
(MVA) on a per-mile basis (Graca, 1986; Klein, 1992; Vernon, 1995), and elderly individuals
with moderate to severe dementia are at even greater risk (Rabins et al., 1997). What is unclear
is the extent to which driving ability is compromised in individuals with early-stage cognitive
decline, and whether neuropsychological assessment can assist in the determination of driving
competency in these individuals. Specifically, the relationship between cognitive factors and
driving competence has not been adequately explored to date.
Brief mental status examinations, often insensitive to early changes in dementia (Whelihan,
Lesher, Kleban, & Granick, 1984), have yielded variable results. Some researchers have found
that impaired elderly drivers scored lower on the Mini-Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975) than non-impaired drivers (Carr, Jackson, & Alguire,
1990; Fitten et al., 1995; Fox, Bowden, Bashford, & Smith, 1997); whereas others have not
found such a relationship between global measures of cognitive status and driving ability
(Foley, Wallace, & Eberhard, 1995; Odenheimer et al., 1994; Trobe, Waller, Cook-Flannagan,
Teshima, & Bieliauskas, 1996).
The few studies investigating the relationship between driving ability and neuropsycho-
logical measures have also yielded inconsistent results. In their study of on-road driving per-
formance in 25 older adults, Hunt, Morris, Edwards, and Wilson (1993) found that several
neuropsychological measures [Wechsler Memory Scale-R Logical Memory, Benton Visual
Retention Test (BVRT), Boston Naming Test, Trails A, Wechsler Adult Intelligence Scale-R
Digit Symbol] were significantly related to driving performance, but Verbal Fluency was not.
However, Rebok, Keyl, Bylsma, Blaustein, and Tune (1994), using driving simulation, found
that Verbal Fluency was correlated with driving performance. Furthermore, Fox, Bowden, and
Smith (1997) did not find a relationship between neuropsychological measures (Visual Form
Discrimination Test, Judgment of Line Orientation Test, Trails A and B, BVRT, and WAIS-R
subtests) and results of an on-road driving evaluation.
More consistent findings have been reported with computer-administered visual attention
tests. Ball and Roenker (1998) and Ball and Owsley (1993) developed the Useful Field of
View (UFOV), a test now available commercially that shows promise as a predictor of driving
ability. Using logistic regression models, Sims, Owsley, Allman, Ball, & Smoot (1998) found
that a 40% reduction in useful field of view (the visual area available in a single glance, without
head or eye movements) was associated with increased crash involvement. In addition, Owsley
et al. (1991, 1994) reported that statistical models incorporating the UFOV and the Dementia
Rating Scale (Mattis, 1976) have been useful in predicting accident frequency in samples of
older drivers.
Duchek, Hunt, Ball, Buckles, and Morris (1998) studied healthy elderly and elderly with
very mild or mild DAT using three computerized tasks (Visual Search, Visual Monitoring,
UFOV) as predictors of on-road driving ability. While the study incorporated a number of
neuropsychological tests, there was none beyond a mental control measure from the Wechsler
Memory Scale that could be considered an executive measure. The authors found that error rate
and reaction time on the Visual Search task were the best predictors of driving performance. It
is interesting to note that while UFOV performance was significantly correlated with on-road
 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228 219

driving performance, it was far too difficult for the majority of individuals with dementia to
complete. The authors proposed that a simpler version of the UFOV would be necessary to
adequately assess its predictive utility in a dementia sample.
Interestingly, neuropsychological studies of driving competence in the elderly have for
the most part neglected or limited the assessment of executive functioning. Yet, intuitively
it would appear that higher level executive and visuoperceptual functions are critical to the
complex skill of driving. Results of two recent studies suggest that executive abilities are
important determinants of driving ability among elderly drivers. A study of Daigneault, Joly,
and Frigon (2002) showed that elderly drivers with a history of accidents had difficulty on
several executive measures compared to participants without an accident history. In a second
study, Ott et al. (2003) reported strong correlations between subjective ratings of driving ability
obtained from a care-provider and performance on an executive maze task among individuals
with mild cognitive difficulties.
To our knowledge, no study has examined relationships between executive abilities and
road-test driving performance among elderly individuals with mild cognitive impairment. To
further explore the inconsistencies in the literature and to assess more thoroughly the role of
executive and visual attention functions in driving ability, we investigated which measures in
a traditional and computer-administered neuropsychological battery were predictive of older
participants driving ability determined by actual road-test performance. We hypothesized that
executive and visual attention measures (specifically, a novel Maze Navigation Test, a visual
scanning/divided attention test (Trails B), a visual scanning/attention Letter Cancellation Test,
and the UFOV) would be critical determinants of driving ability in patients with early-stage
cognitive decline.

2. Method

2.1. Participants

All 46 participants gave informed consent, had a corrected visual acuity of 20/40 or better
in both eyes, had unrestricted driving licenses, and had performed well on a screening measure
of rules of the road and traffic sign recognition. No participant had a major medical illness
(e.g., seizure disorder) or sensorimotor impairment that would preclude driving. In addition,
no participant was taking sedative medication.
The 23 participants in the patient group (12 males, 11 females) were referred by their pri-
mary care physician or neurologist to the Memory Disorders Clinic at Roger Williams Medical
Center, Providence, RI, USA. They were recruited sequentially for the study if they met the
criteria indicated above and if they had a Clinical Dementia Rating (CDR; Morris, 1993) of
0.5 [questionable dementia] and a collateral source available to provide additional informa-
tion about driving history and functional ability. Fifteen patients had primary cerebrovascular
etiologies, confirmed by documented changes on neuroimaging and/or histories of cerebrovas-
cular events. The remaining patients had possible Dementia of the Alzheimer’s Type (DAT; n
= 1), mixed etiology of cerebrovascular disorder and possible DAT (n = 1) or other cognitive
risk factors (n = 6; remote histories of alcohol abuse or head trauma).
220 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

Table 1
Means and standard deviations for patients and controls for age, education, cognitive screening examinations, and
Rhode Island Driving Evaluation (RIDE) score
Group

Patient (n = 23; 12 males, Control (n = 23; 7 males,

11 females ) 16 females)

Test scores M S.D. M S.D. t

Age 78.2 9.3 74.3 7.3 1.6
Education 12.7 2.9 14.3 2.4 −2.0∗
MMSE 25.7 2.4 29.3 0.8 −6.8∗∗∗
DRS 130.9 9.0 141.6 2.6 −5.0∗∗∗
RIDE 130.4 84.1 46.1 34.5 4.5∗∗∗
∗
P < .05
∗∗∗
P < .001.

Nine additional patients who met inclusion criteria for the study declined full participation.
While these individuals (seven men and two women) willingly completed neuropsychological
assessment, they refused to complete road-test examinations. They expressed concern that
the road test would result in driving restrictions or revocation of their driving licenses. In
addition, their family members expressed concerns about restrictions of their freedom and
independence. All nine of these individuals demonstrated early signs of possible DAT based
on their histories, clinical presentations, and performances on neuropsychological testing.
The 23 participants in the control group (7 males, 16 females) were recruited from local
senior centers and advertisements in local media sources. They were required to have a CDR
of zero [cognitively intact], to be living independently, and to be without a significant current
psychiatric condition or sensorimotor impairment.
Demographic data and performance on screening measures of global cognitive impairment
[Mini Mental Status Examination (MMSE) and Dementia Rating Scale (DRS)] for the two
groups are presented in Table 1. The control group consisted of several more women than
men, unlike the patient group that had an approximately equal number of male and female
participants. A number of potential male volunteers in the senior centers utilized for recruitment
declined participation, due to fear of losing their driving privileges.

2.2. Procedure

After informed consent, participants and family members completed interviews and ques-
tionnaires to provide data on medical, educational and social history, activities of daily living,
and driving history. Participants in both the patient and control groups were then administered
the following battery of traditional and computer-administered neuropsychological tests:
General screening measures:

• Mini Mental Status Examination (Folstein et al., 1975)

• Dementia Rating Scale (Mattis, 1976)
• Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983)
 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228 221

Intellectual functioning/premorbid marker:

• AMNART (American version of the National Adult Reading Test; Grober & Sliwinski,
1991).

Attention/executive measures:

• Useful Field of View (UFOV; Ball & Roenker, 1998) [computer-administered]

• Wisconsin Card Sort Test (WCST, 64-item short form; Axelrod, Henry, & Woodward,
1992)
• Action Fluency (Piatt, Fields, Paolo, & Troster, 1999)
• Ruff Figural Fluency (Ruff, Light, & Evans, 1987)
• Trail Making Test (A and B)
• Maze Navigation Test (Whelihan, DiCarlo, Comparetto, & Donovan, 2001)

Language measures:

• Generative Naming [Controlled Oral Word Association (COWA; Benton & Hamsher,
1989)]
• Generative Naming (Animals)

Learning/memory measures:

• Brief Visual Memory Test—Revised (BVMT-R; Benedict, 1997)

Visual–spatial measures:

• BVMT-R Copy
• Letter Cancellation Test (random As),
• Visual Form Discrimination Test (VFDT; Benton, Hamsher, Varney, & Spreen., 1983)

The Action Fluency test, a purported measure of executive functioning analogous to other
word generation tasks, requires participants to name as many action words (verbs) as they
can within 1 min. The Maze Navigation Test is an instrument developed by our group that is
a modification of the Porteus Mazes Test (Porteus, 1965). It consists of a sample maze and
eight additional paper and pencil mazes. The mazes are thought to be a reasonable analog
of driving, because the participant is required to plan a route and arrive at a goal efficiently
while staying within the lines. A number of the mazes have obstacles, as one might en-
counter while driving. All mazes are administered, and both time to completion and number
of errors committed are recorded. WISC-III criteria were utilized in scoring the mazes. De-
scriptions of other tests in the battery are available in Lezak (1995) and Spreen and Strauss
(1998).
222 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

The computer-administered UFOV utilized a touch screen interface to eliminate potential

participant difficulties with mouse or keyboard. This test was administered on a single Pentium
desktop computer in a darkened room, after participants were oriented to the touch screen
interface.
Participants returned within one week of the neuropsychological assessment for the Rhode
Island Driving Evaluation (RIDE) that was standardized as a 4-mile course through city streets,
in a vehicle with automatic transmission, power steering and dual controls. All road tests were
conducted by the same professional examiner during daylight hours, satisfactory weather
conditions, and light to moderate urban traffic. The driving examiner had over 35 years of
experience conducting examinations and providing driving instruction to individuals of all
ages in the state of Rhode Island.
The driving examiner, who was blinded to the neuropsychological data, CDR status and
group membership, provided participants with an orientation to the vehicle prior to each road
test. He judged the performance of each participant on a pass/fail basis, according to his training
and expertise. In addition, the driving examiner rated the driving behavior of each participant
according to the RIDE scale, a measure similar to one developed by Hunt et al. (1993, 1997a,
1997b) in the Washington University driving studies.
The 31 items on this RIDE scale include an assessment of operations (inserting key, turning
on ignition, checking seat and mirrors), maneuvers (turns, stops, negotiating through intersec-
tions), adherence to traffic signs and regulations, speed and distance from objects, awareness of
driving environment (obstacles, events, how one’s driving affects others), and general cognition
(comprehension of instructions, concentration on task). The examiner rated participants’ per-
formance on each item according to frequency of occurrence (always, sometimes, not enough).
In addition, each item was weighted by level of importance for driving safety, as determined
by review of the Washington University Road Test (Hunt et al., 1993), various occupational
therapy-based driving protocols, and the official Rhode Island State driving examination. For
example, failure to pay attention to a stop sign was weighted higher than failure to use a turn
signal. Possible scores on the RIDE scale range from 0 to 570, with higher scores indicating
poorer performance.
All methods and procedures included in the current study were approved by the Institu-
tional Review Board and legal counsel of the Roger Williams Medical Center, Providence, RI.
Participants in both groups were provided feedback regarding their performance on neuropsy-
chological assessment and road-test evaluation. In the event of marginal or failed performance
on the road-test evaluation, participants were warned of the risks of continued driving. In
addition, participants in the patient group and their caregivers were aware at the onset of
the evaluation that their referring physicians would receive reports, and that their physicians
had the right to inform the Department of Motor Vehicles (DMV) of the findings. Moreover,
patient participants were provided verbal and written feedback that included specific recom-
mendations for driving. Such recommendations may have included the following: (a) drive
only under optimal conditions (non-highways, familiar routes, short distances, daylight hours,
non-rush hour traffic, good weather, with accompaniment); (b) drive under optimal conditions
and participate in re-evaluation in 6–9 months time; (c) stop driving, given the risk of accident
or injury on the road. Finally, patient participants were provided with information regarding
community resources and alternate methods of travel, whenever necessary.
 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228 223

3. Results

Significant differences between the patient and control groups were found in terms of
years of education, MMSE, DRS, and RIDE error scores but not age (see Table 1). Table 2
provides means and standard deviations for patient and control participants on the cognitive
test measures.
MANCOVAs were computed to compare the two groups on the cognitive measures, control-
ling for differences in education. Three separate MANCOVAs were conducted that separately
included measures of attention, executive function, and visual memory. Performances on Trails
A, Letter Cancellation (omissions), Visual Form Discrimination total score, Visual Form Dis-
crimination peripheral errors, and the three conditions of the UFOV test were included in the
first MANCOVA. Results of this analysis revealed significant group differences on the cogni-
tive tests (Wilks’ Lambda = 0.40, F (7, 25) = 5.29, P < .001). Univariate comparisons revealed
that the patient group performed significantly more poorly than the healthy control participants
on each of the dependent measures. Dependent variables in the second MANCOVA included
Trails B, Maze Navigation (time to complete and errors), WCST perseverative responses and
perseverative errors, Ruff Figural Fluency unique designs and perseverative errors, COWA,
animal naming, and Action Fluency. The omnibus test was significant (Wilks’ Lambda = 0.18,
F (10, 18) = 8.0, P < .001). Univariate comparisons revealed that the patient group performed
significantly more poorly than the control group on each of the dependent measures except
Ruff perseverative errors. The final MANCOVA included BVMT-R total learning score and

Table 2
Means and standard deviations for patients and controls for cognitive test measures
Group

Test Patient, mean (S.D.) Control, mean (S.D.)

Trails A time 57.0 (18.2) 35.9 (12.3)

Trails B time 209.7 (74.5) 77.5 (23.6)
Maze Navigation errors 11.7 (7.9) 4.1 (2.4)
Maze Navigation time 626.9 (270.9) 298.4 (111.2)
WCST perseverative responses 21.9 (12.5) 9.9 (4.6)
WCST perseverative errors 18.9 (9.6) 8.9 (3.4)
Ruff unique designs 38.8 (10.2) 74.2 (23.2)
Ruff perseverative errors 19.4 (19.0) 8.6 (10.3)
Letter Cancellation (omissions) 5.5 (10.2) 1.2 (1.2)
Generative Naming (COWA) 27.5 (10.1) 40.8 (12.2)
Generative Naming (Animals) 12.8 (4.8) 19.4 (5.1)
Action Fluency 10.5 (5.0) 17.6 (5.6)
VFDT Total score 27.3 (2.5) 30.8 (1.7)
VFDT peripheral errors 2.5 (2.1) 0.4 (0.8)
BVMT-R Total learning 11.3 (5.5) 21.5 (6.1)
BVMT-R delayed recall 4.1 (3.2) 8.5 (2.0)
UFOV—Part I 97.8 (69.5) 34.8 (65.8)
UFOV—Part II 370.5 (167.3) 147.4 (102.6)
UFOV—Part III 449.9 (103.4) 275.1 (110.5)
224 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

delayed recall score. The omnibus test was significant (Wilks’ Lambda = 0.60, F (2, 41) =
13.65, P < .05), with the patient group performing significantly more poorly on both dependent
measures.
Zero-order correlations are presented in Table 3 for both the patient and control groups. For
the patient group, significant relationships were found only between RIDE and the executive
and visual attention measures [Trails B time, Maze Navigation time, and UFOV (parts I–III)].
Letter Cancellation (omissions), which we had hypothesized would be related, were not signif-
icantly related to RIDE performance. For the control group, only age was significantly related
to RIDE performance.
Maze Navigation time, Trails B time, and UFOV—Part I were entered into a hierarchical
regression analysis to explore the relative contribution of each measure to RIDE performance;
these were selected based on initial hypotheses and significant zero-order correlations with
RIDE. These three measures accounted for 46% of the variance in RIDE performance [F (3, 19)
= 5.5, P < .01; see Table 4]; however, Trails B time added insignificantly to the variance. Only
Part I of the UFOV was utilized in this analysis since 11 of the participants in the patient group
were unable to complete the more challenging Part II and Part III of the UFOV. The t-tests were
utilized to compare patients who failed and those who passed the more challenging parts of the
UFOV. No significant difference between the groups was found for any of the selected measures

Table 3
Zero-order correlations: RIDE score and selected demographic and cognitive test measures
Patients Controls

r P r P
∗
Age .40 .45
Education −.04 −.22
Trails A time .32 .09
∗
Trails B time .46 −.03
Maze Navigation errors .08 .25
∗∗
Maze Navigation time .52 −.27
WCST perseverative responses −.32 −.13
WCST perseverative errors −.30 −.07
Ruff unique designs −.16 −.19
Ruff perseverative errors −.27 −.02
Letter Cancellation (omissions) −.16 .09
Generative Naming (COWA) .06 −.03
Generative Naming (Animals) −.25 −.11
Action Fluency .25 −.24
VFDT Total score −.13 −.06
VFDT peripheral errors .20 −.11
BVMT-R Total learning −.17 −.32
BVMT-R delayed recall −.28 −.28
∗∗
UFOV—Part I .61 −.23
∗
UFOV—Part II .46 −.15
∗
UFOV—Part III .46 .06
∗
P < .05
∗∗
P < .01.
 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228 225

Table 4
Hierarchical regression analysis using executive and visual attention measures to predict RIDE performance
Test entry order R2 F Significant F change d.f.
∗∗
Maze Navigation (time) .27 7.7 .01 1, 21
Trails B time .28 3.9∗ .55 2, 20
UFOV—Part I .46 5.5 ∗∗ .02 3, 19
∗
P< .05
∗∗
P ≤ .01.

utilized in the hierarchical regression analysis other than Part I of the UFOV. Furthermore,
there was no significant difference in RIDE scores between patients who failed and those who
passed the more challenging parts of the UFOV (t = −1.68; n.s.).
A discriminant function analysis was utilized to explore which subset of the measures
chosen for the hierarchical regression best categorized the entire group of patient and control
participants in terms of pass/fail status on the RIDE examination. Only Maze Navigation time
entered the analysis with a classification accuracy of 80%; (Wilk’s lamda = 0.69; chi-square
= 11.6, P = .001). Cross validation classification accuracy was also 80%.

4. Discussion

The purpose of the current study was to examine neuropsychological predictors of driving
ability in older individuals with early-stage cognitive impairment. Previous studies, for the most
part, have utilized global or non-executive measures of cognitive functioning and have focused
on participants with more extensive cognitive impairments. The current findings demonstrate
that a novel executive measure (Maze Navigation Test) and a visual attention test (UFOV—Part
I) are significantly related to driving ability, as measured by actual road-test performance, in
individuals with early-stage cognitive decline. The findings lend further support to the efficacy
of the UFOV, with the caveat that some subtests of the latter may in fact be too challenging
for individuals with even early-stage cognitive impairment.
In regard to study limitations, it is important to consider the relatively restricted sample
sizes included in this study, and the possibility that some relationships did not meet statistical
significance due to reduced power, or the possibility that our findings reflect a biased sampling
of the distributions. Fortunately, we do not believe that power was insufficient considering
the very small effect sizes for most variables as signified by the results of the correlation
analyses. Further, the robust relationship between Maze navigation and RIDE evident in this
study is consistent with previous reports (Ott et al., 2003); this suggests that our findings
are reliable. A larger study will be important to determine this with greater certainty, how-
ever, this will be a difficult task given individuals’ reluctance to participate in a study where
they risk losing their driving license. This reluctance, unfortunately, is going to be a factor in
any studies of this kind where samples may be biased toward higher functioning participants
who can be persuaded to participate by researchers or physician gatekeepers. While it would
be important to replicate findings by means of additional empirical studies, it is important
to keep this potential bias in mind. Furthermore, our patient group was composed primar-
226 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

ily of individuals with cerebrovascular disorders, thus limiting our findings to this clinical
population.
Neuropsychological assessment may have the potential to identify deficits that are not
evident in an on-road driving examination. In several cases, patient participants passed the
road test but demonstrated significant executive deficits on testing. For those, the investigators
were able to raise concerns with participants and family members during the feedback session
that resulted in restrictions or termination of driving. Longitudinal studies of these individuals,
in conjunction with acquisition of accident data and motor vehicle department records, may
help to further address this issue.
It is noteworthy that we had difficulty recruiting males in our control group and individuals
with possible early DAT in our patient group, most likely due to fears of loss of driving
privileges. Moreover, family members of this latter group appeared to be more reluctant than
other participant families to restrict independence. These issues further highlight the need for
clinical neuropsychologists to focus on intervention strategies with patients and families and
to collaborate with other healthcare professionals to affect a balance between safety concerns
on the one hand and autonomy on the other.
Clearly, older persons who continue to drive with cognitive impairments present a serious
public health problem. Some studies report that even individuals with serious cognitive impair-
ments and history of motor vehicle accidents continue to drive (Carr et al., 1990; Odenheimer
et al., 1994). Professionals who would like to intervene are often restricted, since only physi-
cians are protected from litigation in a number of states. Many state governments have not
taken a proactive role in assessing the driving competence of older persons or individuals with
dementia. This is a major issue for older individuals, their families, and for society at large.
Further research is necessary, but it appears that neuropsychologists can play an important
role in the assessment and treatment of older individuals with early-stage cognitive decline by
providing objective data related to driving competence.

Acknowledgement

This research was funded by a grant from the National Academy of Neuropsychology.

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