St. Joseph’s Health Care LondonDriveABLE in London

Evaluating the Medically At-Risk Driver

Dr. Allen Dobbs

Mary Anne McCallum

Learning Objectives

• To understand the impact of cognitive decline on driving competence

• To understand the legal obligations of the physician

• To understand the processes around formal driving assessments

80 YEARS OF AGE

• At age 80 and every two years thereafter, MTO requires Ontario drivers to complete a vision test, written test and attend a group seminar

• A road test may be required

• This is not a substitute for a medical driving evaluation

Highway Traffic Act

• Section 203, (1) Mandatory Reporting for:

• “Every person 16 yrs of age or over, attending upon the medical practitioner for medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to operate a motor vehicle.”

When MTO Is Informed:

• The licence may not be suspended• A file is opened with the Medical Review

Section• The case is reviewed by an analyst• MTO will determine the next course of

action• Once report is made, it can take 4-6 weeks

for response

MTO Process

• May request additional medical information• May request client to go through the standard

licensing procedure• May request client to undergo a driving ax from

an approved rehabilitation centre• May immediately suspend licence• May refer to the Medical Advisory Committee for

expert opinion• May monitor by requesting follow-up reports

MEDICAL ASSESSMENTS

• MTO provides a list of Approved Driver Rehabilitation Centres

• In Ontario, an Occupational Therapist is required to conduct the assessments in these centres

• The purpose of the assessment is to determine the impact of a medical condition on driving

• Other roles include recommending training and adaptive equipment, if appropriate, supporting driving independence and monitoring performance over time

WHAT IS DRIVING?

• A primary means of meeting one’s transportation needs

• A symbol of independence and autonomy• Synonymous with self-respect, social

membership and independence• An indicator of competence, providing the

older individual with a non-age related, non-stigmatized identity

Driving

• a complex activity requiring a wide range of mental abilities

• number of older drivers is increasing rapidly

• medical conditions or medications can severely affect driving competence

• evaluation of driving competence can be challenging

Decisions About DrivingDecisions About Driving• Why are decisions about driving

difficult?

– importance of the decision– driving is central to maintaining independence

and mobility– protecting safety of others on the road– uncertainty about competence when there is a

cognitive impairment– how much mental decline makes a person unsafe

to drive?

– is insight regarding driving ability impaired?

Loss of Driving Privileges

• A loss of independence, mobility and freedom

• Feelings of diminished self-worth, reduction in self-esteem and loss of identity

• One of the most difficult aspects of dementia for the individual, as reported by caregivers

STATISTICS

• 60% OF INDIVIDUALS 65 OR OLDER (2 MILLION INDIVIDUALS) HELD A DRIVER’S LICENSE

• Reference: Statistics Canada, 1999

• 83% of these individuals are drivers

STATISTICS

• 8% of Canadians aged 65 & over have a dementing illness

• An additional 17% have some other diagnosed form of cognitive impairment

• Reference: Graham et al. 1997

Senior Drivers and Crashes• Fatalities and Injury crashes Up 47% for age 65+

drivers

• By comparison: Down 8.0% drivers under 65

years of age (Canadian Motor Vehicle Traffic

Collision Statistics, Transport Canada, 1979 - 1995)

Ontario Relative Risk (Fault) by Age

0

0.5

1

1.5

2

2.5

3

16-19 20-24 25-44 45-59 60-69 70-79 80+

Rel

ativ

e R

isk

MaleFemale

AGE

Driving Projections

• Number of older drivers will more than double by 2030.– Driving more

• Travel of seniors projected to increase by 4 to 5 times by 2030

– Driving longer into old age• Where impairing medical conditions are most likely

Is age Is age thethe problem? problem?

• Age-associated changes do not account for older driver crashes

• Some of the most prevalent and impairing medical conditions are age associated

•The “Older Driver Problem” is really a problem of “Medical Conditions and Driving”

Letter to Ann Landers

• “I’ve had two bypass surgeries, a hip replacement, new knees, fought breast cancer and diabetes. I’m half-blind and can’t hear anything quieter than a jet engine. I take 10 different medications that make me dizzy, winded and subject to blackouts. I have bouts of dementia.

Continued…..

• I have poor circulation and can hardly feel my hands and feet anymore. I can’t remember whether I am 85 or 87 and there’s nobody I can ask. All my friends are dead. But thank God, I still have my Florida driver’s licence. N.S., Bloomfield, Michigan

The Road Test: Defining the Essentials

Costs of Crashes

• Seniors involved in a crash are 4 times more likely to be seriously injured and hospitalized than younger drivers

• Seniors recover more slowly and less completely

• Crashes often involve multiple vehicles`

Increased Crash Risk (at-fault crashes)

• Visual Acuity……..…..2.8• Diabetes ………..…… 2.2• Cardiovascular……… 1.8• Pulmonary…………… 2.1• Psychiatric………… …2.5 • Epilepsy……...…….….3.0• Musculoskeletal……… 4.5• Neurologic………..….. 5.1

Diller et al. (1998) for unrestricted drivers

Cognitive Impairment 7.6

Accident risk as function of Blood Alcohol Content

0

5

10

15

20

25

30

35

0

0.0

2

0.0

4

0.0

6

0.0

8

0.1

0.1

2

0.1

4

0.1

6

0.1

8

19641994

Od

ds

Rat

io:

Rel

ativ

e C

rash

Ris

k

BAC in Percent

~2.5 1964

1994

DriveABLE Driven by Research

Impairment of Executive Functions

• 1. Organization: attention, decision-making, planning, sequencing, and problem-solving

• 2. Inhibition: initiation of action, self-control, self-regulation, repetition and temper control

• 3. Unawareness: denial of deficits, unintentional non-compliance

Driving and Dementia

• 30 to 50% of people with dementia have at least one crash before they stop driving

• 80% of people with dementia who have a crash continue to drive

• 40% of those have at least one more crash

Questions for the Patient

• 1. Have you noticed any change in your driving skills?

• 2. Do others honk at you or show signs of irritation?

• 3. Have you lost any confidence in your overall driving ability?

• 4. Have you ever become lost while driving?• 5. Have you ever forgotten where you were

going?

Questions for the Patient

• 6. Do you think that AT PRESENT you are an unsafe driver?

• 7. Have you had any car accidents in the past year?

• 8. Any minor fender-benders with other cars in parking lots?

• 9. Have you received any traffic citations?• 10. Have others criticized your driving or refused

to drive with you?

Questions for the Family

• 1. Do you feel uncomfortable in any way driving with the patient?

• 2. Have you noted any abnormal or unsafe driving behaviour?

• 3. Has the patient had any recent crashes?• 4. Has the patient had near misses that could be

attributed to mental or physical decline?• 5. Has the patient received any tickets or traffic

violations?

Questions for the Family

• 6. Are other drivers forced to drive defensively to accommodate the patient’s errors in judgement?

• 7. Have there been any occasions where the patient has gotten lost or experienced navigational confusion?

• 8. Does the person need many cues or directions from passengers?

• 9. Does the patient need a co-pilot to alert them of potentially hazardous events or conditions?

• 10. Have others commented on the patient’s unsafe driving?

Warning Signs

• Lack of awareness of driving errors• Tendency to get lost or confused while driving• Seeming lack of awareness of other vehicles• Tendency to miss traffic signs• Inability to keep up with the speed of traffic• Close calls, especially if unnoticed• Frequent honking from other drivers

Typical Driving Errors

• Errors at intersections and left turns

• Driving too slowly

• Difficulty merging with traffic

• Accidents close to home

Decisions About Driving

• Self Perceptions of Driving Competence • Among Drivers with Dementia

• comparison of self-ratings of driving ability to actual on-road performance of 117 dementia patients.

• drivers with dementia consistently overrated their competence.

What is needed?

• Driver evaluations:

– based on competence

– relevant to actual driving performance

– fair and objective

– accurate and defensible

Research StrategyResearch Strategy• Provided a standard road course

• Put safe and unsafe drivers in a car

• unsafe drivers: cognitively impaired drivers • safe drivers: healthy, normal older drivers• healthy, normal younger

drivers• all participants currently driving

• Compared driving errors of both groups to identify differences

Research Strategy:Research Strategy:• All Three Groups Received:

• Clinical Assessment• - Neuropsychological Testing (6 hours)

• - Rehabilitation Testing (2 hours)

• Research Tests of Driving-Relevant Mental Abilities

• Research Road Test

Non-Discriminating ErrorsNon-Discriminating Errors

• Made equally by ALL groups

• Examples include:– One-hand steering– Early or late signalling– Failure to come to a complete stop– No shoulder checks

Discriminating ErrorsDiscriminating Errors

• Potentially dangerous errors that reliably discriminate cognitively impaired older drivers from healthy older and healthy younger drivers

• Examples include:– Positional and observational errors on LEFT HAND

TURNS or WHEN CHANGING LANES

Criterion ErrorsCriterion Errors

• Displayed ONLY by drivers from the cognitively impaired group

• CATASTROPHIC – traffic has to adjust or the examiner has to take control to avoid a crash or dangerous situation

• Examples include:– Driving the wrong way on the freeway– Stopping at a green light

•

Empirically Based Pass/Fail Empirically Based Pass/Fail CriterionCriterion

• Category Cog. Impair. Old Young• 1

• 2

• 3

• 4

• 5

• 6

•

Criterion

Discriminating

none none

Frequency and severity of driving errors Frequency and severity of driving errors shown to signal competence decline shown to signal competence decline

reveal competence which is outside the reveal competence which is outside the range of normalrange of normal

Validation of DriveABLE Evaluation

• validated on a new sample (n=376)

• referral sources extended

• extended to other medical conditions

• extended to other age groups

• new road course

• Competence Screen highly accurate

Maximizing Safety

• Road testing all clients on public roadways can place other road users in danger.

• Some medically impaired drivers are very dangerous.

• Need a way to identify at least the most dangerous drivers without a road test.

Traditional Approach

Road Test ScoresAttention

Spatial

Judgement

Perception

Decision Time

Apraxia

Motor Skills

Recognition

Strength

Memory

Inhibition

Orientation

Language

STM

Vision

Sequencing

Planning

RT

Balance

New Approach

Road Test Scores

Attention

Judgement

PerceptionMemory Motor Skills Vision

VisionMemory

Decision Time

Comprehension

Spatial Abilities Response

Speed

Decision Making

Attentional Field

Need for a New ApproachNeed for a New Approach

• Need for:• Pre-driving screen that accurately predicts road test

performance

• Complex tasks to test many abilities at once

– shortens testing time– enables testing of concurrent use of abilities which is

more relevant to driving performance

• Procedures amenable to automated scoring

DriveABLE Competence ScreenDriveABLE Competence Screen

• Complexity• Client “Friendly”

– Touch Screen– Push Button

• Objective Scoring• Predictive of Road Test Performance

The DriveABLE EvaluationThe DriveABLE Evaluation

Competence Screen

Road Test

PassFail

Indeterminant

PassFail

Two-Thirds Identified by Screen, 95% accurate

Two Phase Evaluation

DriveABLE Appointment• Office Assessment with Occupational Therapist:

• Interview: Medical History/Health Status

• Review of Eye Exam Results

• Physical Assessment

• Cognitive/Perceptual Assessment(using DriveABLE Competence Screen)

• Road evaluation conducted by certified driving instructor in dual brake automobile

• Physical Driving performance observed by Occupational Therapist

Urban and Rural Driver Comparison

• Matched 100 urban with 100 rural drivers on age, sex, diagnosis, level of cognitive impairment (MMSE).

• Examined p/f rate of the urban and rural drivers.

• Found performance of two groups not different (2% difference)

The assessment is equally fair for urban and rural drivers.

Cost and Value• Cost: • $367.50 for comprehensive assessment

• Value:• objective assessment • empirically justifiable decisions• safer communities• reduced costs to health system

Annual Cost of Operating a Car

• Depreciation=$2,000• Maintenance=$500• Insurance=$1,500• Gasoline=$780 (at $15 per week)• Total is $4,780—not counting licence fees,

parking, car washes• This means that the driver could spend $92

per week on taxis

CASE—MR. PM

• Diagnosis: Alzheimer’s type dementia

• April’02—seen in clinic

• Reassessed one year later—MMSE 23/30: started on Exelon

• October’03—ongoing cognitive decline

• Referred for driving ax because of hesitancy and slowness in driving

CASE—MR PM

• Competence Screen : 92% predicted probability of failing the DriveABLE Road Test

• Road test errors: turning too wide, being unsure of right-of-way and failing to yield right-of-way

• Overall score “ borderline pass”• Recommendations: continue driving with caution

and reassessment if further cognitive decline occurs

CASE—MR PM

• Client returned to ABC in December, 2004• Exelon was increased to 6 mg bid• Most abilities had been maintained• Client driving at appropriate speeds, but

exhibiting hesitancy at intersections• MMSE score decreased to 20/30• Client was referred for reassessment of

driving abilities

CASE—MR PM

• Client returned to DriveABLE in December, 2004• Competence Screen results: 67% predicted

probability of failing the DriveABLE Road Test• Road test errors: position-on-turn, unsure of right-

of-way at intersections, turning too fast ( creating a hazardous situation) and not checking blind spot before changing lanes

• Errors out of normative range-fail score

CASE—MR G

• Client diagnosed with AD in May, 2002• Client referred to DriveABLE from ABC with

concerns that he turned left instead of right, and entered the oncoming lane

• Hx of progressive memory impairment, word-finding difficulties, headaches and two episodes of “black outs”

• MMSE score was 22/30• Was prescribed Galantamine

CASE—MR G

• Assessed by DriveABLE in April, 2003• Client displayed insight regarding his declining

cognition and the potential impact on driving safety

Performance on the Competence Screen resulted in a 33% predicted probability of failing the road test

• NO significant errors on the road test; passed• Recommendations: close monitoring of cognition

by doctors and reassessment if decline noted

CASE—MR P

• Four-year history of AD, taking Aricept• Valid licence, drove to Florida each winter, no

accidents or charges• On Competence Screen, significant difficulty with

processing and retaining instructions• 88% predicted probability of failing road test • Road test errors: positional, unsure of right-of-way

at intersections, slowing/stopping for no reason, reacting late

• Recommendation was driving cessation

Conclusions

• Evaluating the Medically-At-Risk Driver

• focused medical evaluations and record keeping• • early planning with patients and families

• use of, or advocating for validated driver assessments

• notification of licensing bodies when incompetence occurs

Resources

• Website for RGP in Ottawa

• Safe Drive Checklist

• CMA guide “Determining Medical Fitness to Drive”

• DriveABLE in London

• For referrals:• Phone (519) 685-4028• Fax (519) 685-4574

• E-mail drive.able@sjhc.london.on.ca