Transcript Driver Assessment & Training Services

THE ASSESSMENT OF FITNESS-TO-DRIVE IN PERSONS WITH
DEMENTIA
Dr. Frank Molnar, Division of Geriatric Medicine, University of Ottawa
Conflict of interests

None



No Pharmaceutical Industry support
More relevant to driving – no Automotive
Insurance Industry support
Honorarium donated to the University of
Ottawa, Division of Geriatric Medicine
Academic Rounds fund
Objectives

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
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To describe the scope of the problem of unfit
drivers that will impact on the medical system
To highlight the complexity of the assessment of
fitness to drive
To provide practical approaches for assessing
fitness to drive in persons with dementia
To describe what happens after an assessment
Driving
The Scope of the Problem
The Aging Driving Population
1986-1996
Percent Change
80
70
60
40
22.4
20
1.7
0.4
0
-2
-12.5
-20
-25.4
-40
16-19 20-24 25-44
45-59
60-69
70-79
80+
Driver Age Grouping
*Data Source: An Over view of Senior Driver Collision Risk, Safety
Policy Branch Ministry of Transportation of Ontario, September 9, 1998.
The U-Shaped Curve MVC / Km
Projections
Projected Increase in
Casualty Crashes by Age
(2006-2026)
Projected Change in
Collisions by Driver Age
(2006-2026)
300
Projected Percent Increase
175
166
150
140
100
82
50
22
9
3
2534
Fatalities
Injuries
250
200
150
100
50
16
15
0
0
<20
Projected INCREASE
200
4554
6574
85+
<20
2534
A ge R ange
Source: L’Écuyer et al. (2006). Transport Canada
4554
A GE
6574
85+
A Major Public Health Concern
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When involved in a crash, seniors are over 4
times more likely to be seriously injured and
hospitalized than are drivers 16-24 years of age.
Treatment of injuries to seniors is more costly,
recovery slower, less complete.
Majority of crash-injured seniors were driving the
vehicle.
Most (3 of 4) crashes involving older drivers are
multiple vehicle crashes (e.g. merging into traffic,
left hand turns across oncoming traffic).
Assessment of Fitness-to-Drive
The Complexity of the
Medical Driving Evaluation
It is Not Age

Medical conditions and medications are the primary
cause of declines in older driver competence.
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Can make even the best of drivers unsafe to drive.
Can affect drivers of any age: Increasingly likely as we
age due to the cumulative effect of multiple diseases.

Not presence but severity and/or instability of
conditions +/- high doses and/or changing doses of
medications
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Medical community best placed to first recognize
possibly impairing medical conditions.
Medical Conditions
Any medical condition or medication that results in a
change of physical, sensory, mental or emotional
abilities has the potential to compromise driving
performance.
Physical: weakness; slow / limited movement
Sensory: vision loss; limited feeling in limbs
Cognitive/Perceptual: slowed thinking; decreased
attention
Emotional: anxiety, panic reactions
Hierarchical Model of Driving
Realistic Conclusions

No screening or assessment protocol will ever predict
100% of risk of Motor Vehicle Crash (MVC)
 Only test stable intrinsic features
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Cannot predict extrinsic factors
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operational > tactical, strategic
Miss new or fluctuating illness
weather, other drivers, road conditions, car …
Full complexity cannot be fully addressed with time
available in front-line clinical settings
Therefore objective is to improve not to perfect
the assessment of fitness to drive
Increased Risk of an At-Fault Crash
8
7.6
6
5
4
3
2
1
0
Risk of an At-Fault Crash
7
5.0
2.8
3.0
1.8 2.1 2.2
2.5
5.0
Assessment of Fitness-to-Drive
DEMENTIA & DRIVING
The Facts
Estimated Numbers of Drivers with
Dementia in Ontario1
120000
98,032
100000
80000
60000
40000
20000
34,105
21,803
14,909
30,642
24,083
32,373
0
8
2
20
0
from Hopkins, et al., (2004)
0
20
9
9
19
8
9
19
4
9
19
2
9
19
6
8
19
1
The Scope of the Problem
Hopkins
2.5% of the elderly are DDs (demented drivers)
Canada
3,500,000 elderly
87,500 DDs
Ottawa
100,000 elderly
2,500 DDs
Toronto
Montreal
500,000 elderly
350,000 elderly
12,500 DDs
8,700 DDs
BUT

The diagnosis of dementia does not automatically
mean no driving (some people with mild dementia can
drive albeit for a limited period of time before they
must hang up the keys)

The diagnosis of dementia does mean:
 You
 You
must ask if the person is still driving
must assess and document driving safety
and follow your provincial reporting requirements
Consensus statements
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Swedish (1997)
Australian Geriatrics Society (2001)
American Academy of Neurologists
(2000)
AMA and Canadian Medical
Association guidelines
http://www.cma.ca/index.cfm/ci_id/1
8223/la_id/1.htm
Conclusions of Consensus statements (cont)

Recognize limitations of data
 those with moderate to severe dementia should not
drive (CMA: Moderate = 1 ADL or 2 iADLs
impaired due to cognition)
 individual assessment for those with mild dementia
 periodic follow-up is required (every 6 - 12 months)
 “gold standard” is comprehensive on-road
assessment
Expert / Consensus Guidelines
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Limitations of Guidelines
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Based on expert opinion recommend tests such as
MMSE, Clock Drawing, Trails B
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Lack of operating instructions (i.e. guidance
regarding how to interpret the results of the tests)
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Do not provide guidance regarding HOW physicians are to
apply such tests (e.g. how to respond to different scores,
what cut-offs to use, errors = automatic failure …)
Operating instructions: Lack of
evidence-based cut-offs

Clinical Utility of Office-Based Cognitive
Predictors of Fitness to Drive in Persons with
Dementia: A Systematic Review.
(Molnar, Marshall, Man-Son-Hing et al., JAGS 2006; 54:1809–1824)
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No cognitive tests that could potentially be
used in an office-setting had cut-off scores
validated in persons with dementia!
Assessing Dementia and Driving
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Start by asking older patients if they drive!
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Seems simple but most MDs do not ask (too busy, fear of
opening Pandora’s box... Lack of awareness does not provide
legal protection)
Keep in mind that driving capacity depends on a
GLOBAL CLINICAL PICTURE:

including cognition, function, physical abilities, medical conditions, behavior,
driving record ….
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Many patients will be more comfortable with the idea of driving
cessation if the decision is made for physical reasons (e.g. loss of
vision, syncope etc.)
Review medical conditions that when severe, poorly
controlled or changing rapidly can impact on driving
(would you get in a car with them based on these findings?)
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3Ds: Dementia / Delirium / Depression
Diabetes
vision and hearing
cardiac disease
Stroke
Parkinson’s
Arthritis
Sleep apnea
Getting the most out of cognitive
tests
Test Specific Cognitive Domains

Judgment
Test response to situation
(fire, yellow light)
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Visuospatial
MMSE (Pentagons)
Clock Drawing
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Executive function Trails A and B
Clock Drawing
Animal-naming (1minute)
Overlapping
Cognitive Scores
(Dichotomization)
Trichotomization
single cut-off
Unsafe drivers’
scores
uncertain,
needs further
testing
Safe drivers’
scores
Fail
Pass
%
%
Fail
Pass
Cognitive
score
Cognitive
score
Applying Trichotomization
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Given the results of the cognitive test
would you get in the car with the patient
driving (or would you let a loved one drive
with them)?
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Yes
Uncertain
Absolutely not
The MMSE
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The MMSE can provide a rough framework
for assessing driving safety. Unless you feel a
low score is due to a language barrier, low
education or sensory deficits, patients scoring
under 20 are likely unsafe to drive.
Higher scores are more difficult to interpret.

Trichotomization (obviously unsafe, uncertain
safety, obviously safe) approach may be helpful
Clock Drawing Test
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A test of Executive Function and
Visuospatial function
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Gestalt method: “The good, the bad or the
ugly”
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Once again Trichotomization (obviously
unsafe, uncertain safety, obviously safe)
approach may be helpful
Trail Making A and B (available at
www.rgpeo.com).
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Trail Making A:
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Unsafe = >2 minutes or 2 or more errors
Trail Making B (Trichotomization):
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Safe = <2 minutes and <2 errors (0 or 1 error)
Unsure = 2–3 minutes or 2 errors (consider qualitative dynamic
information regarding how the test was performed—slowness,
hesitation, anxiety or panic attacks, impulsive or perseverative
behaviour, lack of focus, multiple corrections, forgetting
instructions, inability to understand test, etc.)
Unsafe = >3 minutes or 3 or more errors

The longer the patient takes and the more errors they make, the
more certain you can be that they are unsafe
Applying these ideas in the
context of a systematic approach
Geriatrics and Aging article

Approaches based on clinical acumen
(experience and opinion)
10-Minute Office-Based Dementia and Driving
Checklist (will review)
 CANDRIVE acronym (see article)

10-Minute Office-Based Dementia
and Driving Checklist
1. Dementia Type
 Generally unsafe:
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Lewy Body dementia
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fluctuations, hallucinations, visuospatial problems
Frontotemporal dementias
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if associated behaviour or judgment issues
10-Minute Office-Based Dementia
and Driving Checklist
2. Functional Impact of the Dementia

Consider ADLs and IADLs as a hierarchy with Driving being at the top as the
highest level IADL (the only one where fractions of a second can result in
accidental death)
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According to CMA guidelines and Canadian Consensus Guidelines on
Dementia, persons with dementia are unsafe to drive if:

Impairment of >1 IADL due to cognition (IADL mnemonic = SHAFT):
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Shopping,
Housework/Hobbies,
Accounting,
Food,
Telephone / Tools
OR impairment of 1 or more personal ADLs due to cognition (ADL mnemonic =
DEATH:
 Dressing,
 Eating,
 Ambulation,
 Transfers,
 Hygiene
10-Minute Office-Based Dementia
and Driving Checklist
3. Family Concerns - ask in a room separate from the
patient:
 If family feels the patient is safe/unsafe (make sure family
has recently been in the car with the person driving).
 The granddaughter question—Would you feel it was safe
if a 5-year-old granddaughter was in the car alone with the
person driving? (Often different response from family’s
answer to previous question)
 Generally if the family feels the person is unsafe to drive,
they are unsafe. If the family feels the person is safe to
drive, they may still be unsafe as family may be unaware
or may be protecting the patient.
Ask Family Specific Questions - Signs of a
Potential Problem
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Collisions and/or damage to the car
Getting lost
Near-misses with vehicles, pedestrians
Confusing the gas and brake
Traffic tickets
Missing stop signs/lights; stopping for green light
Deferring right of way
Not observing during lane changes/ merging
Others honking/irritated with the driver
Needing a co-pilot (cannot compensate for
emergencies)
10-Minute Office-Based Dementia
and Driving Checklist
4. Visuospatial Issues
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Intersecting pentagons/clock-drawing test
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if major abnormalities, likely unsafe.
10-Minute Office-Based Dementia
and Driving Checklist
5. Physical Inability to Operate a Car (Often a
“physical” reason is better accepted).
 musculoskeletal problems, weakness/multiple
medical conditions affecting
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neck turn,
use of steering wheel/pedals,
ability to move feet rapidly
ability to feel the gas / brake pedals,
level of consciousness
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cardiac/neurological problems (episodic “spells”).
10-Minute Office-Based Dementia
and Driving Checklist
6. Vision/Visual Fields
 Significant problems including visual
acuity, field of vision.
10-Minute Office-Based Dementia
and Driving Checklist
7. Drugs (If associated with side effects—
drowsiness, slow reaction time, lack of focus)
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especially high doses or changing doses
Alcohol, benzodiazepines, narcotics, neuroleptics,
sedatives, anticonvulsants
Anticholinergics—antiparkinsonian drugs,
muscle relaxants, tricyclic antidepressants,
antihistamine (OTC), antiemetics, antipruritics,
antispasmodics, others (next slide)
Reference List of Drugs with
Anticholinergic Effects
Miscellaneous
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Antidepressants
Antipsychotics
Antihistamines/
Antipruritics
Antiparkinsonian
Antispasmotics
Antiemetics
Flexeril
Lomotil
Rythmodan
Tagamet
Digoxin
Lasix
The medications in the miscellaneous category have been shown to
have anticholinergic properties by radioimmunoassay but are less
anticholinergic than the other medications listed. However, they may
add to total anticholinergic load.
10-Minute Office-Based Dementia
and Driving Checklist
8. Trail Making A and B (available at www.rgpeo.com).
 Trail Making A:
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Unsafe = >2 minutes or 2 or more errors
Trail Making B:
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Safe = <2 minutes and <2 errors (0 or 1 error)
Unsure = 2–3 minutes or 2 errors (consider qualitative
dynamic information regarding how the test was performed—
slowness, hesitation, anxiety or panic attacks, impulsive or
perseverative behaviour, lack of focus, multiple corrections,
forgetting instructions, inability to understand test, etc.)
Unsafe = >3 minutes or 3 or more errors

The longer the patient takes and the more errors they make, the
more certain you can be that they are unsafe
Trails A
Trails B
Trails A + B
Trails A and B are tests of memory, visuospatial, attention and executive
function. Any errors or scoring below the 10th percentile in the time taken
raises concerns about driving safety.
Norms for Trails A and B by age (in seconds) and education
Age
Percentiles: 90th/50th/10th
90/50/10
Trails A*
Trails B
≤Grade 12 >Grade 12*
65-69
90
50
10
25
37
53
60
86
137
52
68
77
70-74
90
50
10
26
38
61
70
101
172
59
84
112
75-79
90
50
10
27
46
70
78
120
189
57
81
178
80-84
90
50
10
31
52
93
72
140
158
89
128
223
*Trails A:
performance
decreases with
age but is NOT
affected by
education
*Trails B:
performance
decreases with
age AND with
education
85+
90
36
79
70
50
54
143
121
Although this test
who should
10 does help determine
120
319 not be driving,
240passing Trails A+B does not
necessarily mean that the patient is safe to drive
TN Tombaugh Arch clin neuropsychol 2004;19.pg 203-14
(Failure = error(s) or time <10th percentile)
10-Minute Office-Based Dementia
and Driving Checklist
9. Ruler Drop Reaction Time Test (Accident
Analysis and Prevention 2007;39:1056–63.)

The bottom end of a 12 inch (30-cm) ruler
is placed between thumb and index finger
(1/2 inch (1 cm) apart) → let go and person
tries to catch ruler (normal = 6-9 inches
(15–22 cm); abnormal = 2 failed trials out
of 3trials

No validated norms / cut-offs
Reaction Time
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If you notice slow reactions on routine clinical
interaction (history, physical examination) the
patient may already be too slow to drive and
merits further dynamic (i.e. timed) testing.
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Stroke(s), delirium, depression, Parkinson’s
Look at Trails A and B
May need on-road if trails A and B do not answer
the question
10-Minute Office-Based Dementia
and Driving Checklist
10. Judgment/Insight - ask the person:
 What would you do if you were driving
and saw a ball roll out on the street ahead
of you?
 With your diagnosis of dementia, do you
think at some time you will need to stop
driving?
 Other ideas/ scenarios?
Other RED FLAGS
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Delusions
Disinhibition
Hallucinations
Impulsiveness
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Agitation
Anxiety
Apathy
Depression
After the Assessment
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Outcomes of Assessment
Reporting duties
Further testing
Disclosure Techniques: telling
the patient
Physician assessment of person with dementia
Patient not safe
Uncertain safety
Patient safe
Discuss
with patient
and family
Provincial Ministry
of Transport notification
Patient notification
(letter), copy
for chart
Discuss
with patient
and family
Patient wishes to continue
driving → referral to
specialist or specialized
on-road driving evaluation +
report to Ministry of
Transportation
*At some
time driving
cessation will
be necessary
*Suggest driving
training and
self-limitation
or
Patient decides
to stop driving – report
to Ministry of
Transport notification
Book six- to
nine-month follow-up
to reassess driving safety +
report to Ministry of
Transportation
Province
Obligation to Report
Protection
British Columbia
Mandatory
Yes – report is privileged. No right of action against
physician for reporting
Alberta
Discretion
Yes – No liability for reporting.
Saskatchewan
Mandatory
Yes – Report is privileged. No right of action against
physician for reporting.
Manitoba
Mandatory
Yes – Report is privileged. No right of action against
physician for reporting.
Ontario
Mandatory
Yes – Report is privileged and not admissible. No
action against physician for complying with
reporting.
Quebec
Discretion
Yes – No action against physician for reporting.
New Brunswick
Mandatory
Yes - No action against physician for reporting.
Prince Edward Island
Mandatory
Yes - Report is privileged. No right of action against
physician for reporting.
Nova Scotia
Discretion
Yes - No action against physician for reporting.
Newfoundland
Mandatory
Yes - Report is privileged and not admissible. No
action against physician for complying with
reporting.
Yukon Territory
Mandatory
Yes – No liability for reporting
North West Territory
Mandatory
Yes – There can be no action unless physician acted
maliciously or without reasonable grounds. Report is
privileged.
How to Report

Mild dementia (no concerns re.
driving)

“Patient has mild dementia with
MMSE ___, Trails B ___. I have
not noted any evidence to suggest
they are not fit to drive but feel they
should be re-evaluated every __
months.”




Frequency (6 or 12 months based on
clinical judgment
Warn family to notify you if they
note cognitive change or signs of
delirium
Would report if there is a risk patient
will not return for follow-up
Do not forget to advise the patient to
start planning for eventual driving
cessation

Moderate to severe dementia


“Patient is not safe to drive
due to the following
findings:_______________
______________________
______________________
_____________________”
Q? How much information
can we disclose?


If potentially litigious then
only include the findings of
the testing.
If patient tells you that you
cannot report them then
write: “patient will not
provide consent to forward
my findings”
Disclosure – unfit to drive

Refer to Geriatrics
and Aging article
http://www.geriatricsa
ndaging.ca/fmi/xsl/art
icle.xsl?lay=Article&recid=2003&-find=find
Notification About Driving Safety
Name: _________________________________
Date: __________________________________
Address: _________________________________________________________________________
You have undergone assessment for memory/cognitive problems. It has been found by comprehensive assessment that
you have ________________________ dementia. The severity is _________________.
Even with mild dementia, compared to people your age, you have an 8 times risk of a car accident in the next year.
Even with mild dementia, the risk of a serious car accident is 50% within 2 years of diagnosis.
Additional factors in your health assessment raising concerns about driving safety include:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________
As your doctor, I have a legal responsibility to report potentially unsafe drivers to the Ministry of Transport. Even with
a previous safe driving record, your risk of a car accident is too great to continue driving. Your safety and the safety of
others are too important.
___________________________ M.D.
__________________________ Witness
Fitness to drive unclear
Further Assessment Required

Notify jurisdictional authorities as per
provincial reporting requirements

Report:

“Fitness to drive unclear – more testing needed”
or

“Deficits may be temporary (e.g. delirium) –
requires follow-up”
Specialized Driving Assessment

Cognitive tests (Neuropsychologist, OT)
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Driving Simulator Evaluation

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can assess the more obviously impaired
do not refer to specialty dementia clinics if the only
issue is driving (inadequate resources)
not fully acceptable for ultimately determining fitness
to drive
can give insight to the evaluator for the on-road
assessment
On-Road Assessment (OT / Driving Instructor)


Present Gold Standard
Expensive – warn patient that need to repeat every
6 months (and have to pay each time)
Figure 1: Thre e- Tier Model of Dr iving Assessment in Ontario
Active Older Drivers
(reassess every 6 – 12 months
in dementia)
(Tier 1a)
(Tier 1b)
MD screening
& assessment
informal screening
during MTO 80+
group education
sessions
* Safety unclear
Safe
Clearly unsafe
(Tier 2)
Cognitive tests
(OT/Psychology)
Driving Record
or
Police Reports
Identifies drivers who
may be at risk
* Safety unclear
(Tier 3a)
(Tier 3b)
OT on-road testing
MTO on-road
assessment
(specialized MTO
certified testing centers)
Safe
Unsafe – report to MTO
MTO (Ministry of Transportation of Ontario
OT (Occupational Therapy)
* In some instances drivers whose safety is unclear are reported to the MTO
MTO Reviewers and/or Committees
Stop driving
Safe
Key Learning Points
1.
2.
3.
4.
If dementia is diagnosed, driving must be asked
about, formally assessed, and documented.
Physicians can perform a comprehensive driving
safety clinical evaluation in approximately 15 to 20
minutes.
If you are unsure of safety, refer to specialized
assessment or specialized on-road testing.
In dementia, driving safety must be reassessed every
6 to 12 months.
Resources

Alzheimer Knowledge Exchange


Geriatrics and Aging


www.geriatricsandaging.ca
www.cma.ca/index.cfm/ci_id/18223/la_id/1.htm
Driving and Dementia Tool Kit for Family Physicians (Dementia Network of OttawaCarleton)


(leading Geriatric CME journal)
CMA: Determining Medical Fitness to Drive: A Guide for Physicians. Canadian
Medical Association Driver’s Guide 7th edition.


www.drivinganddementia.org
www.rgpeo.com or www.CanDRIVE.ca
US Physicians’ guide to Assessing an Counseling Older drivers

http://www.nhtsa.dot.gov/people/injury/olddrive/OlderDriversBook/pages/Introduction.ht
ml
Clinical Scenario

You have found a patient unfit to drive and
have informed them and their family. The
patient says you are not permitted to send
their medical information to the ministry of
transportation or they will sue you and call
the college. What do you do?
Clinical Scenario

A patient is in your office who is clearly
unfit to drive home. MMSE 16/30. You tell
them they should not drive home but they
refuse to comply. You feel they are an
imminent threat to public safety. What do
you do?
Clinical Scenario - OCFP

You receive a report from a Sleep
Specialist which reads ‘The findings of the
sleep study indicate your patient may be
unsafe to drive. I recommend you report
them to the Ministry of Transportation”

What do you do?