Transcript Driver Assessment & Training Services

Fitness To Drive
Nellemarie Hyde, OT Reg. (Ont.); CDRS
Beth Crystal, OT Reg. (Ont.)
The Participants
• Who has previously referred a client for a driving
assessment?
• What types of diagnoses do your clients have?
(stroke? ABI? amputation? SCI? MS?
dementia?)
• Has anyone in whole or in part, conducted a
driving assessment?
• Prescreening for a driving assessment?
Objectives
• Determining who is at risk for medically impaired
driving
• Mandatory reporting and MTO process
• Comprehensive Driving Assessment: What to
expect
• Case Studies
Road back to Driving
• Who is at risk for medically impaired
driving?
Who is at risk?
It is not age alone!!
• It is medical conditions
• Medical conditions and medications are the
primary cause of declines in driver competence.
• Can make even the best of drivers unsafe to
drive.
• Can affect drivers of any age: Increasingly likely
as we age.
• Medical community best positioned to first
recognize possibly impairing medical conditions.
Medical Conditions
Any medical condition that results in a change of physical,
sensory, mental or emotional abilities has the potential to
compromise driving performance.
• Physical (weakness; limited movement etc)
• Sensory (vision loss; limited feeling in limbs etc)
• Cognitive/Perceptual (slowed thinking; attention etc)
• Emotional (anxiety etc)
Increased Risk of an At-Fault Crash
8
7.6
Risk of an At-Fault Crash
7
6
5.0
5
4
3
2
1
0
2.8
3.0
1.8 2.1 2.2
2.5
5.0
Prevalence of Cognitive Impairment*
0%
10%
20%
30%
40%
50%
60%
70%
AGE
65-74
75-84
85+
Alzheimer’s Disease and Other Dementia
*(CSHA, 1991)
Cognitive Impairment that is not Dementia
Highway Traffic Act 1990 c. H. 8
Doctor reports to the MTO
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.”
The Doctor’s Dilemma
• Doctors are asked to report if a patient’s medical
condition may affect their ability to drive
• If this was carried out to the word, the MTO
would likely be inundated with reports from
doctors
• Instead, doctors are left to determine, from their
office, who should be reported to the MTO
• OT’s offer valuable input to doctors
When MTO is Informed
•
The license may not be suspended.
1.
A file is opened with the Medical Review
Section.
2.
The case is reviewed by an analyst.
3.
MTO will determine the next course of
action.
4.
Once report is made it can take 4-6 weeks
for response.
MTO course of action
•
may request medical information
•
go through the standard licensing procedure
•
may request a driving assessment from an
approved rehabilitation facility
•
may suspend license on a medical basis
(temporary licenses can be obtained for
assessment and/or training)
Who should be assessed?
•
•
•
•
•
•
•
•
•
•
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 when making lane changes, merging
Others honking/irritated with the driver
Needing a co-pilot
Who should be assessed?
Physical Impairment:
• Difficulty moving their body through the motions
of driving (poor coordination, strength, range of
motion)
• Impaired reaction time
Who should be assessed?
Cognitive/Perceptual Impairment
• Impaired processing speed (>150 seconds on
Trails B – may indicate increased crash risk)
• Impaired visual perception (<30/40 on MVPT-R)
• A history of left inattention or neglect
• Impaired judgement, problem solving
• Difficulty with IADLs or ADLs
Who should be assessed?
Psychological / Emotional Impairment
• Driving anxiety
• Psychomotor slowing
• Cognitive deficits
• Side effects from medications
• Impaired judgement
Who should be assessed?
Vision Deficits
• Visual Acuity: minimum 20/50 with both eyes
open
• Visual Field: 120° continuous vision with 15°
above and 15° below the visual field (60° to right
and left)
• MTO Vision Waiver Program for class G license
for visual field impairment
Specialized Assessment
The role of a Rehabilitation Driving
Assessment:
• Determine the impact of a medical condition on
driving.
• Recommend training and adaptive equipment if
appropriate.
• Support driving independence.
• Monitor performance over time.
Specialized Assessment
• In Ontario, an Occupational Therapist is required
to conduct the assessment in order to be a
Ministry Approved Facility.
• The cost of assessment is not covered by the
health care or licensing system – the client
covers the cost.
• Fees are approximately $500 - $600.
Driving Assessment
In the Clinic (1.5-2 hours with OT):
• Medical and Driving History
• Vision Screen
• Cognitive/Perceptual Assessment
• Physical Assessment
Driving Assessment
Cognitive/Perceptual Assessments
• Cognistat or MMSE (as a screen)
• MVPT-R or MVPT-3
• Useful Field of View (UFOV)
• Trail Making A & B
Or
• DriveABLE Assessment
Driving Assessment
In the Vehicle (Driver Rehab):
–
–
–
–
Given in dual-brake vehicle
Occupational Therapist and Certified Driving
Instructor
In-clinic determines course of on-road
assessment
Will abort drive if major errors arise
DriveABLE™
• DriveABLE™ -- developed through research.
• Research won national award of excellence.
• Alberta Heritage Foundation for Medical
Research encouraged championing move from
research to practice through the establishment
of a University spin-off company -- DriveABLE™.
DriveABLE™
Cognitive/Perceptual Assessment
• Completed on a computer
• Touch Screen and push button response
• Assesses areas of:
– motor control
- attention shifting
– judgment
- attentional field
– executive function
• On-road Assessment
DriveABLE™
In the Vehicle:
–
–
–
–
–
Given in dual-brake vehicle
Score only the competence defining errors
Road Course design reliably reveals the
competence defining errors
Bad habit errors not scored
• Protects the competent driver
Fail criterion is “Out of the range of normal”
Driving Assessment
Recommendations are given and may
include:
•
•
•
•
Continue Driving
Future Reassessment
Training
Discontinue Driving
Functional Vision Assessment
• Began May 2005
• Only five MTO approved centres in Ontario
(pilot)
• Goal: to determine if the client can compensate
for vision loss
Functional Vision Assessment
If approved by MTO:
• 2 hour clinical assessment (OT)
– UFOV, CTMT, MVPT-3, Scan Course, Insight,
physical assessment
1.5 hour on road assessment (OT and DI)
• Two road tests: residential, main road, freeway,
break in between to review
Functional Vision Assessment
• Expectation on road is quite high
– Blind spot checks on turns and lane changes
– Anticipatory scanning
– Speed of maneuvers
– Use of mirrors
• Client cannot miss more than two in any
category on any particular maneuver
Functional Vision Assessment
Recommendations include:
• Able to compensate, recommend driving
• Able to compensate, training in community
• Did not compensate, training with MTO
approved rehab facility
• Unable to compensate due to inability and/or
lack of insight, driving cessation recommended
Determining Medical Fitness to
Operate Motor Vehicles
• Published by the Canadian Medical Association
• Addresses:
– Functional Driving Assessment
– Medical Reporting
– Driving Cessation
– Alcohol, Drugs
– Aging
– Sleep Disorders
– Psychiatric Illness
Determining Medical Fitness to
Operate Motor Vehicles
• Addresses (continued):
– Nervous System Impairments
– Vision Deficits
– Auditory-Vestibular Disorders
– TBI and stroke
– Vascular, cardiovascular and cerebrovascular
diseases
– Respiratory diseases, endocrine and metabolic
disorders
– Sections on general debility, anesthesia, surgery, seat
belts and air bags
Determining Medical Fitness to
Operate Motor Vehicles
• Alert box
• Overview
• Detailed breakdown within each
Section
• Identifies where a functional driving
assessment should be considered
Who should be assessed?
• Case Studies
Case Study
Amputation
• 65 year old man with 16 year history of diabetes
• Developed PVD in the (R) lower extremity 2
years ago
• Right below knee amputation 3 months ago
Amputation
• What are this gentleman’s options for driving?
• What are the potential concerns regarding his
driving options?
• At what point in his rehab should he be referred
for a driving assessment?
• Who should inform the MTO and when?
Case Study
Vision Deficit / CVA
• 56 year old female sustained an occipital CVA one year
ago
• Visual field testing indicates a (L) homonymous
hemianopia
• Doctor notified MTO and her License was suspended
while she was in the hospital
• Client has asked if / when she will be able to resume
driving
Vision Deficit
• Can someone with HH be considered for
driving?
• What information/documentation will the MTO
require?
• Who can conduct this type of assessment?
• What does the driving assessment entail?
Case Study
Traumatic Brain Injury
• 18 year old male sustained a severe TBI as a passenger
in a MVA
• At the time of the injury, he held a G1 license
• Recent neuropsych testing shows deficits in attention,
concentration, judgement
• Family reports changes in his behaviour
• He has expressed a desire to resume driving with his
dad.
Traumatic Brain Injury
• What red flags might the OT look for when
considering the assessment?
• Does he require a driving assessment or can he
simply proceed through MTO testing?
• At what point in his rehab should driving be
considered?
• Is it okay for him to practice driving with his dad?
Case Study
Spinal Cord Injury
• 38 year old male sustained a C5/6 spinal cord injury
during an ATV roll over 6 months ago
• Reports dizziness upon rising in the morning
• Has expressed frustration with having to rely on Wheel
Trans
• Wishes to pursue driving
Spinal Cord Injury
• Is this an appropriate referral?
• At what point in his rehab should he be referred
for a driving assessment?
• What types of assessments might be
appropriate at this time?
• When should the MTO be advised of the medical
condition?
Resources
• Determining Medical Fitness to Operate Motor
Vehicles; Canadian Medical Association Driver’s
Guide 7th edition. (available online)
• www.saintelizabeth.com (select “services”;
“driver”)
• www.driveable.com (for cognitive impairment)
• Medical Review Section 416-235-1773 (client
inquiries; for a list of assessment centres)
Thank you!
Nellemarie Hyde, OT Reg. (Ont.);
CDRS