Transcript DavidCarSCCACARR - College of Health, Education and

The Driver with Dementia:
How Far Can They Go and For
How Long?
David B. Carr, M.D
Associate Professor of Medicine and Neurology
Clinical Director
Division of Geriatrics and Nutritional Science
Alzheimer’s Disease Research Center
Medical Director, The Rehabilitation Institute of St. Louis
Disclosures
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Funding Support
• National Institute on Aging (NIA)
• AAA Foundation
• Missouri Department of Transportation
• LongerLife Foundation
Consulting Relationships
• American Medical Association (AMA)
• ADEPT
• SeniorSMART
Speakers Bureau
• St. Louis Alzheimer’s Association
Drug Industry Sponsored Trials
• None
Investment/Stock/Equity
• None
Objectives for Today’s Lecture

Something Old: 20 minutes/20 slides
• Studies on Driving and Dementia

Something New: 20 minutes/20 slides
• WU Dementia and Driving Efforts

Something Borrowed: 20 minutes/20 slides
• Future Research Efforts

Something Blue: Last slide
• A solution for demented drivers
In 60 minutes or less!!
Something Old: Dementia/Driving

Dementia
• The Spectrum
• The Numbers
• Rating Severity

Driving
•
•
•
•
Crashes
Road Test
Functional Abilities
Cessation
Normal
Cognition
Brain Aging
Prodromal
Dementia
Mild Cognitive
Impairment
Dementia
Stable or
Reversible
Impairment
Alzheimer’s
disease
Other
dementias
Mixed
From Golomb, Kluger, Ferris
NeuroScience News, 2000
Vascular
Dementia
Mixed
Alzheimer’s Disease
16
4 Million AD Cases Today—
Over 14 Million Projected Within a Generation
14.3
14
11.3
12
10
8.7
8
6
4
5.8
6.8
4
2
0
2000
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2010
2020
2030
Year
2040
Affects > 4 million people in the U.S. (20 million world-wide)
Results in > 100,000 deaths per year
Costs > $100 billion annually
2050
Clinical Dementia Rating (CDR) Table
Very Mild
Important Driving Outcomes

Crashes
 Road Tests
 Simulators
 Cessation
 Alcohol
 Caregiver assessment
Number of Licensed Drivers
Older Adults in Motor Vehicle Crashes
http://search.cga.state.ct.us/dtSearch_lpa.html
Exposure: Vehicle Miles Traveled
d
Anticipated Finding
of 2005 Survey
The Issue of Low Mileage Bias
Langford J, et al. 2006 Accident Analysis and Prevention, 28(3), pp. 574-578
Summary of Crash Rates/Dementia
Group
Crashes/driver/year
National Crash Rates
Older Drivers (65+ yrs)
4%
National Crash Rates
Young Drivers (16-25yrs)
12%
Control subjects in
studies cited
~ 4%
Drivers with dementia
~8%
Motor Vehicle Crashes/CDR
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OBJECTIVE: To determine whether there is a difference in crash rates and
characteristics between drivers with dementia of the Alzheimer type (DAT) and
nondemented older persons who were controls.
SETTING: Alzheimer's Disease Research Center at Washington University in St.
Louis, Missouri. Subjects were enrolled as volunteers in a longitudinal study of
aging and DAT.
PARTICIPANTS: 58 nondemented older drivers and 63 drivers with DAT which
was diagnosed using validated clinical diagnostic criteria and was staged by the
Clinical Dementia Rating (CDR) Scale. (CDR = 0.5) or mild (CDR = 1) stages.
MAIN OUTCOME MEASURE: 5-year retrospective analysis of state-recorded
crash data.
CONCLUSIONS: In our pilot study, individuals with very mild or mild DAT who
continued to drive seemed to have crash rates similar to those of the controls.
Carr DB. Et al. JAGS. 48(1):18-22, 2000.
Dementia and Driving Crash Studies
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~30% of demented drivers will have a crash when
followed over 3 years
~50% of the drivers with dementia stop driving within
3 years of disease onset
Crash risk increases with the duration of driving and
males appear to be at higher risk
Studies indicate that at least 30% of older adults
with dementia that present to subspecialty clinics
will still be driving
Possibly 20% of drivers over age 80 years that
present for license renewal may be demented
Driving exposure is probably less with demented
drivers in comparison to older adults
Limitations of Crash Data:
Association or Causation?
Washington University Road Test
Closed course test
 Open road test
 Qualitative score 0-108
 Quantitative score

• Safe, Marginal, or Unsafe
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Traffic Skills
•
•
•
•
•
•
traffic signs
negotiating intersections
changing lanes
signaling
left turns
maintaining speed
*Hunt et al, Archives of Neurology
1997;54:707-712
Characteristics of Study Participants
Clinical Dementia Rating
0
0.5
1
(nondemented)
N=56
(very mild DAT)
N=36
(mild DAT)
N=29
76.8  8.6
74.2  7.6
73.1  8.2
48
23
50
Education (y)
14.9  3.3
13.7  3.7
13.4  3.2
Short Blessed
Test Score (0-28)
Years driving
1.4  2.1
4.8  5.9
14.2  6.7
55.0  13.5
57.0  40.2
51.6  14.5
Age (y)
% Female
Hunt et al. Arch Neurol 1997;54:707-712
Driving Performance
Control
Very Mild
Mild
Safe
78%
67%
41%
Marginal
19%
14%
18%
3%
19%
41%
Unsafe
Longitudinal Study
Study Conclusions
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Clear relationship between impaired driving and
dementia severity
Diagnosis alone is not the best predictor
• 41% of mild DAT drivers failed
Some mild DAT individuals remain safe drivers testing
• variable rate of decline
At-risk drivers: repeat drive evaluations 6-12 months
CDR 1 level (mild dementia) appears to be the
transition phase
Driving and Dementia: When is it
time to hang up the keys?

Green Light
• No red flags
• Monitor at intervals

Yellow Light
• Red flags
• Refer for driving evaluation
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Red light
• Driving
Cessation/Retirement
Dubinsky, R. et al. Practice
parameter: Risk of driving and
Alzheimer’s disease
Neurology 2000;54:2205-2211
Reger MA, et al. Neuropsychology
2004; 18: 85-93
Something New
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Studies

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Stakeholders
Education
Questionnaire
Fitness-to-Drive
AARP Website, 2007
Top 10 Strategies to Help Drivers Retire
1) Hiding/filing down the keys
2) Do not repair the car
3) Remove the car by loaning, giving or selling
4) Disable the car
5) Replace keys
6) Raise concern about losing life savings
7) Ask non-family member to talk with driver
8) Ask physician to “prescribe” driving retirement
9) Use a contract (see At the Crossroads guide)
10) Initiate the revocation process
Washington University St. Louis ADRC
• Clinicians assessed older adults in the Alzheimer's
Disease Research Center (ADRC) for the presence and
severity of dementia.
• The diagnosis of DAT was comparable to the DSM-IV
Manual (APA)
• We identified 143 DAT subjects in our data base who were
driving at entry between 1981 and 2000, but who stopped
driving according to collateral source report at a
subsequent follow-up.
• We identified active DAT drivers of comparable age,
dementia status, and length of time in the data base, who
were still driving.
Carr DB et al, Gerontologist 45: 824-827, 2005
Sample Characteristics
Variable
Active Drivers
(n=65)
M, SD
Stopped Driving
(n=158)
Age (yrs)
79.5 (6.6)
78.3(7.9)
Education (yrs)
13.1 (2.9)
13.7(3.5)
Female (%)
50
62
White (%)
97
93
# Meds
2.9(2.3)
2.8(1.9)
Short Blessed
8.2(6.8)
8.5(5.9)
Acuity OD
20/38(35)
20/35(38)
Acuity OS
20/31(12)
20/45 (85)
3.2(2.3)
3.3(2.0)
Sum of Boxes
Psychometric Tests
Active Drivers
(n=65)
Stopped
Driving
(n=158)
Factor Score
-2.00(1.77)
-2.08(1.36)
Logical memory
3.95 (3.00)
3.46(2.50)
Block design
21.09(10.61)
19.39(9.24)
Digit symbol
29.51(12.87)
28.25(12.99)
Trails A (secs)
70.14(38.05)
70.4(37.83)
Trails B (secs)
154.67(37.84)
157.57(32.54)
Variable
Discussion
• Cognitive impairment/unsafe driving behaviors were the most
common reasons cited for driving retirement
• The majority of drivers had very mild DAT and mild cognitive
impairment at the time of driving retirement
• Psychometric tests were no different between active drivers and
recently retired drivers
• Non-cognitive factors (e.g. psychosocial issues), are likely
important in the decision to stop driving
• More research is needed on “when to say when” in the driver
with DAT
• More pertinent may be the question “how to say how” to stop
driving
Driving Questionnaire Study

LongerLife Foundation: Activities in Late -Life
• Nancy Morrow-Howell, PI
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Focus on Activities and Activity Portfolios
Background
•
•
•
•
•
20,000,000 older adults driving in 2006
Driving life expectancy
Negative outcomes with driving cessation
Primary goal was to document “at-risk” activities
Secondary goal was to document
–
–
–
–
Decline in traffic skills
Barriers in the process of driving cessation
Key decision-makers in driving retirement
Psychological impact

RQ1
• What are the negative consequences of driving retirement in older adults
with dementia referred to MDC?

H1
• Caregivers will document a reduction in out-of-home activities and an
increase in depressive symptoms.
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RQ2
• Do caregivers observe impaired traffic skills in demented patients that are
evaluated in MDC?

H2
• When provided a specific list, caregivers will document the presence of
impaired traffic skills.
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RQ3
• What are the barriers to driving retirement in MDC patients with dementia?

H3
• Patient characteristics may delay driving retirement.
Methods

Site
• Patients were drawn from referrals to the Memory
Diagnostic Center (MDC), a dementia specialty
practice of Washington University School of Medicine
• Five neurologists, one geriatrician, and six nurse
clinicians
• Referrals to MDC are made by primary care
physicians and from the community
• Evaluations are usually for cognitive, behavioral, and
mood disorders
• Less than 1% are unable to identify a collateral source
Methods

Sample (Inclusion Criteria)
• Patients with a history of driving
• First time diagnosis of dementia either on
initial or subsequent visit to MDC
• 2001-2006
• Collateral source with an address
• Approved by Human Studies
• Consent obtained from both the Informant
and patient via mail.
Driving Questionnaire (DQ)
DQ mailed to 564 patient-informant dyads in August 2006 to
those patients who were evaluated between 2001-2006 in
MDC
 Subsequent Exclusions
• 18 patients never had a history of driving when the charts
were abstracted by the nurse clinician
• An additional 19 charts were off-site
 This left 527 patients in our MDC sample
 119 questionnaires were returned response rate of 23%
• 65% spouse, 25% child, 10% other
• average age 64 years (+12.9)

Table 2: Driving Behaviors
Variable
Active Drivers
Valid License
Rated as poor or unsafe
Rated as fair/questionable
Distant areas (>15 mil es)
Far areas (>100 miles)
Crash in past year*
Days of driving per week*
N=34 Active Drivers
Questionnaire (N = 119)
N
%
34
28.7
68
56.7
20
16.7
43
35.8
39
32.5
21
17.5
6
17.6
4.7
+2.0 SD
Table 2 (cont): Driving Behaviors
Variable
Monitoring for traffi c
Maintaining speed
Turns/Intersection
Backing up
Staying in Lane
Traffi c Signs/Signals
Parking
Yielding
Gas/Brake Peda ls
1 or More
Questionnaire (N = 119)
N
%
36
30.2
30
25.2
25
20.8
22
18.3
21
17.5
17
14.2
13
10.8
11
9.2
8
6.7
85
70.0
Table 3: Negative Consequences
(At-Risk Activities)
(N=93)
Variable
Shopping
Working
Meetings
Social Visits
Health
Trips
Religious
Recreation
Restaurants
Movies
Civic
Cosmetics
Stopped Activity
N
%
42
45.2
30
32.2
24
25.8
23
24.7
23
24.7
20
21.5
17
18.2
16
17.2
16
17.2
12
12.9
12
12.9
10
11.0
Reduce Activity
N
%
40
43.0
15
16.1
43
46.2
40
43.0
12
12.9
21
22.5
16
17.2
21
22.5
26
30.0
16
17.2
15
16.1
12
12.9
Table 3 (cont): Negative Consequences
(Psychological Impact)
(N=79 of 85)
Variable
Depression
Anxiety
Motivation
Social Interest
Activities
Worse
N
37
27
32
37
41
No Change
%
46.8
34.1
40.5
46.8
51.9
N
35
35
36
35
31
%
44.3
44.3
45.6
44.3
39.2
***Other columns not listed are “better”, “unable to predict”
Table 4 (cont): Driving Retirement
(Education)
Variable
None below
OT evaluation
Other*
36 Hour Day
Social worker
Educational info organization
Questionnaire (N = 85)
N
%
56
65.9
10
11.8
9
10.6
8
9.4
2
2.4
0
0
*No write in candidates under “other”
Discussion
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The number of active drivers that present to MDC with dementia is
consistent with reports from other sites
Non-DAT drivers were present in this sample
Informants are aware of abnormal driving behaviors and rate some
patients driving skills as fair to poor
Crashes were documented in the active group of drivers at a rate
higher than our MAP sample
Those active drivers are making frequent trips and a significant
minority are driving far distances
Discussion (cont).
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There are “at-risk” activities in MDC demented drivers
There appears to be a psychological effect on some drivers
after retirement
Family and physicians were most influential in the decision to
stop driving in this sample
Patient and caregiver characteristics or personality traits
appear to play a role in delaying driving retirement
Educational resources and social workers were rarely utilized
by caregivers
Research on Fitness-to-Drive: CVA

Fitness-to-Drive in Dementia/Stroke: Timeline
• Funded by the MoDot/LongerLife Foundation
• Started October 1st, 2007
• Purpose: To identify patient characteristics that predict failure on a
standardized road test (WURT) and/or at-fault crash data
• Human Studies approval (9/07)
• Telephone Screening (10/07)
• Identify and hire study coordinator (10/07)
• Identify and hire driving evaluator (10/07)
• Identify and hire additional OT’s (11/07)
• Create family and patient questionnaire (11/07)
• Final selection of off-road tests (11/07)
• Modification of the WURT (11/07)
• Trial testing of off-road and on-road tests 12/07
• 1/07 start assessments
Annie
Screening
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INCLUSION
•
•
•
•
•
•
Johnson, Research Patient Coordinator
Center for Applied Research Science
Campus Box 8009, 660 South Euclid Avenue
St. Louis, Missouri 63110-1093
(314)362-0881 phone, (314)747-1404 fax
[email protected]
Active License
History of a CVA with any type of deficit
Physician referral for a driving evaluation
Age 25 years or older
NIHSS scores between 1-13
TOAST Classification
Screening
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REASON FOR EXCLUSION
•
•
•
•
•
•
•
•
•
•
•
•
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not interested
too young <age 25
advanced disease
current major depression
unstable disease
severe orthopedic/musculoskeletal impairments
severe visual, hearing, or language impairment
no informant
Medications causing sedation
less than 10 years driving experience
participant refuses
Drivers license not active
Failed recent (past year) driving evaluation
Expanded Fitness-to-Drive Study

Create a set of standards for driving evaluations (OT’s)
• History (DHQ, Destinations, etc)
• Physical Exam (DHI, Muscle Strength, etc)
• On-the-road performance testing (WURT, DMV, etc)

Recruit OT’s across the state of Missouri
• Urban
• Rural

Create a common data base that would be shared by sites
• Desktop
• Web-based
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Develop disease specific fitness-to-drive models
• Diseases: Dementia, CVA, other
• Outcomes: Road Test, Cessation, Crashes, At-fault Crashes, etc
Statistical Methods
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Independent variables: continuous, categorical
Dependent variables: continuous, categorical
Use t-tests for continuous, chi-squre for categorical
Inter-rater and intra-rater reliability and perhaps measures of test
stability
Determine unadjusted correlations with pass/fail
Stepwise logistic regression for those variables that were significant,
along with important demographics
Models will be created to determine the combinations of
independent variables that best predict road test failure
ROC curves to be created with the AUC to reflect graphically and
quantitatively the ability of the model to discriminate those that fail
from those that pass
Something Borrowed: Future Efforts
•
•
•
•
•
Neurological Disease and Driving
Functional Abilities and Driving
Heterogeneity
Simulators
Functional Brain Imaging
Driving Studies by Diagnosis*
DX
Total
MVA’s
SIM
CVA
18
2
6
8
2
BI
12
1
2
7
2
SC
2
0
0
2
0
PD
7
2
2
1
2
DAT
33
3
5
13
9
ROAD RETIRE
Searching Medline last 10 years MESH headings; driving, automobile driving,
traffic accidents, rehabilitation, cva, brain injury, sc, ms, pd, dementia: English
Clock Drawing Task/Driving
 119
community-dwelling older adult drivers
 CDT showed a high level of accuracy
 Analysis revealed a CDT score of 4 or less, had a
likelihood ratio of +27.58 for predicting unsafe
driving (sensitivity 64%, specificity 97%)
 Outcome measure was failure on a driving simulator
3 points for using two hands correctly, 2
points for using correct numbers, 2 points
for appropriate spacing
Freund et al, Drawing Clocks
and Driving Cars. J Gen Intern Med 2005;
20:240-44
Summary and Conclusions from
Maryland Pilot Older Driver Study
Visualization of missing information
(MFVPT; Visual Closure)
Directed visual search
(Trail-Making B)
Working memory
(Delayed Recall)
Information processing speed
(Useful Field of View, subtest 2)
Lower limb strength
(Rapid Pace Walk)
Head/neck flexibility
(Recognizing Clock Time)
Staplin L, et al. MaryPODS revisited.
Journal of Traffic Safety, 2003: 389-397
Peak valid at-fault OR
4.96
3.50
2.92
2.48
2.64
2.56
Neuropsychological Assessment Battery
Brown LB, Stern RA, Cahn-Weiner DA, et al. Driving scenes test
of the Neuropsychological Assessment Battery and on-road
driving performance in aging and very mild dementia. Arch Clinic
Neuropsychol 2005;20: 209-15
Driving and non-DAT Dementia
Alzheimer’s
Disease
Rapidly
evolving
dementias
Frontotemporal
dementias
Vascular
dementia
Lewy body
dementia
Non-DAT dementia and driving

De Simone V, et al. Driving abilities in frontotemoral
dementia patients. Dementia and Cognitive Disorders
2007; 23: 1-7
• 15 FTD and 15 healthy controls on a simulator
• FTD patients higher speed, missed stop signs, MVA’s

Fitten LF, et al. Alzheimer and vascular dementias and
driving. JAMA 1995; 273: 1360-5
• 12 VD and 26 healthy controls on road test
• VD patients were more impaired on the road test
• Correlates with short term memory, visual tracking, MMSE
Dr. Rizzo and colleagues: U of Iowa

Rear-end collisions are the most common crash
 Study to test REC avoidance
 61 drivers with DAT and 115 controls
 89% of drivers with DAT had unsafe outcomes
compared to 65% of controls
• REC or risky avoidance behavior
• Abrupt slowing increased the odds of a REC
• Unsafe outcomes were predicted by psychometric tests
Uc EY, et al. J of Neuro Science
2006: 251: 35-43
The Neural Correlates of Driving
• fMRI/SPECT and driving: 12
normal subjects did active and
passive driving
• Driving impairment correlated
with both a reduction of right
hemispheric cortical perfusion
(temporo-parietal region) as well
as decrease in perfusion of the
frontal cortex
• Left sensorimotor cortex active
(pre and post central gyrus)
• Mainly BA 19 occipital
areas and BA 7 parietal
cortex bilaterally are
involved
• Vermis and both cerebellar
hemispheres
• Other area activity is
suppressed
• Active driving produced
increased activity in a
number of brain regions
including temporal, frontal,
hippocampal, and
Ott BR, et al. Dement Geriatr Cogn subcortical regions.
Disord 2000; 11: 153-60
The Future

Neurological Diseases
 OT vs. DMV vs. Rehab vs. Physician settings
 Fitness-to-Drive Outcome Measures
 Rehabilitation Efforts
 Statistical Approaches
 Simulators
 Others?
Something Blue: The Real Solution
Driving Restriction is the Answer
Acknowledgments(1): WUSTL

ADRC

Program of OT
• Carolyn Baum
• Peggy Barco
• Susan Stark
• Holly Hollingsworth
• Lisa Connor
• Jami Croston

Neurology
• Clinical Core
–
–
–
–
–
–
John Morris
Jim Galvin
Virginia Buckles
Mary Coats
Vicki Weir
MAP/MDC Clinicians/Staff
• Psychometric Core/Psychology
– Martha Storandt
– Jan Duchek

• Biostat Core
– Betsy Grant
– Cathy Roe
– Staff
• Educational Core

– Jim Galvin
– Barbara Kuntemeir
School of Social Work
• Nancy Morrow-Howell

• David Holtzman
• Mauricio Corbetta
• Rob Fuscetola
Division of Geriatrics/NS
• Sam Klein
• Ellen Binder
• Stan Birge
• Dennis Villareal
• JoAnn Wilson
Civil Engineering
•
Gudmundur Ulfarrson
Acknowledgments(2): The Village

St. Louis

• TRISL
• Tom Meuser
–
–
–
–
– Center for Aging, UMSL
• Marla Berg-Weger
– SLU School of Social Work
• Pat Niewoehner
– Jefferson Barracks VAH

• Michael Taylor
• Shel Suroff
– Alzheimer’s Association
• Independent Drivers
– Steve Ice
• Alzheimer’s Association
Missouri
– MoDOT
– VP AAA St. Louis
• Katie McLean
Barbara Jacobsmeyer
Gerry Hefele
Jackie McClanahan
Stacy Luters
• Leanna DePue/Jackie Rogers
• Mike Right
– CARD
St. Louis
– Rusk

External Advisors
• Linda Hunt
– Pacific University
• Loren Staplin
– Transanalytics
Why is the need for research urgent?