Transcript LDI Presentation

LDI Curriculum:
Behind-the-Wheel Refresher
for Older Adults
Emily Seymour, Mattea Wieberdink, Patrick Giblin, Dan
Wackler, & Jordan Wiertzema
General Andragogy Principles
Andragogy is the method and practice of teaching adult learners.
Basic principles include:
• Collaboration
• Learn by doing
• Immediate Application of Material
• Self Motivation
http://www.aacps.org/aacps/PTPLEAES/pta.asp
Considerations When Working with Older Adults
Theory of Selective Optimization with Compensation
● Each older adult is an expert in themselves-they have learned to
adapt/compensate for age related losses-build on the positive strategies
they have developed and help them break any bad habits!
Changes in Cognitive Skills
● Need for repetition/trouble with divided attention
● Older adults can learn new things!
Emotion to Events
http://www.adpcomplianceinsights.com/otherconsiderations-related-to-the-aca-5/
● Anxiety-especially in older women/overconfidence in men
Driving and Well-being
• Driving is linked to autonomy
and independence
• Driving cessation creates
barriers to everyday tasks
http://www.ethocare.org/events/fall-2014-healthy-eating/
• Driving cessation is linked to
depression, social isolation, and
institutionalization
• Creates role shifts
Reasons OAs seek out Driving Instructors
• Referral from DVS
• Advice from concerned family
member
• Personal concern about
abilities
http://www.eyedoctorguide.com/eye_care/senior_citizen_driving.html
Young vs. Old Drivers
http://www.nhtsa.gov/people/injury/olddrive/pub/Chapter1.html
Young vs. Old Drivers
Young Drivers
Older Drivers
• Lack experience
• Experience is a strength
• Engage in risky behaviors
• Better at self-regulation
• But are in the prime of their lives
• But have a declining skillset
Role of Occupational Therapy
•
Driving=IADL
•
Restorative: Training of component performance skills
o Work on physical and cognitive components
o Tailor to specific clinical conditions
o Offer driving simulator practice
o UFOV training
•
Compensatory: Assistive devices and training
o Adaptive devices
o CarFit
•
Refer client for a comprehensive driving evaluation
•
Present community mobility options
http://kotaonline.org/events/conference/2015Con
ferenceHandouts/Nichols%20Handout.pdf
Role of Certified Driving Rehabilitation Specialist (CDRS)
•
Assessment to determine fitness to drive
o Both in the clinic and on the road
o Generally lasts 4 hours and costs $200-$400+
•
After assessment may recommend:
o Continuing to drive with/without adaptive devices
o Driving limitations
http://www.slrc.org/outpatient/programs/driver-rehabilitation/
o Ceasing to drive
•
CDRS can only make recommendations to doctor or patient/family, not DVS
•
Referral to a CDRS from a doctor is NOT required
Role of Physician
• Assesses driving-related functional abilities, both physical and
cognitive
• Treat medical conditions underlying driving issues
• Refer to OT for IADL assessment
• Refer to CDRS
• Recommend restricted driving license
Normal Aging vs Medical Conditions
❏ Physical
❏ Sensory
❏ Cognitive
https://www.google.com/search?q=generalist+Occupational+therapist+with+driving
Normal Aging vs. Medical Condition
https://umsl.mediaspace.kaltura.com/media/Driving+Test+with+MO+State+Hi
ghway+Patrol+Examiner+++Woman+with+Vision+Loss/0_my0ht6c1
As you watch this video, consider the following:
•
What is the examiner looking for?
•
What are some warning signs that the driver displays?
•
What would you do if this person signed up to a refresher behind-the-wheel
course?
Follow along on page 34 of the curriculum
PHYSICAL
CHANGES
Physical Changes and Impact on Driving
Strength/Endurance
Implications
• Leg strength and pedal controls
•Be aware of limitations
• Handgrip strength and steering
wheel control
•Fatigue will impact cognitive
processing speed and ultimately
reaction time
• Length of driving trip can lead to
fatigue
•Increase following distance
•Exercise programs
Physical Changes and Impact on Driving
Reaction Time
Implications
• Needed to respond appropriately and
•Increase following distance
in time to traffic, signs, pedestrians,
etc.
•Racquet sports
• Complex skill to assess. Sensory ->
Cognitive -> Physical components
•There are also apps that can
improve reaction time
https://smithcollegesquash.files.wordpress.com/2013/09/logo-racketlon-nieuw.png
Physical Changes and Impact on Driving
Flexibility
•Neck/trunk and checking blind spots
• Shoulders and steering wheel use,
putting on seat belt
•Lower body and pedal control
Implications
•Proper mirror setup
•Consider wide-view mirrors
•Seat belt aid
•Yoga, other exercise programs
can increase range of motion
http://blogjob.com/mymessagetotheworld/wpcontent/themes/wumblr/themify/img.php?src=http://blogjob.com/mymessag
etotheworld/files/2015/09/neck-stretching.jpg&w=590&h=&zc=1
Arthritis
•
•
•
Common condition affecting older
adults
Causes joint stiffness and pain
•
Can cause difficulties with:
http://westonmedicalhealth.com/arthritis/
Solutions:
o Grasping the wheel
o Provide exercise resources (p. 14)
o Applying brakes
o Train to leave extra room
o Pinching and turning key
o Adaptive key holders
o Putting on safety belt
o Adaptive safety belt
o Getting in/out of car
o Leg lifter, exercise handout
o Drowsiness from medications
o Rx Review website (p. 42)
Stroke/CVA
•
Residual symptoms can affect driving ability
o Left-sided vs. right-sided weakness
•
Can lead to difficulties with:
o Complex tasks (ex. Left turns), reading signs
o Navigating & noticing entire environment
o Grasping wheel & applying brakes/gas
•
http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/
RegainingIndependence/Driving/Driving-AfterStroke_UCM_311016_Article.jsp#.VyZidjArLIU
Solutions
o Practice complex tasks
o Drive in familiar environments; train to scan entire environment
•
•
Make sure that the individual is medically cleared to drive
Refer to CDRS if symptoms are severe or complex adaptive equipment is
required
SENSORY
CHANGES
Vision
Key Points
● Aspects of vision tested/required for licensure don’t completely match
research
● Research shows which aspects of vision are important, but lacks cut points
Acuity
● Tested, but weakly linked
● 20/20 vs. 20/40
● Dynamic vs. static testing
http://www.imedicalapps.com/wpcontent/uploads/2015/01/snellen-chart-app.png
Vision
Field of view (peripheral vision) – also tested, but might not be tested in the
most effective way.
• Better test involves more than just left/right
• Testing vs. actual driving skill (scanning, neck movement)
Contrast Sensitivity – should be tested
• Refers to variations in brightness
• Testing conditions vs. driving conditions
http://www.visus.de/shop/images/product_images/original_images
/n80242.jpg
Vision
● Night vision – low contrast situation.
● Glare – older drivers are more susceptible to glare due to changes within
the eye.
● Depth perception – partly a visual task, partly cognitive. Difficult to test,
and link to crash rates. Important for judging distance and making safe
turns.
http://www.driversedguru.com/wp-content/gallery/jamie-gallery/Lots%20of%20Glare.jpg
Overcoming & Preventing Vision Problems
• Regular eye exams to prevent decline
• Sunglasses for glare during the day. Limit night driving if headlight glare is
problematic. Look toward right side of the road to avoid looking directly at
the headlight.
• Regular exercise reduces risk for diabetes and high blood pressure, which can
damage eyes.
• Proper nutrition is also important for eye health.
(handout on p. 17)
http://merkurblog.ro/wpcontent/uploads/2016/01/foodinsight.org
_.jpg
Visual Conditions
Cataracts
•
•
•
Macular Degeneration
• Loss of center/ detailed
vision
• Sensitivity to light/glare
• Difficulty seeing
signs/traffic/center line
Cloudy vision
Sensitivity to
glare
Difficulty judging
distances
Glaucoma
•
•
•
Loss of
peripheral vision
Blind spots
Things “come
out of nowhere”
Diabetic Retinopathy
• Difficulty seeing
signs/traffic/center
line
• Sensitivity to light
• Cannot see objects
clearly
Visual Conditions (cont.)
• Those with glaucoma or macular degeneration should be referred to
a CDRS due progressive nature of conditions
o If symptoms of retinopathy and cataracts are severely impacting driving
ability, referral to CDRS would also be warranted
• Solutions behind-the-wheel
o
o
o
o
Educate about self-regulation techniques (ex. Not driving at night)
Train to leave larger distance between car and other objects
Teach to scan entire environment
Practice problem maneuvers
Other Senses
Hearing – not independently linked to increased crash rate, but when paired
with vision problems can magnify impact.
Vestibular – important for balance. Studies link fall risk to increased crash rate.
• Fall prevention programs involving exercise (Pilates, yoga) have also been
shown to improve driving
Touch – important for sensing how much pressure is applied to gas/break pedal.
Also for control of steering wheel.
• Thin soled shoes can help feel the pedals better
Diabetes
● Insulin dependent vs. non-insulin dependent
● Can cause visual and sensory impairments
● If blood sugar is too high or low can result in:
https://supermanherbs.com/diabetes/
○ Drowsiness, confusion, blurred vision, loss of consciousness
● Recommendations:
○ Remind individuals to check blood sugar before driving & drive with medications
○ Have snacks in car if blood sugar gets too low
● If insulin dependent, referral to CDRS may be beneficial
● If non-insulin dependent, can be taken behind the wheel if diagnosis is not
significantly affecting ability to drive
COGNITIVE
CHANGES
Areas of Cognitive Decline
Fluid Intelligence: the ability to think abstractly, problem solve, reason, and
identify patterns
Example: Ability to find a detour after a road closure
●Teaching OA:
○ Introduce complex driving maneuvers/environments gradually
○ Teach new skills in familiar environments
Working Memory: ability to store and manage information required for complex
tasks such as learning, reasoning, and comprehension
Example: Remember and follow complex directions
●Teaching OA:
○ Avoid giving instructions at same time as driving
http://www.psychologicalscience.org/redesign/wpcontent/uploads/2012/04/daydreams_observation_WEB.jpg
Useful Field of View: the attention to and processing of visual information
Example: Paying attention and reacting to traffic signs
●Involves 3 parts of cognition:
○ Processing speed-time it takes a person to interpret and react to stimuli
○ Divided attention-ability to focus on multiple stimuli
○ Selective attention-ability to focus on single stimuli and ignore irrelevant
information
●Implications for teaching OAs:
○ Reduce distractions in the car
○ Avoid giving instructions at the same time as driving
○ Introduce complex situations gradually
○ Practice reaction time in safe driving environment
UFOV Impairment Increases with Age
http://www.visualawareness.com/Pages/whatis.html
Drivers that have lost 50%
of their UFOV are 2 times
more likely to crash than
people with better useful
field of view.
http://www.visualawareness.com/Pages/whatis.html
Cognitive Solutions
• Improve Attention and Memory
• Improve Speed of Processing:
• Word puzzles (e.g. Sudoku, word finds)
• Play catch
• Visual search games (e.g. Where’s Waldo?) • Racquet sports (e.g. ping
pong)
• Connect the dots
• Wii fit
• Mazes
• Memory games
• Reading
• Getting enough sleep
• Physical Exercise
http://www.creativitypost.com/psychology/new_cognitive_training_study_takes_on_the_critics
Computer Programs/Apps for Cognition
Drive Focus-app used to improve visual attention, reaction time, and
identification of critical roadway items (pedestrians, construction signs, brake
lights, etc.)
Brain HQ-online training system to improving attention, memory, brain speed,
people skills, navigation, and intelligence.
Drivesharp-Computer program clinically shown to help drivers see more, react
faster, and cut crash risk by up to 50%.
Cognitive Medical Conditions
/
http://www.smarternootropics.com/2014/01/enhanced-atp-synthesis-and-cognition-with-creatine
Mild Cognitive Impairment (MCI)
•
•
Affects memory and reasoning abilities
Impact on driving
o May lose their way or forget directions
o Trouble staying in lane and judging distance between car and other objects
o Difficulties attending to whole environment
•
Solutions
o Repeat information as necessary; drive in familiar areas
o Navigational assistance
o Train to leave extra distance and scan environment
•
Can use visual and cognitive screen mentioned previously to look for
possible cognitive issues
o If individual is significantly impaired, refer to CDRS
Alzheimer’s Disease
•
•
Most common form of dementia
Early stage
o Also apart of mild neurocognitive disorder
http://stcharlescommunity.org/when-is-it-time-to-give-up-the-keys-older-adults-and-safedriving/
o May still be able to drive, depending on level of function
•
Mid-Late Stage
o Now known as major neurocognitive disorder
o Individuals in these stages should not drive
•
Due to its progressive nature, individuals diagnosed with any stage of
Alzheimer’s Disease should be referred to a CDRS
Parkinson’s Disease
•
•
Progressive movement disorder that
often affects cognition as well
Impact on driving
o Slowed reaction time
o Judgment issues
o Problems with visual search &
getting lost
o Difficulty with movement needed to
control vehicle functions
•
Individuals with this disease should be referred to a CDRS
http://www.vereencenter.com/understandin
g-parkinsons-disease/
Medications
•
Older adults are often on multiple medications
•
Side effects and drug interactions can a have an impact on ability to drive
safely
http://remedymyvertigo.com/best-vertigo-medication/
o Refer to p. 39-40 for common drug types and symptoms to look out for when
taking an older driver behind-the-wheel
•
After first session, can give older drivers handout on p. 41-42 and
encourage them to visit Rx website to understand impact their medications
can have on driving
•
If any red flags are pinpointed during the first session, referral to a CDRS
may be warranted
Self-Regulation
Self regulation is the process of making changes to the way one drives in order
to be safe
•
Remember selective optimization with compensation from earlier?
•
Ability to self regulate increases with age
What are some self regulation techniques you have seen in your experience
with older drivers? Were they effective? Were they Safe?
Take a couple minutes to write them down on page 24
Common Self Regulation Strategies
•
Avoid driving at night
•
Drive without passengers
•
Avoid rush hour & busy streets
•
Cut out excess distractions
•
Avoid driving in bad weather
•
Avoid highway driving
•
Avoid left turns (turn right 3 times)
•
•
Take short distance trips
Follow the car in front of you at a
greater distance to allow for
increased stop time
•
Take familiar routes
•
Plan trips in advance
Behind-the-Wheel Training
Keep in mind the previously discussed andragogy principles when working with older
adult drivers behind the wheel:
•
Any specific skills a driver wants to work on?
o (collaboration)
•
Give opportunity to talk through complex situations as well as repeated
opportunities to practice skills
o (learn by doing/immediate application of meaningful skills)
Remember older adults can have trouble with divided attention skills!
Keep directions short and consider not giving them while the older adult is
driving! Have them pull over and/or instruct before a complex maneuver
Outline of a 1 Hour Behind the Wheel Session
0-10 Minutes
• Introduction/ask driver why he/she is here today
• Ask to see license-make sure it is valid and ask the driver to tell you
the address listed on license (See pg. 33 for visual/cog. screen)
• Have driver demonstrate basic non driving skills
o Put on seatbelt, turn on wipers, turn on signals, turn car on/off,
adjust sideview/rearview mirrors
These basic maneuvers can provide insight into a driver’s physical
and cognitive abilities
Outline of 1 Hour BTW Session Continued
10-20 Minutes
• Have a driver practice basic moves in a parking lot
• Backing up
o Can driver turn head/trunk? Using mirrors?
• Turning
o Can driver grip wheel tight enough to turn safely?
• Driving straight
o Can driver maintain a straight course?
Outline of 1 Hour BTW Session Continued
20-35 Minutes
• Residential area/minimal automobile and pedestrian traffic/low MPH
• 4 way stop intersection
o Stop at appropriate time? Appropriate place? Check environment?
• 2 way stop intersection
o Proceed straight through
 Check both ways (physically able to do so)? Safely judging gaps in
traffic?
o Turning right
 Safely judging gaps in traffic before merging?
Outline of 1 Hour BTW Session Continued
35-50 Minutes
• Higher traffic roads: County/arterial roads/City streets
• Turn left at an intersection with a designated green arrow signal
o Understand meaning of arrow? Proceed at right time?
• Turn left at an intersection w/o a designated green arrow signal
o Position car correctly to prepare to turn? Turn at right time and judges
a safe gap in traffic of when to turn?
• Driver on road with two lanes of traffic and have driver change lanes
Maintain lane position and speed? Use mirrors? Check blind spot?
Outline of 1 Hour BTW Session Continued
35-50 Minutes Continued
• Navigate single or multiple lane
roundabout
o Driver familiar with roundabouts?
o Understand yield sign?
o Understand how to merge?
Roundabouts are becoming much more
common!
Even in rural areas!
http://safety.fhwa.dot.gov/intersection/innovative/roundabo
uts/fhwasa10006/
Outline of 1 Hour BTW Session Continued
50-60 Minutes
• Highway (only if instructor/driver feel comfortable)
• Merge onto highway
o Maintains speed? Check blind spot?
• Change lanes
o Uses mirrors? Check blind spots? Uses turn signals?
• Merge off highway
o Uses turn signals? Check blind spot?
Recap of Problematic Maneuvers/Situations for
Older Drivers
• Maintaining lane position
• Yielding/Merging
• Changing lanes
• Turn left at a stop light
without a left turn arrow
• Navigating roundabouts
• Backing up
A majority of these have to deal with navigating intersections!
Best to start with basic intersections (4 ways stops) before moving on
more complex intersections.
Questions/Comments?