1. The Occupational Therapy Pre-Driving Clinical Assessment
Judith Joseph, OTR, MA, CDRS
TOTA MCC
November 6, 2014

2. Objectives
Develop an occupational profile that addresses the client’s driving needs.
Select specific evidence-based assessments and assessment methods to assist in determining driving readiness.
Using the information gathered from the occupational profile, assessments, and goals determine the need to refer client’s to the DRS.
Gain knowledge in the laws and agencies in the state of Texas that determine driving fitness to assist OT practitioners in establishing treatment plans and goals.

3. About the speaker Introduced to clinical driving evaluations in 1987
Attended my first ADED conference in 1989?
Developed a pre-driving clinical screen and evaluation in 2010
Passed CDRS exam August 2013

4. “So, what are you going to do about driving?”

5. Why should occupational therapist evaluate fitness to drive?

6. Things to consider
There are 20 million drivers in the U.S. 70 and older.
Every year, more than 795,000 people in the United States have a stroke.
400,000 individuals estimated to have MS.
Approximately 60,000 Americans are diagnosed with Parkinson's disease each year, and this number does not reflect the thousands of cases that go undetected.
One in four adults−approximately 61.5 million Americans−experiences mental illness in a given year
Approximately two million Americans have mild low vision which affects driving and reading.

7. Why Should OT evaluate fitness to drive?
Because driving is an instrumental activity of daily living within the domain of occupational therapy practice.
practitioners should be able to accurately determine who is a safe driver, who is at risk for unsafe driving, and who needs further evaluation by a driving rehabilitation specialist (DRS).
AOTA Driving and Community Mobility

8. Occupational Therapy Roles
Generalist: general knowledge and understanding of performance and processing skills related to driving.
Advanced Training: Further education to evaluate the integration of sub-skills associated with driving and provide specific sub-skill training
Specialized Training: Received specialized education, examination, and/or certification.
University of Florida

9. What is in our domain of practice?
Musculoskeletal disorders
Neurological impairments
Cognitive impairment
Memory disorders
Visual impairments
Perceptual impairments
Mobility
Mental impairment

10. Consider the diagnosis and resulting impairment

11. Medical condition examples
Diagnosis/condition
Impairment Risk
Sleep apnea
TBI
CVA
Dementia/Alzheimer’s MS
Impaired arousal, responsiveness, daytime sleepiness
Attention, orientation, visual field
Visual, cog, motor, visual field
Executive functions
Muscle weakness, sensory loss, fatigue, cognitive or perceptual deficits, symptoms of optic neuritis
Sherrilene Classen, Miriam Monahan ADED Conference 2013

12. Let’s Start with the law!
Texas MAB

13. Texas Medical Advisory Board (MAB)
The Texas Medical Advisory Board (MAB) for Driver Licensing was established in 1970 to advise the Texas Department of Public Safety (DPS) in the licensing of persons having medical limitations which might adversely affect driving.
Guidelines established using the following:
AMA Physician’s Guide for Determining Driver Limitation
Driver Fitness Medical Guidelines (NHTSA)
The American Association of Motor Vehicle Administrators

14. Texas Medical Advisory Board/DPS
The ultimate goal is to allow all who can drive safely to do so and to continue to reduce the number and severity of motor vehicle accidents in Texas

15. Functional Ability Profiles
General Debility
Cardiovascular disease
Syncope
Neurological Disorders
Psychiatric Disorders
Excessive Alcohol use/abuse
Drug use/abuse
Metabolic Diseases
Musculoskeletal Defects
Eye Defects
Aging
Recurrent syncope
CVA, Seizures, Dementia
MS, Parkinson's, Peripheral neuropathy
PTSD DM
CP, MD
Diplopia, Peripheral vision
Visual acuity

16. Where do I start?

17. The Association For Driver Rehabilitation Specialists (ADED)

18. ADED Mission Statement
Promoting excellence in the field of driver rehabilitation in support of safe, independent community mobility

19. ADED Best Practices For The Delivery of Driver Rehabilitation Services
Section 1: Interview/Medical History
Section 2: Clinical Visual Assessment
Section 3: Clinical Physical Assessment
Section 4: Clinical Cognitive Assessment

20. Interview/Medical History
History of Present Illness
Past Medical History
Determine medical consent
Review current medications (side effects)
Assess communication status
Review driving history
License status
Driving goals
Vehicle availability

21. Clinical Visual Assessment
ADED recommendation
Possible Deficits
Visual history
Visual acuity
Field of vision
Other visual skills
Cataracts, glaucoma, HH, etc.
Feinbloom eye chart, BiVaba, Snellen
Scatomos, HH
Visual short term memory, figure ground, form constancy, visual discrimination, visual scanning skills, High/Low contrast sensitivity

22. Visual Assessments and Observations
biVABA Brain Injury Visual Assessment Battery for Adults
The cover test
UFOV Useful Field of View
Dynavision
Motor Free Visual Perception Test (MFVPT)
Clock drawing test
Trails B
Pursuits and Saccades
Bumping into walls, furniture, etc.
nystagmus
Head tilting or position
squinting
Position of test paper
Visual scanning efficiency

23. Clinical Physical Assessment
Range of Motion
Strength
Grip strength
Prehension status
Sensation
Proprioception
Coordination (rapid pace walk)
Muscle tone (MAS)
Mobility status (TUG)
Balance (Berg, Teniti,)
Orthotic devices
Mobility aids
Transfer skills
Reaction times (Dynavision)

24. Clinical Cognitive Assessment
Mini Mental State Exam (MMSE)
Short Blessed Test
Clinical Dementia Rating Scale
Montreal Cognitive Assessment (MoCA)
Maze Navigation Test
Single Digit Modality Test (SDMT)
Assessment of Motor Processing Skills (AMPS)

25. Case Study 1: CVA
76 y/o male with R MCA infarct, s/p thrombectomy, left hemiparesis, DM-2, HTN, BPH, small tear in left supraspinatus.
+ multiple falls
Poly pharmacy
Wants to run errands and drive to any appointments
h/o getting lost while driving when blood sugar is uncontrolled
Backed into parked car in grocery store parking lot
Totaled a vehicle 6-7 years ago
Has not driven since onset of stroke

26. Case Study 1 continued: CVA test results
Impaired left peripheral vision
+nystagmus
Rapid pace walk= 10 sec.
Impaired head/neck flexibility
Visual closure, mild impairment
Trail Making B Test- 111sec.
UFOV- unable to complete. Could not see 2nd vehicle
Short Blessed=2
Multiple angry outburst during testing

27. Case Study 1: recommendations
Referred to U of H low vision clinic by Neuro-ophthalmologist
Complete program at U of H prior to attempting to drive or being referred to CDRS for BWT only after being cleared by Ophthalmologist
Consider driving cessation

28. Case Study 2: Parkinson’s Disease
91 y/o male with h/o Parkinson’s Disease, loss of balance, peripheral neuropathy, spinal stenosis, lumbar laminectomy
+ multiple falls
Using walker with seat
Last eye exam 2-3 years ago
History of falling asleep spontaneously
“minor” accident in parking lot when he could not stop in time when another vehicle pulled out in front of him causing a rear end collision
Totaled a car 3 yrs ago when he backed out of the driveway
Wants to cont. driving without restrictions

29. Case Study 2: Test results
High low contrast sensitivity intact
+nystagmus
Failed cover test
Bells Test 3:57 sec.
Trails B test 161 sec.
Right ankle strength 2/5, hip/knee strength 3/5
Limited head/neck flexibility
Unable to locate 50% items on UFOV
Fell asleep during testing
Rapid pace walk= 36 sec.
Scored 100% on sign recognition, map reading (items on MFVPT)

30. Case Study 2: Recommendations
Patient should not resume driving without a BWT.
High risk for having a crash
Consider driving cessation

31. Case Study 3: Left Hip fracture
82 y/o female with dx of left hip fx
Has trouble looking over her shoulder, difficulty backing up, and has gotten lost while driving
Wants to be able to drive to the store, etc. She does not plan on driving on the freeway or at night.
She has not driven in 6 months since hip surgery

32. Case Study 3: Test Results
Mild impairment of low contrast vision
Mild impairment of working memory
Impaired visual closure
Trails Making B test: 353 seconds
Impaired visual processing speed
Impaired UFOV
Rapid pace walk- 17 seconds
No errors on clock drawing test
Impaired head/neck flexibility

33. Case Study 3: Recommendations
Further assessment through BWT
Referral to optometrist

34. Case Study 4: MS
57 y/o female diagnosed with MS. Referred due to recent black out.
h/o ventricular tachycardia, osteoporosis, cataracts, severe scoliosis
+ falls
Wears built up right shoe for leg length discrepancy and R AFO
Gets lost while driving, trouble finding and reading signs in time to respond, feeling tired after driving, had “near misses”, bothered by head light glare, trouble looking over shoulder when backing up.
Recently hit a pole at the drive through bank and backed into trash cans at the end of her driveway.

35. Case Study 4: Test Results
Impaired visual acuity20/50 in left eye
High low contrast intact
No deficits noted with visual closure
Trials Making B test 73 seconds
Mild deficit with visual processing speed on UFOV
Mild deficit with working memory
No errors on clock drawing test
Rapid pace walk 5.8 seconds
Right shoulder flex limited to 90
Limited head/neck flexibility
3+/5 strength in Bil hips, and ankles
Became fatigued during test

36. Case Study 4: Recommendations
Begin to seek alternative transportation if deficits worsen
Use power chair instead of RW for appointments to conserve energy
Do not drive on unfamiliar trips
Do not drive when fatigued
Consult with MD
Referral to PT
Referral to CDRS for BWT

37. Case Study 5: Impaired memory
73 year old female with dx of impaired memory.
Cataract removal
Currently driving
Unable to recall last eye exam
Had one speeding ticket
Wears a hearing aid (not wearing during exam)
No falls
Admits to getting lost while driving, feels others drive too fast, being stressed out by driving, difficulty at busy intersections, friends will no longer ride with her.

38. Case Study 5: Test Results
20/25 binocular vision
Impaired horizontal fixation to right
Bells Test: 1:54, 3 errors
Rapid pace walk- 6 seconds
Scored 14 on the Short Blessed
Trials Making B Test 194 seconds
Intact visual closure, visual processing speed showed mild deficit

39. Case Study 5: Recommendations
Driving should be restricted at best to her immediate neighborhood, however without being able to control what happens such as weather conditions, and changes in traffic volumes driving cessation may need to be considered. If family insist on pt. continuing to drive a referral to CDRS for BWT should be completed.

40. I am not the decider!

41. QUESTIONS?????