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Assessment Group: Discussion and Unresolved Issues.

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Presentation on theme: "Assessment Group: Discussion and Unresolved Issues."— Presentation transcript:

1 Assessment Group: Discussion and Unresolved Issues

2 An assessment flow Why?: Identify drivers with functional changes that may compromise personal or public health or safety Why?: Identify individuals who may benefit from prevention, education, remediation Who?: Many different sources of screening and referral (self, family, law enforcement, DMV, other agencies, health care professionals, driver rehabilitation specialists, driver educators, community-based agencies and groups, etc, etc) What?: Tier One: Brief screening of cognitive, motor, sensory and health/medication functions. The form of Tier 1, and its next steps, are contingent on who does the assessment.

3 An assessment flow What?: Tier One: Brief screening of cognitive, motor, sensory and health/medication functions. The form of Tier 1, and its next steps, are contingent on who does the assessment. What?: Tier Two: In-depth assessment of cognitive, motor, sensory and health/medication functions, personality/motivation/awareness. The next steps, are contingent on who does the assessment. Often done with Tier 3. What?: Tier Three: Behind the wheel assessment At each tier, there should be appropriate referrals

4 Candidate measures The domains that follow in red come from the NHTSA/AAMVA recommendations A goal is that a battery should be evidence-based (with regard to its predictiveness of driving performance, which could include crashes, on-the-road driving errors, or other performance measures). There are alternative pathways. 1.One approach focuses less on specific domains, but tries to include a battery which—in combination—maximizes predictive salience. 2.A second approach tries to represent multiple domains. This will be more useful for making rehabilitation recommendations and identifying the sources of problems. The two approaches are not mutually exclusive.

5 Tier 2 Candidates: Cognition DomainCandidate measures Notes Mental Status Mini-Mental Status Examination Telephone Interview for Cognitive Status Does it make sense to separately predict driving for demented and non- demented elders? Where does MCI fit in? TICS has wonderful advantages, including phone plus better memory than MMSE. Divided Attention Trails A & B Useful Field of View Trails is widely used, and AMA recommended; UFOV is predictive and trainable, but equipment intensive.

6 Tier 2 Candidates: Cognition DomainCandidate measures Notes Perceptual Speed/Visual Search Letter Cancellation Task Digit Symbol Substitution Task Trails Does this add anything beyond the speeded Divided Attention Tasks? Reaction Time Complex Reaction Time (e.g., Doron There is no shortage of CRT tasks. Again, these generally require a computer; Doron is driving stimulus-specific. Is a simulator (not portable) a better choice?

7 Tier 2 Candidates: Cognition DomainCandidate measures Notes Judgment/ Decision Making RoadSmart Judgment Test Driver risk inventory We have not seen this measure, but it is referenced, and raises the intriguing prospect of domain-specific reasoning. Is there room for basic reasoning measures here, like Inductive Reasoning? Episodic Memory Hopkins Verbal Learning Test Telephone Interview for Cognitive Status TICS phone-admin., but picks up memory well; is this really a screen for impairment?

8 Tier 2 Candidates: Cognition DomainCandidate measures Notes Working Memory Digit Span Task (consider also Delayed Memory) Again, does this add anything meaningful beyond divided attention tasks? Are better working memory tasks to be used? Driving Knowledge Rules of the Road Test Traffic Signs Test Cognitive science tells us that in expert domains, the best predictor of performance is domain- specific knowledge; this is also an assumption of state-level licensing programs

9 Tier 2 Candidates: Cognition DomainCandidate measures Notes Spatial abilityBlock Design MVPT (horizontal) Is this too domain- general? Is a specific map-reading task more meaningful? Visualization of missing information Visual closure subtest of MVPT Taps into ability to generate expectancies about impending visual threats? Complexity/situa- tion awareness (not a domain.. belongs in the flow elsewhere) DriveABLE CA/ MD(Grimps+UFOV 2) Model Are these the Tier 1 measures?

10 Tier 2 Candidates: Sensory DomainCandidate measures Notes Proprioception Foot tap time Simulator? Brake reaction time Face validity with moving foot from gas to break pedal Cutaneous sensation (pressure on sole of foot) Semmes Weinstein? Pressure and localization sensation test? Evidence? Pain Jette McGill VAS Association with back pain and vehicle crashes Disability specific pain (Arthritis)

11 Tier 2 Candidates: Sensory – Vision DomainCandidate measures Notes Oculomotor Control Manual assessment Subjective Typically an issue in neurologically involved drivers, not older adults Visual Fields Perimetry testing with Humphrey or Goldmann; Confrontational field testing may be sufficient Identifies blind spots and other visual field disturbances but does not indicate an impact on driving or if driver compensates Visual Acuity Wall charts Automated testing machines Identifies ability to visually decipher the environment Determines if driver meets state vision guidelines Predictability of crashes? Dynamic visual acuity not measured

12 Tier 2 Candidates: Sensory – Vision DomainCandidate measures Notes Depth / Stereopsis (For the newly monocular) Optec Keystone Porto Clinic Stereo Fly Stereopsis is a binocular skill; can’t measure monocular drivers In most vision testing machines Connection to crashes? Color Recognition Optec Keystone Porto Clinic Included in most vision testing machines Connection to crashes? Contrast Sensitivity F.A.C.T. Pelli – Robson Chart Regan Low Contrast Letter Acuity Chart Vision batteries Linked to driving performance and crashes

13 Tier 2 Candidates: Sensory – Visual Motor DomainCandidate measures Notes Visual MotorTest of Visual Motor Skills (TVMS-R) Bender Visual- Motor Gestalt Test Rey-Osterrieth Complex Figure Test Evidence linking assessment performance to driving performance?

14 Tier 2 Candidates: Motor DomainCandidate measures Notes Range of motion Knee flexion Cervical rotation, flexion, extension, lateral bend (head- neck flexibility) Trunk rotation dorsiflexion Upper extremity Limited L knee flexion associated with adverse events. Limited evidence of correlation with driving performance for cervical, UE and trunk ROM. Older impaired drivers > risk at T-intersections Strength (Leg strength especially) Grip Pinch? Manual muscle testing Functional grasp association with crash involvement. Which muscle groups?

15 Tier 2 Candidates: Motor DomainCandidate measures Notes Gross Mobility Rapid Pace Walk Get up and go test Number of blocks walked Foot abnormalities Fall history Association with falls and vehicles crashes; Adverse driving events and distance walked Redundancy with balance and proprioception assessment?

16 Tier 2 Candidates: Sensorimotor DomainCandidate measures Notes Balance (dizziness) Romberg Berg Balance Scale Tandem Stand Side-to-side stand Single leg stand Smart Equitest Sitting balance Complete Romberg or segments? Association with weighted error score for tandem stand. History of falls associated with vehicle crashes Neurocom Equitest assessment (Quantify/train or cost prohibitive)? Reaction Time Foot reaction time (brake) - Doron? Association with increase vehicle crashes among women

17 Behavior, Personality, Beliefs: Driver Risk Assessment (risk taking), impulsivity, empathy, aggression, cautiousness Depression Mania

18 Unresolved issue: The Criterion Problem By which criteria should we evaluate the predictive salience of our battery? –Accidents? –Simulator? –Field driving tests? –Standardized driving courses? –Subjective driving evaluations? Is the more sensible goal the multidimensional assessment of different aspects of driving?

19 Unresolved issue: Measurement selection There is a wide variety of studies Few multidimensional studies in which measures evaluated simultaneously Great variation in dependent variables used across studies It seems important to first identify demented individuals; different prediction equations likely for non-demented elders; more likely to predict subtle driving errors

20 Unresolved issues: Cognition Should we do a gross check for dementia, and triage such individuals out of further assessment? Or do we need tests like Clock Drawing (special Freud scoring), Cognitive- Linguistic Quick Test, Boston Naming, Wechsler Memory Scale, WAIS Picture Completion Some commonly used tests seem redundant with what we have shown (Stroop, Minnesota Rate of Manipulation, AARP Reaction Time) Interesting dimensions not commonly studied, including Motor-Free Visual Perception Test, Unilateral Neglect

21 Unresolved issues: Sensory Is there a better proprioception test for the lower extremity? What amount of pressure is needed for breaking? Should pain assessment be used and if so, which pain assessment is the most appropriate?

22 Unresolved issues: Motor Should all ROM measurements be functional rather than exact? Should upper extremity ROM be tested? Should MMT be done on lower extremity muscle groups (such as knee extension) and if so, should it be quantified with hand-held dynamometry? If we were to choose one gross mobility test only, which is the best?

23 Unresolved issues: Sensorimotor Should a balance (dizziness) test be used?

24 Unresolved issues Who is screened? (everyone? just at risk drivers? just older drivers?) Who screens? (what kind of training is needed?) Who pays? (what is the estimated cost, and what are some possible sources of funding?) What are the legal implications? (what supportive policy/legislation is needed?)

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