1. Are We Safe Drivers… How Do We Know?
Craig Harington Occupational Therapist OTRS

2. What is Driving? DRIVING….. Intrinsically complex task
 Well learned routines
 Ability to respond flexibly
Driving skills are a complex set of tasks involving integration of visual, cognitive and psychomotor skills. The driving environment consists of multiple hazards including other vehicles, pedestrians, fluctuating light and varying road surfaces. Consequently a driver must pay attention to a wide range of information and make a number of complex judgments in a relatively short time. The operation of a vehicle and traffic participation simultaneously requires adequate psychomotor competence of over-learned tasks and a great deal of flexibility and executive processing in order to cope with even non-complex traffic situations. Therefore driving never becomes completely habitual or routine.

3. What Is Our Role?
The question that we need to answer is, what is the impact of a condition on an individual’s ability to drive.
“In assessing an individual’s fitness to drive, remember that the issue is often not whether the individual has a particular medical condition, but whether the condition has produced significant risk factors in respect to an individual’s ability to drive safely and whether they are a danger to themselves or others”. Medical aspects of fitness to drive, NZTA.

4. Common Language
No Dementia
No cognitive impairment
May continue to drive
Check for other medical conditions
MMSE > 27/30
ACE III >90/100
MOCA >26/30
RUDAS> 26/30
Mild Cognitive Impairment
A mild but noticeable decline in cognition
Most people safe to drive
Consider OT driving assessment, restricting or stopping driving if concerns.
MMSE: /30
ACE III: /100
MOCA: /30
RUDAS: /30
Mild Dementia
Definite cognitive decline and impairment
Driving safety uncertain:
OT driving assessment **(preferred and recommended)
MMSE: /30
ACE III: /100
MOCA: /30
RUDAS: /30
Moderate Dementia
Significant impairment of cognition/ function
Must stop driving!
Notify NZTA
MMSE: 10 – 18/30
ACE III: 35 – 64/100
MOCA: 6 – 10/30
RUDAS: 10 – 16/30
Severe Dementia
Profound impairment of cognition/ function
MMSE: <10/30
ACE III: <35/100
MOCA: <6/30 (or not testable)
RUDAS: <10/30
An issue faced with communicating results is the understanding of the assessment and communicating the message effectively.
Slide is taken from the Dementia and Driving, Driving with Dementia Working Group Auckland, Counties Manukau, Waitemata and Northland DHBs – Revision 2014

5. Assessment Process Initial Interview Physical Assessment
Cognitive Assessment
On Road Assessment
Recommendations
Follow-up
The assessment pathway typically follows the same route for most if not all driving assessments with the off-road taking anything between 60 and 90mins.
OTs can pick and choose from a range of standardised and non-standardised assessments. Literature supports that no one assessment can meet all the assessor’s needs and the information that they are trying to elicit. This is due to the complexity of the task, conditions seen and the nature of what it is that we are trying to assess – Executive functioning.
This can however lead to several potential problems – “lack of consistency in assessment experience and potential outcome for clients, and the second being the potential lack of validity and reliability in the results obtained from unstandardized assessments” (Carolyn Unsworth et al – Development of a Standardised OT –Driver Off-Road Assessment Battery).
In addition this also raises the question of inter-rater reliability between practices - Especially of note for agencies such as MOH and ACC

6. Vision Dynamic & static visual acuity Visual field
Visual processing speed
Visual search
Need to have confirmation that the client meets the minimum eyesight requirements as set out by NZTA – 6/12 for class 1 and 6/9 for class 2 and higher.
Need to get approval from NZTA to proceed with assessment if there is any indication of visual field loss.
Typical assessments used;
Snellen’s eye chart
confrontation test
binocular eye movement – H pattern with pen
Fast tracking – simulating looking from dashboard to mirror to road and back

7. Physical Assessment Strength Coordination Muscle tone Range of motion
Sensation
Balance
To confirm if physical ability is functional for driving, what difficulties a client may have and what strategies may be employed to address these e.g. modifications.
Most of the study in this area (driving assessment) has related to on-road protocol and cognitive and visual screening to predict on-road performance. There has not been as much research to develop standardized, comprehensive off-road assessment that includes physical as well as cognitive and sensory components (Development of a standardised OT driver off-road assessment battery article).
When undertaking the physical screen the OT is not so much concerned with specific measurements but more so the functional implications of the client’s ability with regards to driving. For example when assessing ROM at OTRS rather than using a goniometer we report range by dividing the plane of movement into thirds and reference inner/ middle/ and outer range.
This does need to be considered and reported functionally. Use grip strength and dynamometer as example.
Assessment battery can include:
Active range of movement
Manual muscle testing
Grip strength
Coordination
Sensation

8. Task analysis of cooking – relate this to driving; planning, sequencing, problem solving, executive functioning.
What is it that we are trying to assess? Executive functioning – this involves the interplay of various components, including decision making;
abstract thinking; planning and carrying out plans; mental flexibility; deciding which behaviours are appropriate under what circumstances; time management;
insight and judgment; concept formation and categorization (World Health Organization, 2010).
Put it another way - come up with a concept, develop a plan and undertake that plan.
Often clients family will be supportive of them driving, but wouldn’t allow them to cook a complex meal. Have already established that driving is an inherently complex task that requires flexibility.

9. Cognitive Assessment Tools
Montreal Cognitive Assessment (MOCA)
Mini Mental State Exam (MMSE)
Canterbury Driver Assessment (CanDat)
OT Driver Off Road Assessment (OT-DORA)
Screen for the Identification of Cognitively Impaired Medically At-Risk Drivers a Modification of the DemTect (SIMARD MD)
DriveSafe DriveAware (DSDA)
Is now available as an app. This assessment is frequently used by medics to determine cognitive ability. Is listed in the Dementia and driving document, as discussed earlier. Mixed results which were improved with clients with confirmed diagnosis of cognitive impairment. Generally predictive validity is not strong enough for sole instrument for identifying unfit drivers.
MMSE – Low sensitivity for identifying an unsafe driver. Open licence has been withdrawn.
MMSE is a commonly used tool to assist with making decisions about driver competency. However, the MMSE was not designed for that purpose and there is now research that indicates that the MMSE is not adequately sensitive to predict on-road performance and is therefore of questionable use when it comes to identifying cognitively impaired drivers whose driving has declined to an unsafe level.
Dec 2013 article in The New Zealand Medical Journal – diagnosis of cognitive impairment and the assessment of driving safety in New Zealand: a survey of Canterbury GPs identified that 71% of respondents used the MMSE as a cognitive screen for older patients in their practice. This was followed by the MOCA at 54%.
Numbers of respondents endorsing the use of different cognitive screening tests
Cognitive test N (%)
Mini Mental State Exam16 (MMSE) 131 (71%)
Montreal Cognitive Assessment17 (MoCA) 100 (54%)
Modified Mental State Exam18 (3MS) 29 (16%)
IQCODE19 (short or long version) 11 (6%)
None 3 (2%)
Addenbrooke’s Cognitive Examination20 (ACE-R) 0
Other – SIMARD-MD 8 (4%) – GP-Cog 5 (3%) – 6CIT 3 (2%) – Road Sign Test 2 (1%) – Hopkins Verbal Learning Test  1 (1%) – Abbreviated MMSE 1(1%)

10. Canterbury Driving Assessment Tool (CanDAT)
Can get good information regarding reaction speed, physical control, spatial awareness, divided attention etc. but seems like a very complex assessment. Time consuming and difficult to set up. User manual is 105 pages – today’s market is plug and play.
Not portable
No information regarding the CanDAT readily available
??ongoing research and development??

11. Cognitive Assessment Tools
OT DORA
Berg Balance Scale
OT Drive Home Maze Test
Bells Test
Road Law and Road Craft Test.
MMSE (needs to be obtained separately).
OT-DORA – Developed at La Trobe University in Australia. Is used in the UK, USA and Australia. Was intended to provide a battery of physical and cognitive assessments in an attempt to gain consistency for driving assessments, particularly with regards to the older driver. Takes up to 90 mins to complete.
MMSE – Due to licencing the MMSE is able to be used freely in Australia
Provides an administration/ interview format which includes a sensory assessment (communication and hearing), visual assessment, physical assessment which includes ROM using goniometer, and manual muscle testing, berg balance scale – review of sitting and standing, pain, Road law and road craft,

14. Screen for the Identification of the Cognitively Impaired Medically At-Risk Driver (SIMARD) developed in Alberta Canada. It is quick and easy to administer.
Test assesses immediate and delayed word recall, number conversion, creative think (? Executive functioning)
Very few NZ GP use this assessment or are aware of it.
“There was no statistically significant association found in this study between the score on the SIMARD MD and the clinical driving decision made by the geriatrician in an outpatient setting in persons with mild dementia or mild cognitive impairment. Based on our findings, we would not recommend that the SIMARD MD be used exclusively to assist physicians in deciding fitness to drive in patients with mild dementia or MCI”.
“Some concern has been raised regarding the predictive validity of the SIMARD as a screening tool to assess fitness to drive...The SIMARD demonstrates promise as a fitness-to-drive screening tool…requires further refinement of cut-off scores to improve predictive validity before widespread use can be recommended”.
SIMARD MD uses a scoring guide that almost sets up the senior or anyone else for failure. A number of community leaders and educators, all actively employed have taken the test, including one MLA.  All but two failed.* - Elder Advocates of Alberta Society

15. DSDA was developed by Dr Lynn Kay and Professor Anita Bundy at the University of Sydney. Recently converted to into a touch screen test for use on a tablet.
“DSDA is an off road computer test, developed to predict with substantial accuracy, fitness to drive for people with cognitive impairments. The test measures the constructs of ‘awareness of the driving environment’ and ‘awareness of ones abilities related to driving’”.
DriveSafe DriveAware combined assess impulse control, self awareness/ insight, cognitive flexibility and working memory determined to have a high positive sensitivity (84%) specificity (94%). Only the Drive ABLE scored higher - Assessing executive function in relation to fitness to drive: a review of tools and their ability to predict safe driving. Julia Asimakopulos et al
Have found that older people struggle with the concept of an iPad. Become very fixated on the iPad and not focussed on the assessment.

16. Example of the intersection slides
Example of the intersection slides. Person needs to indicate in which order the vehicles would move.
Comment on stylised road signs.

17. Scores trichotomise drivers into likely to fail, further testing required and likely to pass. These were previously categorised as being unsafe, further testing and safe. Kay, Bundy and Clemson 2009 stated that the DSDA can more accurately predict the on-road performance than any other off-road assessment and therefore only clients falling into the “further testing” category require an on-road assessment.
The factor that alters/ impacts the score is DriveAware i.e. client insight.
Any reference to time aspect noted in flowchart?!

19. Kintsugi – When the Japanese mend broken objects, they aggrandise the damage by filling the cracks with gold. They believe that when something has sustained damage and has a history it becomes more beautiful.
GP who mentioned that she found advising a patient to stop driving far more difficult than giving them a terminal diagnosis.

20. References
Assessment Tools Predicting Fitness to Drive in Older Adults: A Systematic Review. Anne E. Dickerson; Danielle Brown Meuel; Cyrus David Ridenour;Kristen Cooper American Journal of Occupational Therapy, November/December 2014, Vol. 68, doi: /ajot
Validity of the Mini-mental State Examination and the Montreal Cognitive Assessment in the Prediction of Driving Test Outcome Ann M. Hollis, OTR/L; Haley Duncanson, MA; Lissa R. Kapust, LICSW; Patricia M. Xi, MA; Margaret G. O'Connor, PhD Journal of the American Geriatric Society. 2015;63(5):
MMSE as a predictor of on-road driving performance in community dwelling older drivers. Crizzle AM1, Classen S, Bédard M, Lanford D, Winter S. Accid Anal Prev. 2012 Nov;49: doi: /j.aap Epub Mar 2.
Comparison of the SIMARD MD to Clinical Impression in Assessing Fitness to Drive in Patients with Cognitive Impairment Madelaine Wernham, BNSc,1 Pamela G. Jarrett, MD, FRCPC, FACP,2 Connie Stewart, PhD,3 Elizabeth MacDonald, MD, FRCPC,2 Donna MacNeil, PhD, MD, FRCPC,2 and Cynthia Hobbs, MD, FRPC2
Can Geriatr J Jun; 17(2): 63–69. Published online 2014 Jun 3. doi: :   /cgj
Predicting fitness to drive in people with cognitive impairments by using DriveSafe and DriveAware. Lynette G. Kay, BOccThy, Anita C. Bundy, ScD Lindy M. Clemson PhD. Archives of Physical Medicine and Rehabilitation Vol 90. No.9 Sept 2009.
Dementia and Driving: Maximising the utility of in-office screening and assessment tools. Frank J. Molnar, Mark J. Rapoport, Mononita Roy. CGS Journal of CME, Vol 2, Issue

21. References
Validity and reliability of the on-road assessment with senior drivers. Lynette Kay, Anita Bundy, Lindy Clemson, Neryla Jolly. Accident Analysis and Prevention 40 (2008),
The introduction of a new screening tool for the identification of cognitively impaired medically at-risk drivers: The SIMARD A Modification of the DemTect. Dobbs, B. M., & Schopflocher, D. (2010). Journal of Primary Care and Community Health, 1(2),
DemTect: A new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia. Kalbe, E., Kessler, J., Calabrese, P., Smith, R., Passmore, A. P., Brand, M., & Bullock, R. (2004). International Journal of Geriatric Psychiatry, 19(2),
Predictive validity of the Montreal Cognitive Assessment (MoCA) as a screening tool for on-road driving performance. Jade Chiu Wai Kwok, Isabelle Gelinas, Dana Benoit British Journal of Occupational Therapy

22. References
Diagnosis of cognitive impairment and the assessment of driving safety in New Zealand: a survey of Canterbury GPs. The New Zealand Medical Journal 2013
Comparison of the SIMARD MD to Clinical Impression in Assessing Fitness to Drive in Patients with Cognitive Impairment. Madelaine Wernham, BNSc,1 Pamela G. Jarrett, MD, FRCPC, FACP,2 Connie Stewart, PhD,3 Elizabeth MacDonald, MD, FRCPC,2 Donna MacNeil, PhD, MD, FRCPC,2 and Cynthia Hobbs, MD, FRPC2. Canadian Geriatrics Journal Jun; 17(2): 63–69. Published online 2014 Jun 3. doi: /cgj
Assessing executive function in relation to fitness to drive: A review of tools and their ability to predict safe driving. Julia Asimakopulos,1 Zachary Boychuck,1 Diana Sondergaard,1 Vale´rie Poulin,1 Ingrid Me´nard2 and Nicol Korner-Bitensky1. Australian Occupational Therapy Journal (2012) 59,
Development of a standardised Occupational Therapy Driver Off-Road Assessment Battery to assess older and/or functionally impaired drivers. Carolyn A. Unsworth,1 Anne Baker,2 Carla Taitz,3 Siew-Pang Chan,4 Julie F. Pallant,5 Kay J. Russell6 and Morris Odell7. Australian Occupational Therapy Journal (2012) 59, 23-36