1. St. Joseph’s Health Care London DriveABLE in London Evaluating the Medically At-Risk Driver Dr. Allen Dobbs Mary Anne McCallum

2. Learning Objectives To understand the impact of cognitive decline on driving competence To understand the legal obligations of the physician To understand the processes around formal driving assessments

3. 80 YEARS OF AGE At age 80 and every two years thereafter, MTO requires Ontario drivers to complete a vision test, written test and attend a group seminar A road test may be required This is not a substitute for a medical driving evaluation

4. Highway Traffic Act Section 203, (1) Mandatory Reporting for: “Every person 16 yrs of age or over, attending upon the medical practitioner for medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to operate a motor vehicle.”

5. When MTO Is Informed: The licence may not be suspended A file is opened with the Medical Review Section The case is reviewed by an analyst MTO will determine the next course of action Once report is made, it can take 4-6 weeks for response

6. MTO Process May request additional medical information May request client to go through the standard licensing procedure May request client to undergo a driving ax from an approved rehabilitation centre May immediately suspend licence May refer to the Medical Advisory Committee for expert opinion May monitor by requesting follow-up reports

7. MEDICAL ASSESSMENTS MTO provides a list of Approved Driver Rehabilitation Centres In Ontario, an Occupational Therapist is required to conduct the assessments in these centres The purpose of the assessment is to determine the impact of a medical condition on driving Other roles include recommending training and adaptive equipment, if appropriate, supporting driving independence and monitoring performance over time

8. WHAT IS DRIVING? A primary means of meeting one’s transportation needs A symbol of independence and autonomy Synonymous with self-respect, social membership and independence An indicator of competence, providing the older individual with a non-age related, non-stigmatized identity

9. Driving a complex activity requiring a wide range of mental abilities number of older drivers is increasing rapidly medical conditions or medications can severely affect driving competence evaluation of driving competence can be challenging

10. Decisions About Driving Why are decisions about driving difficult? –importance of the decision –driving is central to maintaining independence and mobility –protecting safety of others on the road –uncertainty about competence when there is a cognitive impairment –how much mental decline makes a person unsafe to drive? –is insight regarding driving ability impaired?

11. Loss of Driving Privileges A loss of independence, mobility and freedom Feelings of diminished self-worth, reduction in self-esteem and loss of identity One of the most difficult aspects of dementia for the individual, as reported by caregivers

12. STATISTICS 60% OF INDIVIDUALS 65 OR OLDER (2 MILLION INDIVIDUALS) HELD A DRIVER’S LICENSE Reference: Statistics Canada, 1999 83% of these individuals are drivers

13. STATISTICS 8% of Canadians aged 65 & over have a dementing illness An additional 17% have some other diagnosed form of cognitive impairment Reference: Graham et al. 1997

14. Senior Drivers and Crashes Fatalities and Injury crashes Up 47% for age 65+ drivers By comparison: Down 8.0% drivers under 65 years of age (Canadian Motor Vehicle Traffic Collision Statistics, Transport Canada, 1979 - 1995)

15. Ontario Relative Risk (Fault) by Age MaleFemale AGE

16. Driving Projections Number of older drivers will more than double by 2030. –Driving more Travel of seniors projected to increase by 4 to 5 times by 2030 –Driving longer into old age Where impairing medical conditions are most likely

17. Is age the problem? Age-associated changes do not account for older driver crashes Some of the most prevalent and impairing medical conditions are age associated The “Older Driver Problem” is really a problem of “Medical Conditions and Driving”

18. Letter to Ann Landers “I’ve had two bypass surgeries, a hip replacement, new knees, fought breast cancer and diabetes. I’m half-blind and can’t hear anything quieter than a jet engine. I take 10 different medications that make me dizzy, winded and subject to blackouts. I have bouts of dementia.

19. Continued….. I have poor circulation and can hardly feel my hands and feet anymore. I can’t remember whether I am 85 or 87 and there’s nobody I can ask. All my friends are dead. But thank God, I still have my Florida driver’s licence. N.S., Bloomfield, Michigan

20. The Road Test: Defining the Essentials

21. Costs of Crashes Seniors involved in a crash are 4 times more likely to be seriously injured and hospitalized than younger drivers Seniors recover more slowly and less completely Crashes often involve multiple vehicles`

22. Increased Crash Risk (at-fault crashes) Visual Acuity……..…..2.8 Diabetes ………..…… 2.2 Cardiovascular……… 1.8 Pulmonary…………… 2.1 Psychiatric………… …2.5 Epilepsy……...…….….3.0 Musculoskeletal……… 4.5 Neurologic………..….. 5.1 Diller et al. (1998) for unrestricted drivers Cognitive Impairment 7.6

23. Accident risk as function of Blood Alcohol Content Odds Ratio: Relative Crash Risk BAC in Percent ~2.5 1964 1994 DriveABLE Driven by Research

24. Accident risk as function of Blood Alcohol Content Odds Ratio: Relative Crash Risk BAC in Percent Increased Crash Risk for Cognitive Impairment associated with a medical condition is 7.6 7.6 DriveABLE Driven by Research

25. Impairment of Executive Functions 1. Organization: attention, decision- making, planning, sequencing, and problem-solving 2. Inhibition: initiation of action, self- control, self-regulation, repetition and temper control 3. Unawareness: denial of deficits, unintentional non-compliance

26. Driving and Dementia 30 to 50% of people with dementia have at least one crash before they stop driving 80% of people with dementia who have a crash continue to drive 40% of those have at least one more crash

27. Questions for the Patient 1. Have you noticed any change in your driving skills? 2. Do others honk at you or show signs of irritation? 3. Have you lost any confidence in your overall driving ability? 4. Have you ever become lost while driving? 5. Have you ever forgotten where you were going?

28. Questions for the Patient 6. Do you think that AT PRESENT you are an unsafe driver? 7. Have you had any car accidents in the past year? 8. Any minor fender-benders with other cars in parking lots? 9. Have you received any traffic citations? 10. Have others criticized your driving or refused to drive with you?

29. Questions for the Family 1. Do you feel uncomfortable in any way driving with the patient? 2. Have you noted any abnormal or unsafe driving behaviour? 3. Has the patient had any recent crashes? 4. Has the patient had near misses that could be attributed to mental or physical decline? 5. Has the patient received any tickets or traffic violations?

30. Questions for the Family 6. Are other drivers forced to drive defensively to accommodate the patient’s errors in judgement? 7. Have there been any occasions where the patient has gotten lost or experienced navigational confusion? 8. Does the person need many cues or directions from passengers? 9. Does the patient need a co-pilot to alert them of potentially hazardous events or conditions? 10. Have others commented on the patient’s unsafe driving?

31. Warning Signs Lack of awareness of driving errors Tendency to get lost or confused while driving Seeming lack of awareness of other vehicles Tendency to miss traffic signs Inability to keep up with the speed of traffic Close calls, especially if unnoticed Frequent honking from other drivers

32. Typical Driving Errors Errors at intersections and left turns Driving too slowly Difficulty merging with traffic Accidents close to home

33. Decisions About Driving Self Perceptions of Driving Competence Among Drivers with Dementia comparison of self-ratings of driving ability to actual on-road performance of 117 dementia patients. drivers with dementia consistently overrated their competence.

34. What is needed? Driver evaluations: –based on competence –relevant to actual driving performance –fair and objective –accurate and defensible

35. Research Strategy Provided a standard road course Put safe and unsafe drivers in a car unsafe drivers: cognitively impaired drivers safe drivers:healthy, normal older drivers healthy, normal younger drivers all participants currently driving Compared driving errors of both groups to identify differences

36. Research Strategy: All Three Groups Received: Clinical Assessment - Neuropsychological Testing (6 hours) - Rehabilitation Testing (2 hours) Research Tests of Driving-Relevant Mental Abilities Research Road Test

37. Research Strategy Comparison of errors made by safe and unsafe drivers is critical to identify: Errors signaling competence decline that must be scored Errors irrelevant to measuring competence decline (errors made by both groups)

38. Non-Discriminating Errors Made equally by ALL groups Examples include: –One-hand steering –Early or late signalling –Failure to come to a complete stop –No shoulder checks

39. Discriminating Errors Potentially dangerous errors that reliably discriminate cognitively impaired older drivers from healthy older and healthy younger drivers Examples include: –Positional and observational errors on LEFT HAND TURNS or WHEN CHANGING LANES

40. Criterion Errors Displayed ONLY by drivers from the cognitively impaired group CATASTROPHIC – traffic has to adjust or the examiner has to take control to avoid a crash or dangerous situation Examples include: –Driving the wrong way on the freeway –Stopping at a green light

41. Differentiating Driving Errors CategoryCog. Impair.Old Young 1 2 3 4 5 6 7 8 9 10 11 12 13 Non- Discriminating Must not score. These errors do NOT signal decline.

42. Empirically Based Pass/Fail Criterion CategoryCog. Impair.Old Young 1 2 3 4 5 6 Criterion Discriminating none Frequency and severity of driving errors shown to signal competence decline reveal competence which is outside the range of normal

43. Validation of DriveABLE Evaluation validated on a new sample (n=376) referral sources extended extended to other medical conditions extended to other age groups new road course Competence Screen highly accurate

44. The Road Test: Defining the Essentials 1. Scoring System (What driving errors matter?) 2. Road Course (Revealing the competence problems) 3. Performance Criterion (Defining unsafe to drive) 4. Standardization (Outcome comparability across assessment sites) 5. Quality Assurance (Maintaining the quality standard) 6. Urban and Rural Drivers ( Fairness/Adequacy for both) 7. Effective Reports (Meaningful, clear, and useful) 8. Maximize Safety (For client, public, and evaluator)

45. Maximizing Safety Road testing all clients on public roadways can place other road users in danger. Some medically impaired drivers are very dangerous. Need a way to identify at least the most dangerous drivers without a road test.

46. Safety concerns need to be Accommodated Road Test Non-Driving Assessment Tool Most dangerous drivers accurately identified & not Road Tested Remaining drivers Maximizing Safety

47. Traditional Approach Road Test Scores Attention Spatial Judgement Perception Decision Time Apraxia Motor Skills Recognition Strength Memory Inhibition Orientation Language STM Vision Sequencing Planning RT Balance

48. Selecting Tests, Traditional Approach Domain B Domain C Domain D Domain E Domain F Domain G Battery Domain A Test A Best predictor from domain Select tests to represent domains Will not maximize the predictability of battery. Test B Best Predictor from domain Approach does not indicate the predictability of the BATTERY

49. Traditional Approach Most importantly: Driving requires concurrent use of different abilities from different domains and shifting among abilities from different domains. Traditional approach misses this essential component.

50. New Approach Goal is to predict driving performance. Complex tasks to test many abilities at once –Shortens testing time –Enables testing of abilities, and concurrent use of abilities, and ability to shift –Does not enable identification of specific deficits (Goal is to predict functional outcome for driving)

51. New Approach Road Test Scores Attention Judgement Perception Memory Motor Skills Vision Memory Decision Time Comprehension Spatial Abilities Response Speed Decision Making Attentional Field

52. Need for a New Approach Need for: Pre-driving screen that accurately predicts road test performance Complex tasks to test many abilities at once –shortens testing time –enables testing of concurrent use of abilities which is more relevant to driving performance Procedures amenable to automated scoring

53. DriveABLE Competence Screen Complexity Client “Friendly” –Touch Screen –Push Button Objective Scoring Predictive of Road Test Performance

54. The DriveABLE Evaluation Competence Screen Road Test PassFail Indeterminant PassFail Two-Thirds Identified by Screen, 95% accurate Two Phase Evaluation

55. DriveABLE Competence Screen Client guided through computer presented assessment touch screen and push button responses provide measurement precision in a non- threatening environment clients given opportunity to practice

56. DriveABLE Appointment Office Assessment with Occupational Therapist: Interview: Medical History/Health Status Review of Eye Exam Results Physical Assessment Cognitive/Perceptual Assessment (using DriveABLE Competence Screen) Road evaluation conducted by certified driving instructor in dual brake automobile Physical Driving performance observed by Occupational Therapist

57. Urban and Rural Driver Comparison Matched 100 urban with 100 rural drivers on age, sex, diagnosis, level of cognitive impairment (MMSE). Examined p/f rate of the urban and rural drivers. Found performance of two groups not different (2% difference) The assessment is equally fair for urban and rural drivers.

58. DriveABLE in London Ontario Ministry of Transportation vision standards for Class G driver’s license: Visual acuity of no less than 20/40 in the better eye with or without the use of corrective lenses and up to 0 or nil in the other eye. Less than 20/40=20/40-1, 20/40-2, 20/50 or 20/70. Better than 20/40=20/30, 20/25, 20/20, 20/15 or 20/10 A total horizontal visual field of 120 degrees as measured by confrontation

59. Cost and Value Cost: $367.50 for comprehensive assessment Value: objective assessment empirically justifiable decisions safer communities reduced costs to health system

60. Annual Cost of Operating a Car Depreciation=$2,000 Maintenance=$500 Insurance=$1,500 Gasoline=$780 (at $15 per week) Total is $4,780—not counting licence fees, parking, car washes This means that the driver could spend $92 per week on taxis

61. CASE—MR. PM Diagnosis: Alzheimer’s type dementia April’02—seen in clinic Reassessed one year later—MMSE 23/30: started on Exelon October’03—ongoing cognitive decline Referred for driving ax because of hesitancy and slowness in driving

62. CASE—MR PM Competence Screen : 92% predicted probability of failing the DriveABLE Road Test Road test errors: turning too wide, being unsure of right-of-way and failing to yield right-of-way Overall score “ borderline pass” Recommendations: continue driving with caution and reassessment if further cognitive decline occurs

63. CASE—MR PM Client returned to ABC in December, 2004 Exelon was increased to 6 mg bid Most abilities had been maintained Client driving at appropriate speeds, but exhibiting hesitancy at intersections MMSE score decreased to 20/30 Client was referred for reassessment of driving abilities

64. CASE—MR PM Client returned to DriveABLE in December, 2004 Competence Screen results: 67% predicted probability of failing the DriveABLE Road Test Road test errors: position-on-turn, unsure of right- of-way at intersections, turning too fast ( creating a hazardous situation) and not checking blind spot before changing lanes Errors out of normative range-fail score

65. CASE—MR G Client diagnosed with AD in May, 2002 Client referred to DriveABLE from ABC with concerns that he turned left instead of right, and entered the oncoming lane Hx of progressive memory impairment, word- finding difficulties, headaches and two episodes of “black outs” MMSE score was 22/30 Was prescribed Galantamine

66. CASE—MR G Assessed by DriveABLE in April, 2003 Client displayed insight regarding his declining cognition and the potential impact on driving safety Performance on the Competence Screen resulted in a 33% predicted probability of failing the road test NO significant errors on the road test; passed Recommendations: close monitoring of cognition by doctors and reassessment if decline noted

67. CASE—MR P Four-year history of AD, taking Aricept Valid licence, drove to Florida each winter, no accidents or charges On Competence Screen, significant difficulty with processing and retaining instructions 88% predicted probability of failing road test Road test errors: positional, unsure of right-of- way at intersections, slowing/stopping for no reason, reacting late Recommendation was driving cessation

68. Conclusions Evaluating the Medically-At-Risk Driver focused medical evaluations and record keeping early planning with patients and families use of, or advocating for validated driver assessments notification of licensing bodies when incompetence occurs

69. Resources Website for RGP in Ottawa Safe Drive Checklist CMA guide “Determining Medical Fitness to Drive”

70. DriveABLE in London For referrals: Phone (519) 685-4028 Fax (519) 685-4574 E-mail drive.able@sjhc.london.on.ca