Assessing and Counseling
Older Drivers
Developing and Evaluating an
Older Driver Project Curriculum
Developed in cooperation with the National Highway Traffic Safety
Administration as part of the AMA Older Drivers Project
Number of Licensed Drivers
Aging Demographics
• Aging Demographics
• 2007
• 36 Million Older Adults over age 65 yrs (12% US)
• 28 Million Licensed Drivers over 65 yrs (15% US)
• 2050
• 86 Million Older Adults over age 65 yrs (21% US)
• 66 Million Licensed Drivers over age 65 (25% US)
• Chronic Disease
• General Population
• 25 million people or about 1/10 citizens
• 1.7 million die each year
• Older adults
• 50% affected over age 65 years
• 37% report disease is severe
• 16% require assistance
Physician’s Guide to Assessing
and Counseling Older Drivers
Provides physicians
with the tools
necessary for
assessing older
patients for medical
fitness to drive.
Physician’s Plan for Older Driver Safety
(PPODS)
• Screen to determine if patient is potentially at risk
• Assess driving related functional skills (ADReS)
• Treat underlying causes of functional decline
• Refer for further evaluation and/or adaptive training
• Counsel on safe driving behavior/alternative options
• Follow-Up for signs of depression, isolation and compliance
Screening Older Adults for
Driving Impairment
Red Flags
Case Finding
Patient’s or family member’s concern
Referral from the DMV
Referral from colleague/health professional
Identifying Medical/Co-Morbid Conditions
Acute events with/without LOC
Chronic medical conditions
Medications
Medical Conditions that may
Impair Driving in Older Adults
• Acute Conditions • Chronic Conditions
• Cardiac • Cardiac
• Endocrine/Metabolic • Endocrine/Metabolic
• Psychiatric • Psychiatric
• Neurological • Neurological
• Medications • Medications
• Other • Other
Drugs Associated With Impaired
Driving Ability***
• Alcohol • Antihypertensives
• Anticholinergics • Antipsychotics
• Anticonvulsants • Benzodiazepines
• Antidepressants • Muscle Relaxants
• Antiemetics • Narcotic Analgesics
• Antihistamines • NSAID’s
• Stimulants
Screens that can identify
previously undiagnosed illnesses
• Cognition/Attention
• Mini-Mental Status Exam
• Short Blessed Test
• Clock Drawing Test
• Sleep disorders
• Epworth Sleepiness Scale for Sleep Apnea
• Depression
• Geriatric Depression Scale
• Alcohol
• CAGE Questionnaire
Assess for deterioration in traffic skills
and/or driving related functional abilities
(ADReS battery)
• Impaired Traffic Skills
• Driving History
• Functional Abilities
• Vision
• Cognition
• Motor function
Assessment of Driving
Related Skills (ADReS)
• ADReS is a brief, function-based, in-office
assessment of driving-related abilities
• ADReS individual testing components have been
correlated with crash risk
• ADReS battery results should not be the deciding
factor in directing driving retirement decisions
Vision
Visual fields confrontation
testing: any deficit, refer
to ophthalmology
Visual acuity with the
Snellen E Chart: acuity
in any eye less than
20/40, refer to
ophthalmology
Your view, OD, 20/40+
Patient’s View, 20/40+
Would you rather ride with
a driver who has:
20/200 acuity ?
or
20 degree field ?
Trail-Making Test, Part B
• Tests attention, working
memory, visual processing,
visuospatial skills, and
psychomotor coordination
• Patient connects numbers
and letters in alternating
pattern
• Test is scored by time (sec)
to complete and number of
errors requiring correction
• Greater than 180 sec signals
a need for intervention
Clock Drawing Test (CDT)
• CDT can assess:
• memory
• visual perception &
visual spatial skills
• selective attention
• executive skills
• Draw clock face, numbers,
and set time at 11:10
• Errors on any of the
components signals a
need for intervention
Pictures courtesy of Barbara Freund,
PhD Eastern Virginia Medical School
Clock Drawing Task/Driving
• 119 community-dwelling older adult drivers
• CDT showed a high level of accuracy
• Analysis revealed a CDT score of 4 or less, had a likelihood
ratio of +27.58 for predicting unsafe driving (sensitivity 64%,
specificity 97%)
• Outcome measure was failure on a driving simulator
3 points for using two hands Freund et al, Drawing Clocks
correctly, 2 points for using and Driving Cars. J Gen Intern Med
correct numbers, 2 points for 2005; 20:240-44
appropriate spacing
Motor
Function
Rapid pace walk
• Measures lower limb strength, endurance,
range of motion, balance, and gross
proprioception
• Patient walks 20 feet
• Scoring based on time to complete (sec)
• Completion time of greater than 9 sec impaired
Manual test of motor
strength
• Shoulder adduction,
abduction and flexion
• Wrist flexion and
extension
• Hand-grip strength
• Hip flexion and
extension
• Ankle dorsiflexion and
plantar flexion
• Score grade 0 to 5
Manual test of range of
motion
• Neck rotation
• Finger curl
• Shoulder and elbow
flexion
• Ankle plantar flexion
• Ankle dorsifexion
• Score: within normal
limits; not within
normal limits
Treat underlying causes
of functional decline
• Examples of interventions that can improve key driving
functional abilities
• Physical therapy for muscle weakness and/or to improve
range of motion
• Discontinue sedating medications
• Improving visual function with ophthalmology intervention
• Examples of medical interventions that have been shown to
reduce crash risk
• Cataract surgery
• Stopping sedating medications
• Sleep apnea treatment
What is the Next Step?
• Green Light
• No red flags
• Monitor at intervals
• Full speed ahead!
• Yellow Light
• Red flags/co-morbid illnesses
• Decline in traffic skills
• Deficits on ADReS battery
• Consider referral and caution!
• Red light
• Driving Retirement/Counseling
• Stop!
Older Drivers Project (ODP):
2005 Evaluation
Training of Trainers Sample (n=115)
• Multidisciplinary Teams Trained 56% Female
to Provide Educational 69% Physician/Physician in
Programs to Health Training
Professionals
44% Geriatrics,
• 5 Modules / Speaker’s Kit
19% Family/GP/IM
• 6 Teams Trained in 2003 (2 37% Other Specialties
physicians, OT, DMV)
58% in Practice 10 or more years
• 146+ Programs in 2004-2005,
7,700+ Trained
21% (24) Trainers
79% (91) Trainees
Physician’s Guide to
Assessing & Counseling Older
Drivers
(Schwartzberg, J, Phillips, L, Meuser,T, Carr, D, 2005)
Background on Practices
• Before training:
• % patients age 65+ Mean 57%
• Have you ever recommended that an
older patient stop driving? 87% yes
• Is driving fitness a clinical issue in your
practice? 79% yes
In the year since training:
• How often do you address older driver
safety? 59% more often, 41% about the
same
• How often does this come up? Daily
17%; weekly 37%; monthly 22%; less than
monthly 17%
• Do you use the information in the Guide in
your clinical practice? 58% yes, 33 %
somewhat
• Have you recommended the Guide? 70%
yes
2008
Program Evaluation
• 8 Teaching Teams (Oct. 2006, and July, 2007)
• 22 presentations
• 12 different states
• 1 hour rounds (typically offered in hospital
settings)
• 2 hour workshops.
• Marketing included:
mass mailings,
word of mouth,
local media coverage,
cooperative partnerships with hospitals and other
organizations.
Method
Sample:
694 Trainees (returned at least one questionnaire)
332 (1 hour rounds)
362 (2 hour workshop)
Trainees were from 35 different States and Canada
Pre-test (n=622, 90%)
Post-Test (n=399, 57%)
3-month Follow-up (n=235, 28%)
Results: Characteristics of Sample
Total Sample
Total Sample
Physician 219 (32%)
N = 694
OT/PT/Rehab 174 (25%)
67% Female
Other/Unknown 126 (18%)
Mean Age = 46
(SD = 13)
Nurse/PA 114 (16%)
Pre/Post Comparison Possible? (Effective Response
Rate)
61 (9%)
Social Work/Psych
• Family Practice (26%),
• Geriatrics (20%),
• Internal Medicine (18%),
• Trainees (students/residents) (12%)
• Ophthalmology (6%)
85% stated that at least 25% of their practice consisted of older
adults
Results
Quality of Training
• 93% “Just Right” content presentation and
professional level.
• 97% learned a specific tool or strategy
• 66% desired additional training in the future.
Grand Rounds vs Workshop
• 2-hour workshop were somewhat more likely to
endorse an interest in obtaining additional
training (Mann-Whitney U, p < .01).
Results: Knowledge Questions
Percent Correct
Responses
1. Which of the following is not recommended as an initial
technique to help your patients retire from driving?
a. With the patient’s permission, involve family members
and caregivers.
Pre-Test – 97% Correct
b. Explain to the patient why you have recommended that
Post-Test – 97% Correct
he/she retire from driving.
c. Provide your patient with information on alternatives to
driving.
d. Tell the patient’s relatives to hide the car keys. (*)
2. Research has demonstrated that drivers with 20/70
visual acuity have a significantly greater crash risk than
Pre-Test – 73% Correct
drivers with 20/40 visual acuity.
Post-Test – 72% Correct
a. True (*)
b. False
3. Medications that have the potential to impair driving
ability include:
a. Anticonvulsants
Pre-Test – 88% Correct
b. Antidepressants
Post-Test – 85% Correct
c. Antihypertensives
d. A & B only
e. All of the above (*)
Results: Experience and
Confidence
More Less
Item N Confident/ Unchanged Confident/
Experienced Experienced
Comfort with personal knowledge of topic 231 45% 46% 9%
Familiarity with driver rehab options 231 75% 27% 8%
Comfort in counseling patients at risk 228 67% 34% 9%
Familiar with state laws and procedures 230 63% 30% 7%
Regularly discuss driving with patients 220 47% 41% 12%
Mean Change in Confidence
Composite by Profession &
Format
Trends in Behavior Change
Endorsed Endorsed “Yes” at
Item “Y es” at Pre - 3-month Follow-
Test up
Discussed driving as a clinical c oncern with any
177 (77%) 151 (68%)
patient
Incorporated driving questions into regula r
122 (54%) 136 (62%)
assessment
Used Clock Drawing Test 117 (50%) 111 (50%)
Specificall y docume nted driving abilit ies in patient
106 (47%) 114 (52%)
chart
Referred patient for other driving evaluation (e.g.,
92 (41%) 77 (35%)
OT)
Worked with patient/family on driving retirement
81 (36%) 89 (41%)
plan
Reported patient to State DMV for re-evalu ation 55 (24%) 44 (20%)
Used Trail Makin g Test 49 (22%) 66 (30%)
Used AMA ADReS Test Battery 16 (7%) 40 (18%)
Developing a Web-Based
Curriculum
• TOT process
• effective, but
• very labor-intensive and time-consuming
• Increased demand for self-directed
training for young, new physicians
• Online courses or other electronically
based education
• gaining interest of residency programs
• Performance improvement CME.
Faculty Survey
Sample:
• 41 Faculty Members Surveyed
• 20 Responded
Questions in 4 areas:
1. Prioritizing the curriculum
2. Content changes
3. Performance improvement in practice
setting
4. Future delivery methods
Prioritizing the Curriculum
Areas more interesting to the audience
than other
• Assessment (n=15)*
• Legal Issues (n=15)*
• Intervention (n=8)
• Referral (n=6)
• Vision (n=2)*
* Listed as Most Interested Areas
Any changes in practices?
• Increased use of screening tools
• Increased referrals
• Increased comfort level with topic
• Increased reporting
• Increased awareness responsibility
Performance Improvement in
Practice Setting
Are there any methods in place in the practice to complete the
following:
a) Recognizing patients appropriate for Assessment of Driving
Related Skills (ADReS) Screening
70% Yes
25% No
5% n/a
The methods in place to recognize patients appropriate
for ADReS screening include:
1) type of screening,
2) timing of screening (eg office flow)
3) place of screening, and
4) increased referrals for driver readiness screens.
Performance Improvement in
Practice Setting
Are there any methods in place in the practice to complete the
following:
b) Other health professionals besides physicians for
screening?
60% Yes
35% No
5% n/a
Professionals included: APN, RN, PA, PT, and
OT.
“staff perform initial screen except MD performs
range of motion and motor strength”
Performance Improvement in
Practice Setting
Are there any methods in place in the practice to complete the
following:
c) Referral process for Occupational Therapist or driver
rehabilitation?
85% Yes
10% No
5% n/a
Over half identified a method of prescribing OT as:
1) a mode of communication (letter form,
electronic consultation, referral packet)
2) a referral process coming from the OT and
physician
Performance Improvement in
Practice Setting
Are there any methods in place in the practice to complete the
following:
d) What worked and what didn’t work?
Majority of respondents identified what didn’t work
1) Patients refuse
-due to inconvenience;” “they don't follow up;”
and when the “patient makes appt. [it] doesn't
always work out.”
2) No reimbursement,
3) Evaluation is not complete or definitive,
3) Road testers are too lenient.
Minority identified what works:
1) Family intervention,
2) MD’s office,
3) scheduling OT Appt.
Performance Improvement in
Practice Setting
Are there any methods in place in the practice to complete the
following:
e) Process for reporting to State DMV?
80% Yes
15% No
5% n/a
The process for reporting to State DMV requires an emphasis on:
1) the need for an assessment,
2) obtaining forms (on hand or download),
3) fax forms, and
4) include family or hospital.
Other things that could be implemented to benefit the patient
is to encourage self reporting and including Adult Protective
Services.
Any methods in practice for
documentation and billing?
• Many document screening with ADReS or
components
• Some are able to document and code as office
visits
• No difficulty with physician coding and/or
reimbursement
• Much frustration with denial of reimbursement by
DRS
Summary
• Subset of physicians and other healthcare
professionals are hungry for this
information
• Curriculum successful – 97% learned new
techniques to use, confidence increased
• Challenges
• How can we make a web-based program
exciting and interesting for each audience?
• How do you help them make changes in their
practices?
Questions?
• Thank you for your kind attention
• Joanne G. Schwartzberg, MD
• www.ama-assn.org/go/olderdrivers
• Joanne.Schwartzberg@ama-assn.org