Health, Functional Status, Older Driver Safety

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					Health, Functional Status,
  & Older Driver Safety
A Curriculum for State Highway Patrol
    Driver Examiners & Troopers

                   Developed by:
       Older Driver Education & Research Team
       Washington University School of Medicine

              Division of Highway Safety
        Missouri Department of Transportation

             Driver Examination Division
            Missouri State Highway Patrol

                  Version 2 (7/13/07)
     Health, Functional Status, & Older Driver Safety
                    A Curriculum for State Highway Patrol
                        Driver Examiners & Troopers

Table of Contents

1           Introduction & Credits

2           Dementia, Aging & Driving Resource List

3           House Bill 1536 – Missouri’s Voluntary Reporting Law

7           Driver Condition Report (Form 4319)

9           Cited Driver Worksheet (two included, photocopy more as needed)

13          Training Slides

51          Questions & Solutions for Families (Hartford Guide)

73          Evaluation Forms (Tear out and complete if instructed to do so)




* The page numbers above refer to those printed at the bottom center of each page
(“Page __”). Certain items in this booklet were copied from other sources and have
their own numbering as well.
2
        Washington                                              Department of Neurology and
                                                                Neurological Surgery

WASHINGTON⋅UNIVERSITY⋅IN⋅ST.⋅LOUIS
                                                                Neurology
School of Medicine                                              Alzheimer’s Disease Research Center (ADRC)



July 13, 2007


Thank you for participating in today’s workshop focusing on older driver health, functional
status, and on-road safety!
As a group, older adults are very safe drivers. Most restrict their driving voluntarily, avoiding
nighttime, rush hour and bad weather travel so as to maximize safety. Some older adults,
however, will experience changes in health and functional status the may impair their ability
to drive safely. Law enforcement and driver licensing officials are often in a good position
to identify problematic age-related changes and to contribute meaningfully to medical
review process.
The purpose of this workshop is twofold: (1) to raise awareness about how age-related
changes in health and functional ability may impair driving abilty and safety; and (2) to
provide a structure through which observations of age-related concerns can be recorded and
communicated effectively in support of the driver licensing and medical review process.
The workshop curriculum, case example video clips, Cited Driver Worksheet tool, and this
training manual, are products of the Older Driver Education & Research Team1 based at
Washington University School of Medicine in St. Louis. Funding support for the curriculum was
provided by the Division of Highway Safety, Missouri Department of Transportation (MODOT),
and the Alzheimer’s Disease Research Center, Department of Neurology, Washington
University School of Medicine (NIA P50-AG05681, John C. Morris, MD, Principal Investigator).
Many individuals volunteered their time and expertise to make this curriculum possible. The
Team is thankful to officials from MODOT’s Division of Highway Safety, the Missouri State
Highway Patrol (MSHP), and the Driver License Bureau, Missouri Department of Revenue
(MDOR), for their committed support of this educational project.2 We also wish to thank our
volunteer actors3 without whom the case example video clips would not have been possible.
As a participant in today’s workshop, you may be asked to complete pre/post evaluation
forms. The data from these forms will be used to validate the educational effectiveness of
the workshop curriculum and to guide future revisions. Please address any questions or
comments about the curriculum to Project Coordinator, Dr. Tom Meuser, at
meusert@abraxas.wustl.edu. Thank you.


1
  Thomas Meuser, PhD, & David Carr, MD, Washington University; Marla Berg-Weger, PhD, Saint Louis
University; Patricia Niewoehner, OTR/L, CDRS; St. Louis VA Medical Center; Peggy Barco, MS, OTR/L.
2
  Leanna Depue, PhD, & Jackie Rogers, MODOT; Captain Bill Nelson & Rhonda Czarnecki of the Driver
Examination Division, MSHP.
3
  Al & Judy Niewoehner; Sgt. John Enderle & Cynthia Anders, MSG, MSHP.
Alzheimer’s Disease Research Center
Washington University School of Medicine
4488 Forest Park Avenue, Suite 130
St. Louis, MO 63108-2293
(314) 286-2881 (-2882) • FAX: (314) 286-2763

                                               Page 1
Driving, Aging & Dementia: On-Line Resources

Missouri

Division of Motor Vehicles & Driver Licensing, Missouri Department of Revenue
http://www.dor.mo.gov/mvdl/drivers/

   Driver Condition Report (Form 4319) & Physician’s Statement (Form 1528)
   http://www.dor.mo.gov/mvdl/drivers/forms/

Concerned Americans for Responsible Driving, Inc.
http://www.drivingsafe.org/

Alzheimer’s Association, St. Louis Chapter (Driving & Dementia Resources)
http://www.alzstl.org/

Illinois

Driver Services Department, Office of the Secretary of State of Illinois
http://www.cyberdriveillinois.com/

       Medical Report Form
       http://www.cyberdriveillinois.com/publications/pdf_publications/dsd_dc1633.pdf

National

Physician’s Guide to Assessing & Counseling Older Drivers (American Medical Assoc.)
http://www.ama-assn.org/ama/pub/category/10791.html

A Practical Guide to Alzheimer’s, Dementia & Driving (The Hartford Insurance Corp.)
http://www.thehartford.com/alzheimers/

Family Conversations with Older Drivers (The Hartford Insurance Corp.)
http://www.thehartford.com/talkwitholderdrivers/

The Association for Driver Rehabilitation Specialists
http://www.aded.net

Senior Driver Website (AAA Foundation for Traffic Safety)
http://www.seniordrivers.org/home/toppage.cfm

National Highway Traffic Safety Administration
http://www.nhtsa.dot.gov/

AARP Driver Safety Program
http://www.aarp.org/drive/

Research on Driving & Dementia (Washington University ADRC)
http://alzheimer.wustl.edu/adrc2/Education/SpecialTopics/dementiaanddriving.htm

National Center for Injury Prevention & Control – Older Drivers Page
http://www.cdc.gov/ncipc/factsheets/older.htm

                                             Page 2
                 SECOND REGULAR SESSION
           (TRULY AGREED TO AND FINALLY PASSES)
             SENATE COMMITTEE SUBSITITUTE FOR
              HOUSE COMMITTEE SUBSTITUTE FOR

           HOUSE BILL NO. 1536
                    89TH GENERAL ASSEMBLY 1998
                              AN ACT
   To repeal sections 302.291 and 302.292, RSMo 1994, and to enact in lieu thereof two new
 sections relating to the reporting and examination of impaired drivers, with penalty provisions
                                       and an effective date.

Be it enacted by the General Assembly of the state of Missouri, as follows:

Section A. Sections 302.291 and 302.292, RSMo 1994, are repealed and two new sections
enacted in lieu thereof to be known as sections 302.291 and 302.292, to read as follows:

302.291.

       1. The director, having good cause to believe that an operator is incompetent or
       unqualified to retain his license, after giving ten days' notice to such person in
       writing by [registered] certified mail directed to his present known address. may
       require him to submit to an examination as prescribed by the director. Upon
       conclusion of the examination, the director may allow the licensee to retain his
       license. may suspend, deny or revoke the license of the licensee, or may issue to
       the examinee a license subject to restrictions as provided in section 302.30 I. If an
       examination indicates a condition that potentially impairs safe driving, the
       director, in addition to action with respect to the license, may require the licensee
       to submit to further periodic examinations. The refusal or neglect of the [operator]
       licensee to submit to [such] an examination within thirty days after the date of
       such notice shall be [ground] grounds for suspension, denial or revocation of his
       license by the director, an associate circuit or circuit court. Notice of any
       suspension, denial, revocation or other restriction shall be provided by certified
       mail. As used in this section, the term "denial" means the act of not licensing a
       person who is currently suspended, revoked or otherwise not licensed to operate a
       motor vehicle. Denial may also include the act of withdrawing a previously issued
       license.

       2. The examination provided for in subsection I of this section may include, but is
       not limited to, a written test and tests of driving skills, vision, highway sign




                                              Page 3
recognition and, if appropriate, a physical and/or mental examination as provided
in section 302.173.

3. The director shall have good cause to believe that an operator is incompetent or
unqualified to retain his license on the basis of, but not limited to, a report by:

       (1) Any certified peace officer;

       (2) Any physician, physical therapist or occupational therapist
       licensed under chapter 334, RSMo; any chiropractic physician
       licensed under chapter 331, RSMo; any registered nurse licensed
       under chapter 335, RSMo; any psychologist or soc~1 worker
       licensed under chapter 337, RSMo; or

       (3) Any member of the operator's family within three degrees of
       consanguinity, or the operator's spouse, who has reached the age of
       eighteen, except that no person may report the same family
       member pursuant to this section more than one time during a
       twelve month period. The report must state that the person
       reasonably and in good faith believes the driver cannot safely
       operate a motor vehicle and must be based upon personal
       observation or physical evidence which shall be described in the
       report, or the report shall be based upon an investigation by a law
       enforcement officer. The report shall be a written declaration in the
       form prescribed by the department of revenue and shall contain the
       name, address, telephone number, and signature of the person
       making the report.

4. Any physician, physical therapist or occupational therapist licensed under
chapter 334, RSMo, any chiropractor licensed under chapter 331, RSMo, any
registered nurse licensed under chapter 335, RSMo, or any psychologist or social
worker licensed under chapter 337, RSMo, may report to the department any
patient diagnosed or assessed as having a disorder or condition that may prevent
such person from safely operating a motor vehicle. Such report shall state the
diagnosis or assessment and whether the condition is permanent or temporary.
The existence of a physician-patient relationship shall not prevent the making of a
report by such medical professionals.

5. Any person who makes a report in good faith pursuant to this section shall be
immune from any civil liability that otherwise might result from making the re-
port. Notwithstanding the provisions of chapter 610, RSMo, to the contrary, all
reports made and all medical records reviewed and maintained by the department
of revenue under this section shall be kept confidential except upon order of a
court of competent jurisdiction or in a review of the director's action pursuant to
section 302.311.




                                       Page 4
      6. The department of revenue shall keep records and statistics of reports made and
      actions taken against driver's licenses under this section.

      7. The department of revenue shall, in consultation with the medical advisory
      board established under section 302.292, develop a standardized form and provide
      guidelines for the reporting of cases and for the examination of drivers under this
      section. The guidelines shall be published and adopted as required for rules and
      regulations under chapter 536, RSMo. The department of revenue shall also adopt
      rules and regulations as necessary to carry out the other provisions of this section.
      The director of revenue shall provide health care professionals and law
      enforcement officers with information about the procedures authorized in this
      section. The guidelines and regulations implementing this section shall be in
      compliance with the federal Americans with Disabilities Act of 1990.

      8. Any person who knowingly violates a confidentiality provision of this section
      or who knowingly permits or encourages the unauthorized use of a report or
      reporting person's name in violation of this section shall be guilty ofa class A
      misdemeanor and shall be liable for damages which proximately result.

      9. Any person who intentionally files a false report under this section shall be
      guilty of a class A misdemeanor and shall be liable for damages which
      proximately result.

      10. All appeals of license revocations, suspensions, denials and restrictions shall
      be made as required under section 302.311 within thirty days after the receipt of
      the notice of revocation, suspension, denial or restriction.

      11. Any individual whose condition is temporary in nature as reported pursuant to
      the provisions of subsection 4 of this section shall have the right to petition the
      director of the department of revenue for total or partial reinstatement of his or her
      license. Such request shall be made on a form prescribed by the department of
      revenue and accompanied by a statement from a health care provider with the
      same or similar license as the health care provider who made the initial report
      resulting in the limitation or loss of the driver's license. Such petition shall be
      decided by the director of the department of revenue within thirty days of receipt
      of the petition. Such decision by the director is appealable pursuant to subsection
      10 of this section.

302.292.

      1. In order to advise the director of revenue on medical criteria for the reporting
      and examination of drivers with medical impairments, a medical/vision advisory
      board is hereby established within the department of revenue. The board shall be
      composed of three members appointed by the director of the department of
      revenue. The members of the board shall be licensed physicians and residents of
      this state. Of the original appointees, one shall serve for a term of two years and



                                             Page 5
        two shall serve for terms of four years. Subsequent appointees shall each serve for
        a term of four years or until their successors are appointed and approved. Any
        vacancy shall be filled in the same manner as the original appointment for the
        remainder of the term. The members of the board shall receive no compensation
        for their services and shall not hire any staff personnel but shall be reimbursed for
        their actual and necessary expenses incurred in the performance of their official
        duties. After the first full year of operation of the advisory board, the board shall
        meet no more than four times per year .

        2. No civil or criminal action shall lie against any member of the medical/vision
        advisory board of the department of revenue who acts in good faith in advising
        the department under the provisions of this chapter. Good faith shall be presumed
        on the part of members of the medical/vision advisory board in the absence of a
        showing of fraud or malice.

           Section:B. The provisions of this act shall become effective on January 1,
                                              1999.

EXPLANATION: Matter enclosed in bold faced brackets [thus] in this bill is not enacted and is intended to be
omitted in the law.
S. C. S. H. C. S. H. B. 1536




                                                    Page 6
                 MISSOURI DEPARTMENT OF REVENUE                                               Reset                     Print                 FORM
                 DRIVER LICENSE BUREAU, P.O. BOX 200
                 301 WEST HIGH STREET, ROOM 470
                 JEFFERSON CITY, MO 65105-0200
                                                                                              TELEPHONE: (573) 751-2730
                                                                                                     FAX: (573) 522-8174
                                                                                                                                            4319
                 DRIVER CONDITION REPORT                                                        WEB SITE: www.dor.mo.gov                   (REV 8-2006)

Please complete the Driver Condition Report if you have personal knowledge about a driver you believe is no longer
able to safely operate a motor vehicle.
     You should report only your firsthand knowledge of the driver.
     You should complete the entire form and sign your name on the reverse side.
     After reviewing this report, the Director of Revenue may require the driver to take certain tests such as a medical, vision
     or driving test.
     All information contained in this report shall be kept confidential, unless released by a court order.


PERSONAL                    NAME (LAST, FIRST, MIDDLE)                                             SOCIAL SECURITY NUMBER OR DRIVER LICENSE NUMBER

INFORMATION ON
PERSON BEING                LICENSE PLATE NUMBER         STATE OF ISSUANCE             DATE OF BIRTH                    TELEPHONE NUMBER
REPORTED:
Please complete all         ADDRESS                                                    CITY                     STATE           ZIP CODE
available information.


Describe in detail incidents or conditions about this driver. Give              DRIVER
specific information such as dates, places, accident reports and all            BEHAVIOR
other available information to support the need for re-examination.
You should report only information of which you have personal                                      Please check appropriate boxes based on
knowledge or physical evidence. Do not report what you have been                                   personal knowledge of incident if applicable.
told or heard.                                                                                     Please give a detailed description of incident.
                                                                                                   Age alone is not a sufficient reason for
                                                                                                   retesting.


                                                                                   Traffic Violations            Lack of Attention

                                                                                   Dangerous Actions             Caused Traffic Accident/Incident

                                                                                   Poor Driving Skills

                                                                                LOCATION




                                                                                DATE                             TIME




                                                                                   Lack of Knowledge of Traffic Laws

                                                                                   Obstructing Traffic

                                                                                   Other




MO 860-2507 (8-2006)                                                   Page 7                                                              DOR-4319 (8-2006)
                       MEDICAL CONDITIONS
                       Please check    ✔  appropriate boxes if the driver being reported has any of the following conditions that would
                       impair his or her ability to safely operate a motor vehicle:


         COGNITIVE IMPAIRMENTS/PSYCHIATRIC DISORDER                               DISORDERS THAT IMPAIR CONSCIOUSNESS
         (i.e., sees or hears things that are not there, gets lost easily,        (i.e., seizures, blackouts, sleep disorders)
         has problems remembering words for common things,
                                                                                  When was the last loss of consciousness?
         confusion in thought process or judgment)
                                                                                  _______________/ ______________/ ______________
   Please explain:                                                                        (month)               (day)                    (year)

                                                                              Please explain:




         VISUAL IMPAIRMENT
         (frequently runs into objects, cannot see road signs, cannot             LIMITED MOBILITY
         see objects on the side without turning head)                            (i.e., paralysis, problems moving freely)
   Please explain:                                                            Please explain:




         ALCOHOL/DRUG ABUSE                                                       OTHER CONDITIONS
   Please explain:                                                            Please explain:




ADDITIONAL COMMENTS




Please attach additional comments if necessary.

                         Based on my observation(s) of the above named person and/or information relayed to me by the individual, I reasonably and
PERSON                   in good faith, believe that he/she cannot safely operate a motor vehicle.
COMPLETING               PRINT FULL NAME (LAST, FIRST, MIDDLE)                        RELATIONSHIP TO DRIVER                  TELEPHONE NUMBER

FORM:
                         STREET ADDRESS                                               CITY                     STATE          ZIP CODE




                         SIGNATURE                                                                                            DATE




                         ANY PERSON WHO INTENTIONALLY FILES A FALSE REPORT SHALL BE GUILTY OF A CLASS A MISDEMEANOR, AND
                         SHALL BE LIABLE FOR THE DAMAGES WHICH RESULT.
MO 860-2507 (8-2006)                                                     Page 8                                                          DOR-4319 (8-2006)
                                                                Date: ________________ Name of Driver: _________________________
Cited Driver Worksheet
Driver Examination Division, Missouri State Highway Patrol      Examiner: ______________ Location:_____________________________


Utilize this worksheet when conducting a driving skills test for someone cited by the Director of Revenue. Record your observations
and professional opinions below. Note when responses are incorrect or otherwise unusual. Transfer marked information and specific
errors to the narrative section of Form 232 (Driver Information Report).

INTERPERSONAL                                      ORIENTATION & MEMORY                              OPERATION OF VEHICLE
  Appears confused /disoriented                     1.   Ask driver why are you here?                   Speed—Consistently too fast
  Unaware of purpose of evaluation                       Record response as given.                      Speed—Consistently too slow
  Inattentive / easily distracted                                                                       Speed—Variable & Uncontrolled
  Slow to respond to questions                      _______________________________
  Speech is difficult to understand                 _______________________________                     Lane—Weaves/drifts over lane lines
  Forgetful in conversation                                                                             Lane—Drives on/over center line
  Repeats statements/questions                                                                          Lane—Consistently too close to curb
  Possible hearing impairment                       2. Ask driver to state/spell full name.
                                                                                                        Lane—Difficulty when changing lanes
  Poor comprehension of instructions                                                                    Lane—Incorrect use during right turns
  Needs prompting/cues to stay on task                                                                  Lane—Incorrect use during left turns
  Hostile/angry comments to examiner                _______________________________
                                                                                                        Lane—Incorrect use at intersections
  Denies making errors while driving
  Unwilling to accept/discuss feedback              3. Ask driver to state full home address.
                                                                                                        Backing—Weaves when backing up
                                                                                                        Backing—Fails to look where going
                                                    _______________________________
VISION                                                                                                  Parking—Unable to parallel park
  Wearing glasses during evaluation                 __________________Zip___________
                                                                                                        Signs—Inconsistent in responding
  Glasses appear broken
                                                    4. Ask driver to state full home phone.             Signs—Failed to stop or yield
  Driver reports needing new glasses
                                                                                                        Signs—Unaware/oblivious to signs
  Vision appears generally impaired
  Unable to read text on forms                      _______________________________                     Signs—Ran red light
  Unable to read road signs
  Has difficulty judging distances                  5. Ask today’s date, using prompts if               Control—General poor control
  Has difficulty identifying road signs             necessary:                                          Control—Follows too close to others
  Difficulty viewing objects at sides                                                                   Control—Hits/runs over curbs
  Looks straight ahead (Tunnel Vision)              Date: ___________________________                   Control—Stops in traffic for no reason
  Fails to check blind spot                                                                             Control—Near misses observed
  Must strain to see over dashboard                 Day of                                              Control—Almost hit pedestrian
                                                    Week:__________________________
                                                                                                     OTHER OBSERVATIONS:
MOTOR FUNCTION—General
                                                    Month:__________________________                  Consistent failure to check conditions
  Unsteady when walking to car                                                                        Delayed response to road conditions
  Slow, shuffling gait                              Year:___________________________                  Appears confused at intersections
  Balance problem in standing/walking                                                                 Failed to cover brake near pedestrian
  Requires assistance so as not to fall             6. Ask what city or town we are in now:           Unable to chat and drive at same time
  Uses a cane or walker                             _______________________________                   Has difficulty merging into traffic
  Limited head/neck range of motion                                                                   Unable to anticipate potential dangers
  Limited arm range of motion                       7. Ask what is make/model/year of car:            Does not improve with feedback
  Hands/arms shake (tremor)                                                                           I felt unsafe in the car with him/her
  Head shakes                                       _______________________________
  Slow gross motor skills
  Appears generally frail and weak                  _______________________________
                                                                                                    Performance Summary
  Poor endurance / tires easily                     8. Point at each & ask driver to name it.
  Difficulty lifting legs                           Record response as given.                       Score _________          Pass / Fail

MOTOR FUNCTION—Vehicle                              Steering                                        Notes:
                                                    Wheel: _________________________                ____________________________
  Car transfer is awkward / unsteady
  Difficulty locating ignition & placing key        Glove Compartment/                              ____________________________
  Has difficulty starting vehicle                   Box:____________________________
  Difficulty locating & putting on seat belt                                                        ____________________________
                                                    Rear View
  Has difficulty reaching the pedals                Mirror: __________________________
  Has difficulty moving gear shift
  Has difficulty grasping the wheel                 Wind-
                                                                                                    Recommendations:
  Slow foot movement gas to brake                   shield:__________________________                 Too Impaired for Driving Skills Test
  Applies gas & brake simultaneously                                                                  Too Unsafe / No Further Testing
  Confuses gas & brake pedals                       Radio/
                                                    Stereo:__________________________
                                                                                                      Vision Testing is Recommended
  Foot appears to slip off pedal                                                                      Medical Advisory Board Input

 Developed by Washington University researchers in cooperation with officials from the Missouri Department of Revenue and Missouri State Highway
                   Patrol. Funding support provided by the Division of Highway Safety, Missouri Department of Transportation.
                                                                     Page 9
                                  Version 2 (6/6/07) / FOR INTERNAL USE OF MSHP EXAMINERS ONLY
Page 10
                                                                Date: ________________ Name of Driver: _________________________
Cited Driver Worksheet
Driver Examination Division, Missouri State Highway Patrol      Examiner: ______________ Location:_____________________________


Utilize this worksheet when conducting a driving skills test for someone cited by the Director of Revenue. Record your observations
and professional opinions below. Note when responses are incorrect or otherwise unusual. Transfer marked information and specific
errors to the narrative section of Form 232 (Driver Information Report).

INTERPERSONAL                                      ORIENTATION & MEMORY                              OPERATION OF VEHICLE
  Appears confused /disoriented                     1.   Ask driver why are you here?                   Speed—Consistently too fast
  Unaware of purpose of evaluation                       Record response as given.                      Speed—Consistently too slow
  Inattentive / easily distracted                                                                       Speed—Variable & Uncontrolled
  Slow to respond to questions                      _______________________________
  Speech is difficult to understand                 _______________________________                     Lane—Weaves/drifts over lane lines
  Forgetful in conversation                                                                             Lane—Drives on/over center line
  Repeats statements/questions                                                                          Lane—Consistently too close to curb
  Possible hearing impairment                       2. Ask driver to state/spell full name.
                                                                                                        Lane—Difficulty when changing lanes
  Poor comprehension of instructions                                                                    Lane—Incorrect use during right turns
  Needs prompting/cues to stay on task                                                                  Lane—Incorrect use during left turns
  Hostile/angry comments to examiner                _______________________________
                                                                                                        Lane—Incorrect use at intersections
  Denies making errors while driving
  Unwilling to accept/discuss feedback              3. Ask driver to state full home address.
                                                                                                        Backing—Weaves when backing up
                                                                                                        Backing—Fails to look where going
                                                    _______________________________
VISION                                                                                                  Parking—Unable to parallel park
  Wearing glasses during evaluation                 __________________Zip___________
                                                                                                        Signs—Inconsistent in responding
  Glasses appear broken
                                                    4. Ask driver to state full home phone.             Signs—Failed to stop or yield
  Driver reports needing new glasses
                                                                                                        Signs—Unaware/oblivious to signs
  Vision appears generally impaired
  Unable to read text on forms                      _______________________________                     Signs—Ran red light
  Unable to read road signs
  Has difficulty judging distances                  5. Ask today’s date, using prompts if               Control—General poor control
  Has difficulty identifying road signs             necessary:                                          Control—Follows too close to others
  Difficulty viewing objects at sides                                                                   Control—Hits/runs over curbs
  Looks straight ahead (Tunnel Vision)              Date: ___________________________                   Control—Stops in traffic for no reason
  Fails to check blind spot                                                                             Control—Near misses observed
  Must strain to see over dashboard                 Day of                                              Control—Almost hit pedestrian
                                                    Week:__________________________
                                                                                                     OTHER OBSERVATIONS:
MOTOR FUNCTION—General
                                                    Month:__________________________                  Consistent failure to check conditions
  Unsteady when walking to car                                                                        Delayed response to road conditions
  Slow, shuffling gait                              Year:___________________________                  Appears confused at intersections
  Balance problem in standing/walking                                                                 Failed to cover brake near pedestrian
  Requires assistance so as not to fall             6. Ask what city or town we are in now:           Unable to chat and drive at same time
  Uses a cane or walker                             _______________________________                   Has difficulty merging into traffic
  Limited head/neck range of motion                                                                   Unable to anticipate potential dangers
  Limited arm range of motion                       7. Ask what is make/model/year of car:            Does not improve with feedback
  Hands/arms shake (tremor)                                                                           I felt unsafe in the car with him/her
  Head shakes                                       _______________________________
  Slow gross motor skills
  Appears generally frail and weak                  _______________________________
                                                                                                    Performance Summary
  Poor endurance / tires easily                     8. Point at each & ask driver to name it.
  Difficulty lifting legs                           Record response as given.                       Score _________          Pass / Fail

MOTOR FUNCTION—Vehicle                              Steering                                        Notes:
                                                    Wheel: _________________________                ____________________________
  Car transfer is awkward / unsteady
  Difficulty locating ignition & placing key        Glove Compartment/                              ____________________________
  Has difficulty starting vehicle                   Box:____________________________
  Difficulty locating & putting on seat belt                                                        ____________________________
                                                    Rear View
  Has difficulty reaching the pedals                Mirror: __________________________
  Has difficulty moving gear shift
  Has difficulty grasping the wheel                 Wind-
                                                                                                    Recommendations:
  Slow foot movement gas to brake                   shield:__________________________                 Too Impaired for Driving Skills Test
  Applies gas & brake simultaneously                                                                  Too Unsafe / No Further Testing
  Confuses gas & brake pedals                       Radio/
                                                    Stereo:__________________________
                                                                                                      Vision Testing is Recommended
  Foot appears to slip off pedal                                                                      Medical Advisory Board Input

 Developed by Washington University researchers in cooperation with officials from the Missouri Department of Revenue and Missouri State Highway
                   Patrol. Funding support provided by the Division of Highway Safety, Missouri Department of Transportation.
                                                                    Page 11
                                  Version 2 (6/6/07) / FOR INTERNAL USE OF MSHP EXAMINERS ONLY
Page 12
 Health, Functional Status
 & Older Driver Safety

        A Curriculum for State Highway Patrol
        Examiners & Officers




About the Curriculum

 Developed by the Older Driver Education & Research
 Team, Washington University School of Medicine

 In cooperation with the Missouri State Highway Patrol
 (MSHP)

 Funded by a grant from the Division of Highway
 Safety, Missouri Department of Transportation
 (MODOT)
                                        Version 2, July 2007




                       Page 13
Sources

 Driver License Bureau, Missouri Department of
 Revenue
 Missouri State Highway Patrol
 Office of Social & Economic Data Analysis,
 University of Missouri
 Older Drivers Project, American Medical Association
 DriveWell, American Society on Aging
 National Highway Traffic Safety Administration
 AAA Foundation for Traffic Safety




Special Thanks
 Leanna Depue, PhD, Director, Division of Highway Safety,
 MODOT
 Jacqueline Rogers, Systems Management Specialist, Division
 of Highway Safety, MODOT
 Captain Bill Nelson, Director, Driver Examination Division,
 MSHP
 Rhonda Czarnecki, Senior Chief Driver Examiner, Driver
 Examination Division, MSHP
 Norma Hensiek, Manager, Driver License Bureau, Missouri
 Department of Revenue
 Mike Right, Vice President, Public Affairs, AAA Missouri


                            Page 14
Older Driver Education & Research Team

  Cindy Anders, MSG, Chief Driver Examiner, Missouri State
  Highway Patrol, Troop B
  Thomas M. Meuser, PhD, Alzheimer’s Disease Research
  Center, Washington University School of Medicine
  David B. Carr, MD, Division of Geriatrics & Nutritional Science,
  Washington University School of Medicine
  Marla L. Berg-Weger, PhD, School of Social Work, Saint Louis
  University
  Patricia Niewoehner, OTR/L, CDRS, St. Louis VA Medical
  Center




Learning Objectives
At the end, you will understand:

  Older driver safety statistics in Missouri.
  How age-related changes in health and functional
  status may impair driving ability and increase crash
  risk.
  An approach to observing and describing such
  changes in older drivers.
  How to document such changes in support of a
  citation and the license review process.
    Complete pre-test questionnaire now, if required, and hand it
    in to the presenter. Thank you!

                             Page 15
Agenda
 Officer & Examiner Stories
 Missouri Law & Statistics
 Health & Functional Status in Aging
   Dementia
   Vision Loss
   Motor Deficits
 Observing Age-Related Changes
   Cited Driver Worksheet
 Documentation
 Discussion & Evaluation




Traffic Stop

10:22 PM, 9/18/02:
  “Driver (age 73) was traveling westbound on I-44 in
  Shrewsbury… was failing to maintain a single lane and
  drove onto shoulder, almost striking my patrol car… I
  (followed) vehicle for many miles… he exited… stopped
  at a stop light…
  “I exited my patrol car and approached… knocked on the
  window… he drove off… I continued after him for several
  more blocks with my lights and siren on. He finally
  stopped. He stated I thought you were after those other
  speeders.”

                            Page 16
Accident Investigation

1:30 PM, 3/11/04:
  “Subject (age 94) involved in accident where she
  struck a railroad crossing arm. She thought there
  was a curve in the road, obscuring her view (there
  isn’t). She thought there were two sets of gates (only
  one) and thought the second set was in the middle of
  the tracks.”
  “Subject seemed generally confused about her
  surroundings, and may be having vision difficulties.”




Driving Skills Test
10:00 AM, 5/29/02:
  “Mr. Smith (age 86) came to the Owensville Driver
  Examination Station requesting a 3rd road test… He failed
  the test due to a large accumulation of points. The test
  was discontinued before all maneuvers were completed.”
  “He backed out of the parking lot space… without any
  observance of what was behind him. He neglected to
  signal both to and away from the curb or check traffic
  during the start on grade… He drove down the center or
  left… his left turns were so sharp that the turns were
  completed in the wrong lane of the street he was turning
  into…”


                          Page 17
Issues & Red Flags

 Lack of Awareness / Impaired Attention
   “I knocked on the window… he drove off”
   “I thought you were after those other speeders”
 Confusion / Disorientation
   “Subject seemed generally confused about her surroundings”
 Vision Loss
   “May be having vision difficulties.”
 Misperception / Impaired Planning & Execution
   “She thought there was a curve in the road, obscuring her view
   (there isn’t).”
   “His left turns were so sharp that the turns were completed in the
   wrong lane of the street he was turning into.”




Agenda
 Familiar Stories
 Missouri Law & Statistics
 Health & Functional Status in Aging
   Dementia
   Vision Loss
   Motor Deficits
 Observing Age-Related Changes
   Cited Driver Worksheet
 Documentation
 Discussion & Evaluation


                               Page 18
Missouri’s Voluntary Reporting Law

                                          Passed by the MO
                                          Legislature in 1998
                                          following a significant
                                          lobbying effort by CARD,
                                          WU, Alzheimer’s Assoc, &
                                          other organizations.
                                          Not age or disease
                                          specific.
                                          Intended to promote
                                          reporting of impaired
                                          drivers by health
                                          professionals, particularly
                                          physicians.
                                          Forms allow for a range of
                                          health and addiction
                                          conditions to be reported.
                                          Similar to voluntary laws in
                                          45 other states.
                                          Has never been formally
                                          evaluated.




HB-1536 Reporting Process




 Once reported, the cited driver must negotiate each
 step (hurdle) in the process to retain a valid license.
 Failure to submit a Physician Statement (Form 1528)
 leads to license revocation in all cases.


                         Page 19
Specific Forms at Each Step




Driver Condition Report (Form 4319)


                           Specific Observations




                                Additional Narrative – Good
                              place to write general behavioral
   Narrative                  and mental status observations.
  Description
  of Incident.




                 Page 20
Characteristics of Cited Drivers
Based on a sample of drivers 65+ (n = 353) reported 1999-2005


  57% Male
  Mean Age = 82 years
  32% reported by police following on-road incident
  (Form 4319) and 23% reported by license office staff
  Only 10% reported by physicians and 12% by family
  members
  Cognitive Impairment / Dementia in ~60% of cases
  Few (<2% in this sample) passed medical review
  and a driving skills test to keep their licenses.




Driver Information Report (Form 232)
                                               Whether you are a Driver
                                               Examiner, Trooper or a Patrol
                                               Officer, your task is the same:

                                               To observe how the older adult
          Narrative Description
                                               behaves during your encounter
                                               and provide as much
                                               descriptive information as you
                                               can for use in the medical
                                               review process.

                                               Your description can support
                                               recommendations that no
    Test Scores & Pass/Fail Status             further testing be pursued or
                                               that additional Medical Advisory
                                               Board review is needed.

                                     Page 21
   Older Drivers in Missouri:
   Statistics & Safety Concerns




Missouri Population is Aging

Male        Age     Female

                                Percent Missouri Population Age 65+:
                                             1990-2020

                                           20

                                           15
                                 Percent




                                           10

                                            5

                                            0
                                                1990   2000          2010   2020
                                                              Year


       This means more older drivers on our roads in years to come.



                                     Page 22
 >15% of Missouri Drivers are Age 65+



                             14.6% Male Aged 65+
                             16.2% Female Aged 65+




  In some MO
    counties,
 1/4–1/3 of the
population will
soon be 65 or
      older!


                   Page 23
Higher Exposure = Higher Crash Risk for Older Drivers

         Blue = Crash Rate for 1 Million Vehicle Miles Traveled (Exposure)
         Red = Crash Rate per 100 Licensed Drivers




Younger vs. Older Drivers in 2005 (1)

 Of all 2005 Missouri traffic               Of all 2005 Missouri traffic
 crashes, 28.9% involved a                  crashes, 28.8% involved an
 young driver (16-20 years).                older driver (55+ years).

 A total of 267 persons were                A total of 377 persons were
 killed and 19,616 were injured             killed and 17,875 were injured
 in traffic crashes involving               in crashes involving older
 young drivers.                             drivers.

 Of all young drivers in traffic            Of all older drivers involved in
 crashes, 54.0% were male and               traffic crashes, 57.8% were
 46.0% were female. Of those                male and 42.2% were female.
 young drivers in fatal traffic
 crashes, 71.7% were male.



                                  Page 24
Younger vs. Older Drivers in 2005 (2)
 Of all 2005 young driver                  Of all older driver crashes,
 crashes, 63.9% occurred in an             67.7% occurred in an urban
                                           area and 32.3% occurred in a
 urban area and 36.1%                      rural area of the State.
 occurred in a rural area of the           However, 73.4% of the fatal
 State. However, 72.3% of the              older driver crashes occurred
 fatal young driver crashes                in a rural area.
 occurred in a rural area.
 Of all young driver related               Of all older driver related traffic
 traffic crashes, the first harmful        crashes, the first harmful event
                                           in 84.2% of the incidents
 event in 74.9% of the incidents           involved one motor vehicle in
 involved one motor vehicle in             transport striking another
 transport striking another                motor vehicle in transport.
 motor vehicle in transport.
 Of all young driver traffic               Of all older driver traffic
 crashes, 32.4% occurred on                crashes, 87.2% occurred from
                                           7:00 A.M. through 6:59 P.M.
 Friday or Saturday.




                                 Page 25
Crash Characteristics of Cited Drivers in MO

 Males > Females
 Most involved in two-car incidents, in the middle of
 the day, and at slow speeds (<40 mph).
 Most crashes occurred in dry, sunny or cloudy
 conditions, on level roads.
 Failure to yield and improper execution of a turn
 were the most common causal factors recorded by
 Highway Patrol and local police investigators.
 Most were wearing seat belts at the time of the
 crash.
 Fortunately, there were few fatalities or serious
 injuries.




Problem Maneuvers – Left Turn




                        Page 26
Problem Maneuvers – Failure to Yield




Problem Maneuvers – Lane Position




                Page 27
A Recent Crash (Saturday, May 23, 2007)
Jessica, age 16, was on
her way to drop off a job
application at 8:30
AM. She was driving
northbound on Mackenzie
in South St. Louis. An 88
year old woman ran a
stop sign off a side street
and turned left onto the
wrong side of the street,
hitting Jessica head on!

The older woman explained that she did not look left before making the turn;
and she was unrestrained. The impact caused her to hit another car.




Agenda
   Familiar Stories
   Missouri Law & Statistics
   Health & Functional Status in Aging
      Dementia
      Vision Loss
      Musculoskeletal / Motor Impairment
   Observing Age-Related Changes
      Cited Driver Worksheet
   Documentation
   Discussion & Evaluation


                                 Page 28
Components of Driving

 Tasks of Driving:
   Operational (e.g., using the brake)
   Tactical (e.g., deciding when to turn)
   Strategic (e.g., planning a route)


 Basic Requirements for Safe Driving:
   Vision (with at least 20/40 acuity)
   Cognition (attention, memory, planning)
   Sensory & Motor




Medical Fitness to Drive
 Medical Fitness to Drive (MFD) is especially
 relevant for older adults.
 Age-related medical conditions may impair
 driving ability and elevate crash risk.
 The reporting of MFD concerns is a voluntary
 process in most states, including Missouri.
 The first responsibility for addressing MFD
 concerns resides with the individual driver
 (i.e., through self-monitoring and regulation).

                        Page 29
Prevalence of Chronic Illness

 Epilepsy: 2.5 million cases with         Alzheimer’s Disease: 4.5
 180,000 new diagnosed cases              million cases (10% of those
 each year                                over 65 years and nearly
                                          50% of those over 85 years)
 Diabetes: 18.2 million cases
 with 1 million new cases                 Arthritis: 40 million cases
                                          (over 7 million report limited
 diagnosed each year over age             activity)
 20
                                          Eye diseases (5.5 million
 Sleep disorders: 50-70 million           cataracts, 2 million with
 cases                                    glaucoma, and 1.2 million
                                          with late stage macular
 Cardiovascular disease: 23.5             degeneration.
 million cases
                                          Alcoholism 14 million cases
                                          and 40% linked to all
                                          automobile fatalities.




A Few Key Areas

 Dementia
 Vision Loss
 Sensory & Motor/Movement




                                Page 30
Dementia
 Sustained loss of memory &
 thinking that impacts on daily life
 functioning.
 The most common cause of
 memory loss & dementia in older
 age is Alzheimer’s Disease, which
 accounts for ~70% of all
 dementias.
 Advancing age is a primary risk
 factor for dementia, such that
 persons over the age of 85 years
 may a 50+% risk.




Alzheimer’s Dementia
& Driving

 Persons with dementia often experience
 problems in strategic and tactical tasks first,
 followed later by problems with operational
 tasks.
 With regards to driving…
 It is not a matter of if a person with dementia
 must retire from driving for reasons of safety,
 but simply when.

                      Page 31
Symptoms - Forgetfulness

 Persons with early dementia are forgetful of recent,
 new information.
   They forget appointments, get lost in less familiar areas, repeat
   themselves, misplace items and can’t find them, etc.
   Their memory for things that happened long ago remains
   intact, allowing them to seem normal during a brief encounter.
 Persons with more advanced dementia retain very
 little new information and also have difficulty
 recalling information from long past.
   They get lost even in familiar areas and may forget basic,
   operational tasks of driving.




Symptoms - Disorientation

 Persons with early dementia can have subtle
 disorientation that varies over time.
   They may be confused about the day of the week or exact
   date, but usually know the year.
   They may have difficulty saying when a group of events
   occurred in relation to each other.
 Persons with more advanced dementia can be
 quite disoriented to time, and may not know
 always where they are.
   Drivers in this stage may become lost in long familiar
   places.


                            Page 32
Other Symptoms

 Impaired Attention & Executive Skills
   May only be able to pay attention to one task
   Easily distracted in conversation
   May have difficulty following multi-part instructions
   Limited ability to plan ahead


 Language Deficits
   Dysnomia – may forget or use incorrect name of a person
   or object
   Aphasia – may have difficulty understanding commands
   and responding correctly




Stages of Dementia


 Very Mild
     Example: “Pat” has very mild Alzheimer’s. To
     others she seems perfectly normal. She is a little
     more forgetful and it worries her. Her spouse
     notices that she repeats herself occasionally and
     may forget details of a recent event. Her daily
     functioning is OK.

       * Typically able to drive safely in this stage*


                            Page 33
Mild Stage:


  Example: Pat has mild Alzheimer’s disease. She
  generally looks and acts normal. She has difficulty
  remembering conversations and repeats herself.
  Her son supervises her checkbook and helps to
  arrange home repairs, but otherwise she manages
  reasonably well.
         *May be able to drive safely in this stage*




Moderate Stage:



  Example: Pat has Moderate Alzheimer’s. Others
  definitely notice a problem. She sometimes forgets to
  eat, and she has difficulty recalling her address and
  phone number. She has significant word finding
  problems in conversation. She cannot take care of her
  house alone and her children believe that she should
  move to a supervised setting.
     *Unlikely to be able to drive safely in this stage*

                         Page 34
Vision Changes in Age
 Acuity
   The ability to see an object clearly, whether close up or far away.
   Most of us experience changes in acuity as we age and need to
   wear glasses.
   At least 20/40 vision is needed for safe driving.
 Contrast Sensitivity
   The ability to discriminate different shades of color and light. Older
   adults can have difficulty driving at night and in dealing with glare.
 Depth Perception
   The ability to perceive in 3 dimensions (i.e., how objects are
   arranged in visual space).
 Visual Processing
   Sometimes the eye may see fine, but the brain doesn’t interpret
   correctly. It may take a specialist to figure this out.




Diseases of the Eye

 Glaucoma



 Cataracts



 Macular Degeneration



                               Page 35
Movement & Mobility
                                             Able to manage the
 Physical Frailty – General slowing, muscle physical and
 weakness, low endurance                    endurance demands
                                             of driving any
 Kyphosis – Curvature of the spine making
                                             distance?
 it difficult to see over the dashboard.
 Reduced range of motion – neck, arms        Able to see traffic in
                                             the blind spot?
 Arthritis – Stiff, painful joints, slow
 movement
 Parkinson’s disease – rigid muscles,        Getting foot from gas
 tremor (shaking), and slow movement         to brake in time to
                                             stop?
 Peripheral Neuropathy – loss of sensation
                                             How much pressure
 in the legs and feet, making walking and    on the pedals?
 driving more difficult




Your Observations

 Cognition:
   Does she understand the purpose of our
   interaction today?
   Does he know his own address, phone number,
   and model of car?
   Does she understand my requests and respond
   appropriately?
   Does he repeat the same questions or
   comments? Can he find his wallet when needed?
   Does she make errors in responding to basic
   questions of fact or the names of objects?

                               Page 36
Your Observations

 Vision:
   Is he wearing glasses? If not, were they
   forgotten? What is the condition of the glasses?
   Does she report a problem with her vision?
   Can he read a line from her drivers license or
   another document?
   Can she see and identify nearby traffic signs or
   other signs on buildings?
   Does he complain of cloudy, fuzzy, or foggy
   vision? Does he complain of not seeing something
   that you see in his visual field?




Your Observations

 Movement:
   Does he report a movement-related problem?
   Does she move at a reasonable pace or rather slowly?
   Does he appear well-balanced when walking, or rather
   shaky and unbalanced? Does he use a cane or
   walker?
   Do his hands, arms, or head show signs of tremor?
   Does she appear to tire easily?
   Can he turn his head fully from side to side?
   Does she require assistance entering/exiting the
   vehicle, sitting/getting up from a chair?

                        Page 37
Agenda
 Familiar Stories
 Missouri Statistics & Law
 Health & Functional Status in Aging
   Dementia
   Vision Loss
   Motor Deficits
 Observing Age-Related Changes
   Cited Driver Worksheet
 Documentation
 Discussion & Evaluation




Observer Role

 This curriculum is intended to make you more aware
 of driving and aging concerns and to enhance your
 observational skills in this area.
 The more detailed and specific you can be about
 how a person behaves, the more your report can
 help in later medical review and driver licensing
 decisions.
 Detailed descriptions can be especially helpful when
 you are recommending that no further testing take
 place or that more medical input is needed.

                            Page 38
Example Narrative




 A brief, but effective narrative. A general statement (comprehension
 problem) is backed up by specific examples. What other descriptive
 words could have been based on his actions?




Cited Driver Worksheet
  Use the worksheet to
  focus your thinking and
  observations.
  Check (√) items that
  you observe, making
  extra notes in the
  margin or on the back
  to clarify items for later.
  Record answers to
  orientation and memory
  questions as given,
  making note of errors.


                                 Page 39
Cited Driver Worksheet - Interpersonal

 Appears confused                      Hearing impairment
 /disoriented                          Poor comprehension of
 Unaware of purpose of                 instructions
 evaluation                            Needs prompting/cues to
 Inattentive / easily                  stay on task
 distracted                            Hostile/angry comments to
 Slow to respond to                    examiner
 questions                             Denies making errors while
 Speech is difficult to                driving
 understand                            Unwilling to accept/discuss
 Forgetful in conversation             feedback
 Repeats
 statements/questions




Vision

 Wearing glasses during                Has difficulty judging
 evaluation                            distances
 Glasses appear broken                 Has difficulty identifying
 Driver reports needing new            road signs
 glasses                               Seems not to see objects at
 Vision appears generally              sides
 impaired                              Looks straight ahead
 Unable to read text on                (Tunnel Vision)
 forms                                 Fails to turn head to see
 Unable to read signs on               blind spot
 buildings                             Must strain to see over
                                       dashboard


                             Page 40
Motor Function
GENERAL:                                   VEHICLE RELATED:
  Unsteady when walking to car                  Car transfer is awkward / unsteady
  Slow, shuffling gait                          Difficulty locating ignition & placing
  Requires assistance so as not to fall         key
  Uses a cane or walker                         Has difficulty starting vehicle
  Limited head/neck range of motion             Difficulty locating & putting on seat
                                                belt
  Limited arm range of motion
                                                Has difficulty reaching the pedals
  Hands/arms shake (tremor)
                                                Has difficulty moving shifter
  Head shakes
                                                Has difficulty grasping the wheel
  Slow gross motor skills
                                                Slow foot movement gas to brake
  Appears generally frail and weak
                                                Applies gas & brake simultaneously
  Poor endurance / tires easily
                                                Confuses gas & brake pedals
                                                Foot appears to slip off pedal




Orientation & Memory

  Why are you here?                             What city or town are we in
  State and spell your full                     now?
  name.                                         What is the make, model
  What is your home address,                    and year of your vehicle?
  including zip code?                           What is the name of (point
  What is your home phone                       to):
  number, including area                           Steering Wheel
  code?                                            Glove Box
  What is the date today?                          Rear View Mirror
  Day of the week?                                 Windshield
                                                   Radio




                                      Page 41
Characteristics of Cited Drivers
Based on a sample of drivers 65+ (n = 353) reported 1999-2005


  57% Male
  Mean Age = 82 years
  32% reported by police following on-road incident
  and 23% reported by license office staff
  Only 10% reported by physicians and 12% by family
  members
  Cognitive Impairment / Dementia in ~60% of cases
  Few (<2% in this sample) passed medical review
  and a driving skills test to keep their licenses.




Case Example – Driving Skills Test

  Mrs. Mary Brown, age 74, was cited by the Director
  of Revenue to take a Driver Skills Test.
  She is a retired factory worker and lifelong resident
  of Florissant, MO.
  She reports a minor problem with her distance vision
  (“I think I need new glasses, but I still see OK”)
  She is quite anxious about being tested, but tries
  her best to be cooperative during the examination.



                             Page 42
Video Clip




Mary Brown - Review
 Normal Cognition
   Full oriented and recalled everything asked of her.
   Had difficulty naming items in the car, but self corrected.
   Unable to parallel park due to anxiety and poor vision.
   Any appearance of impairment was due to situational anxiety.
 Impaired Vision
   Read the driver license number incorrectly.
   Could not read sign on nearby building.
   Reported needing new glasses.
 Normal Motor / Range of Motion
 Fails Driving Skills Test – Excessive Points
   Errors in parallel parking, drove too close to parked vehicles,
   stopped late at intersection (failed to see stop sign), difficulty
   merging into traffic.



                                 Page 43
Case Example – Traffic Stop

 Mr. Jim Greene, age 73, was pulled over by State
 Trooper for weaving and driving through a stop sign.
 Mr. Greene has lived in Florissant, Missouri, for just
 the past two years, after moving here from Madison,
 Wisconsin, to live closer to his children.
 He wears glasses, but does not report a vision
 problem.
 He seems mildly confused, forgetful and rather
 irritated/embarrassed to have been stopped.




Video Clip




                        Page 44
Jim Greene - Review
 Mild to Moderate Dementia
   No memory of what he did to be pulled over. Asked about it twice.
   Incorrect day of week and date (Wednesday, 23rd).
   Unsure of where he lives and basic information about his daughter.
 Normal Vision
 Motor
   Neck noticeably stiff.
   Walks slightly hunched and slow, but unaided. No apparent balance
   problem.
 Outcomes
   Trooper arranges to drive him to meet with his friends. Later
   contacts the daughter about what occurred.
   Not seen on clip: He is cited for a moving violation and reported
   under HB-1536 for medical and licensing review.




Agenda
 Familiar Stories
 Missouri Statistics & Law
 Health & Functional Status in Aging
   Dementia
   Vision Loss
   Motor Deficits
 Observing Age-Related Changes
   Cited Driver Worksheet
 Documentation
 Discussion & Evaluation


                               Page 45
Basic Principles of Documentation
 Describe your first hand experiences and observations,
 starting with the beginning of your encounter.
   “He repeated the same comment three times over a 10-
   minute period.”
   “She reported that a red traffic signal was green and
   started to enter the intersection until I intervened to stop
   her.”
 Avoid general statements (“he seemed unsure”), unless
 followed by specific examples to back them up.
 Avoid making medical diagnoses.
 It is OK to list diagnoses told to you, but attribute them to
 the older driver or other source (e.g., if a family member
 was present).




                             Page 46
 Narrative on Form 232
Mrs. Brown was a pleasant, willing participant in the driving skills test. She
appeared moderately anxious, as evidenced by rapid breathing, high pitched
tone of voice, and many comments on her performance.
She wore glasses, but appeared to have difficulty seeing both near and far
objects. For example, she misread her driver license number and she could
not read signs on nearby buildings. She reported being at the Hazelwood test
facility, and she stated her name, address and phone number without
difficulty. She gave the correct date and time.
She walked to her vehicle, entered it, and fastened her seatbelt properly. She
pointed correctly to controls named by the Examiner, and she named common
objects giving incorrect names initially, but self-corrected later.
During testing, she frequently drove too close to the curb and parked cars.
She appeared confused when asked to parallel park between cones, and
asked three times to explain what I wanted her to do. I discontinued this
maneuver after a few minutes. At the last intersection on the course, she
appeared not to see the stop sign and continued driving until I instructed her
to stop. She failed due to excessive points.




                                   Page 47
 Narrative on Police Report
I pulled Mr. Greene over after observing him weaving in/out of his lane and
then fail to stop for a stop sign. I knocked on his window several times before
he seemed to notice me and open it. He appeared to have a very stiff neck,
requiring him to move his body to see effectively from side to side.
He asked why I had stopped him on two occasions, both times questioning if
he had done anything wrong and denying that he had seen a stop sign. He
stated “I’m not drunk” three times. He had difficulty recalling his current home
address, stating first that he lives in Wisconsin and later discussing how he is
temporarily living with his daughter in Florissant. He could not recall his
daughter’s phone #, street address, or place of work, stating “I know how to
get there but just can’t recall it right now.”
Although alert and reasonably cooperative, Mr. Greene appeared mildly
confused and quite forgetful. To protect him and others on the road, I
encouraged Mr. Greene to lock his vehicle and I drove him to meet his friends
at a nearby restaurant. His friends were able to tell me how to reach his
daughter, and she accepted responsibility for his car and getting him home. I
issued a citation for his stop sign infraction and submitted Form 4319 to the
Director of Revenue.




 Form 4319 (page 1)




                                    Page 48
Form 4319 (page 2)




Agenda
 Familiar Stories
 Missouri Statistics & Law
 Health & Functional Status in Aging
   Dementia
   Vision Loss
   Motor Deficits
 Observing Age-Related Changes
   Cited Driver Worksheet
 Documentation
 Discussion & Evaluation


                            Page 49
Discussion
 Can you see yourself interacting with an older driver in this
 way?
 What types of observations are you more likely to focus
 on?
 Are you comfortable writing down more of your
 observations in your narrative?
 Do you see any potential challenges or pitfalls?
 What if the driver became resistant or hostile (“I shouldn’t
 have to answer these questions in a driving test”)?
 Are there times when you would choose not to run through
 the Cited Driver Worksheet?




Thank you for your kind attention!

 Please fill out and hand in your post-program
 evaluation form.
 Questions or Comments?
   Cindy Anders, MSG (Cynthia.Anders@mshp.dps.mo.gov)
   Tom Meuser, PhD (meusert@abraxas.wustl.edu)
   David Carr, MD (dcarr@im.wustl.edu)
   Marla Berg-Weger, PhD (bergwm@slu.edu)
   Pat Niewoeher, OTR/L, CDRS (Pat.Niewoehner@va.gov)



                          Page 50
                     Safe Driving for a Lifetime




We need to talk ...
   Family conversations with older drivers
www.thehar tford.com/talkwitholderdrivers
Questions
Families Need
to Ask About
Older Drivers
   Accidents involving older drivers often call attention to the issue of
   older adults and driving safety. The facts alone may seem confusing.
   Statistics actually indicate that most older adults are safe drivers, with
   high safety belt use and few citations for speeding, reckless driving or
   alcohol-related charges. However, medical conditions, medication usage
   and reduced physical function can increase the risk of accidents and
   injury among older adults. Factor in the sense of independence that
   driving represents for older adults, and you can understand why driving
   safety for older adults is an emotionally charged topic.

   The Hartford Financial Services Group, Inc., and the MIT AgeLab
   developed this guide to help families initiate productive conversations
   with older adults about driving safety. These suggestions are based on
   a nationally representative survey of drivers over the age of 50, focus
   groups with older adults who have modified their driving, and
   interviews with family caregivers of persons with dementia.

   Crafting Caring Conversations
   When families discuss driving issues, they must assess the personality
   of the older driver, driving record, availability of transportation
   resources, geographic proximity, and long-term family relationships.
   The following questions and answers can help you assess your family
   situation and have meaningful conversations about older driver safety.




                       Page 51
  Are older drivers at risk?
         For older drivers,    As a group, older drivers are typically safe. The actual
      the rate of fatalities   number of accidents involving older drivers decreases as age
                               increases. Experts attribute this decline to self-imposed
        increases slightly     limitations, such as driving fewer miles and avoiding night
         after age 65 and      driving, rush-hour traffic and other difficult conditions.
significantly after age 75.
                               Therefore, sharing the roadways with older drivers poses a
                               relatively low risk to other drivers.
          This higher rate
              is due to the    However, older drivers, especially after age 75, have a
        increased inability    higher risk of being involved in a collision for every mile
              to withstand     they drive. The rate of risk is nearly equal to the risk of
                               younger drivers age 16 to 24. The rate of fatalities increases
      the physical trauma
                               slightly after age 65 and significantly after age 75. This
                 that often    higher rate is due to the increased inability to withstand
         occurs with age.      the physical trauma that often occurs with age. Although
                               older persons with health issues can be satisfactory drivers,
                               they have a higher risk of injury or death in an accident,
                               regardless of fault.

                               These statistics can help you see the risk for older drivers;
                               however, the decision to limit driving depends on each
                               individual. Each family must ask, “Is my older relative safe?”
                               Ongoing discussions and objective assessments will help
                               older drivers and their families evaluate the risks in their
                               unique situations.

                                        Page 52                                                 2
    Do family conversations
    make a difference?
   Of the older adults    Yes. What you say or don’t say influences the decisions of
surveyed who reported     older adults and can make the difference between safety or
                          injury – life or death.
    that someone had
       talked to them     Although unsafe driving may be an uncomfortable
   about their driving,   subject, these ongoing conversations over time will help
   more than half said    older adults weigh decisions and agree to drive less, avoid
                          certain road conditions or stop driving. Of the older
      they listened to
                          adults surveyed who reported that someone had talked
         and followed
                          with them about their driving, more than half said they
      the suggestions     followed the suggestions of others. Women generally
            of others.    complied more readily than men.




                                                Page 53                                 3
When faced with a discussion
about driving abilities, with whom
do older adults choose to talk?
    Marital status is    Hearing sensitive information from the right person can
  a significant factor   make a big difference. To increase the chances of success,
     that determines
                         carefully select the person who will initiate the discussion
                         and have others reinforce decisions about driving. Older
    who should have
                         adults typically prefer to speak confidentially about driving
the conversation with    safety with someone they trust. Often family members can
     the older driver.   form a united front with doctors and friends to help older
      The top choice     drivers make good driving decisions.
    of married drivers
                         When choosing a family member to initiate the discussion,
        (50 percent)
                         consider the personalities involved and past experience
     is to hear about    approaching difficult topics. Some families mistakenly
     driving concerns    assign the most outspoken or authoritative member to
            first from   deliver their concerns as an ultimatum. Such persons are
       their spouses.
                         not ideal to open the early discussions on driving, but may
                         better serve as the enforcer of driving decisions.




                                    Page 54                                              4
The Hartford/MIT survey indicates that older                This referral may avoid unnecessary conflict when
drivers have specific preferences for these conver-         the doctor, family members, and older driver have
sations that vary based on several factors, such as         differing opinions. Family members should work
marital status, gender, health and presence of              with doctors and share observations about driving
other supportive individuals. Marital status is a           behavior and health issues to help older adults
significant factor that determines who should               make good driving decisions.
have the conversation with the older driver.
The top choice of married drivers (50 percent)              Adult Children
is to hear about driving concerns first from their          Adult children seem to have more influence with
spouses. Older drivers living alone prefer to have          parents over 70 than with younger parents in their
these conversations with their doctors, adult               50s and 60s. These differences often correlate to
children or a close friend. Let’s look more closely         health changes and shifts in parent-child relation-
at each of these groups.                                    ships later in life. Older drivers also tend to be
                                                            more open to adult children who live nearby.
Spouses
Men prefer to hear from a spouse slightly more              Women are generally more receptive than men to
than do women. Spouses have the advantage of                the prospect of hearing from their adult children.
observing driving over time and in different situa-         Men are slightly more inclined to choose sons
tions, as well as years of experience in dealing            over daughters, while women are more likely to
with sensitive topics and each other’s limitations.         choose daughters. Among individuals living alone,
Not all married couples choose their spouses for            almost one third said they would prefer to hear
this conversation. More than 15 percent of older            about unsafe driving from their adult children,
men and women said their spouses were their                 while nearly 15 percent of men and women living
last choice for hearing about driving concerns,             alone ranked their children as the last ones from
reinforcing the importance of assessing individual          whom they want to hear about driving.
preferences before having conversations
about driving.                                              Other Supportive Helpers
                                                            Persons other than spouses and adult children
Doctors                                                     may influence driving decisions. Some older
Outside of the family, the opinions of doctors are          adults would be open to hearing from a close
often valued by older drivers. About 27 percent             friend, a sibling, or an adult child’s spouse.
of those living with spouses and over 40 percent            Approximately 10 percent of older drivers living
of those living alone said they want to hear first          alone said they would choose a close friend to
from their doctor. Many older adults think that             initiate the driving conversation. These preferences
physicians can precisely determine their ability            most likely reflect the quality of their relationships.
to drive safely. And people who have health
problems are more likely to listen to the advice            Police Officers
of a doctor about driving.                                  More than anyone else, older adults strongly
                                                            prefer not to hear about driving concerns from
However, not all doctors agree that they are the            police officers. While some older adults may not
best source for making decisions about driving.             welcome families talking about their driving, they
Physicians may not be able to detect driving                still find it preferable than hearing from police.
problems based on office visits and physical                However, police intervention may be necessary in
examinations alone. They can assess diminished              situations where an older driver is unsafe and
visual, cognitive and motor skills, or refer the            unwilling to curtail driving.
driver to an assessment program for evaluation.

                                                      Page 55                                                         5
How will the older person react to
questions about his or her driving?
       Older adults     Older drivers may express strong emotions when someone
    may agree with      talks to them about their driving. Nearly one-fourth of older
   the assessment
                        adults reported feeling sad or depressed as a result of the
                        conversation. Less than 10 percent reported responding with
             of their
                        anger. Older adults in poor health are more likely to have
      driving ability   negative reactions. They may even agree with the assessment
 but feel depressed     of their driving ability but feel depressed at the thought of
     at the thought     relinquishing driving privileges.
    of relinquishing    Negative reactions are often more about the message than
  driving privileges.   the messenger. Older adults understand the implications
                        of driving cessation:
                          • Fewer trips outside the home.
                          • Increased and permanent dependency on others
                            for transportation.
                          • Becoming a burden to others.
                          • Fewer social opportunities.

                        Families also experience strong emotions. Sometimes
                        family members themselves become angry and frustrated,
                        while others feel guilty for depriving their loved one of
                        the freedom of driving. A calm response will ensure a
                        productive discussion and defuse negative emotions about
                        the topic. Do not postpone the conversation because of fear
                        or guilt. Be prepared to have several conversations to achieve
                        your goal. It is more important to avoid accidents or death
                        than to avoid unpleasant topics.
                                  Page 56
                                     www.thehar tford.com/talkwitholderdrivers           6
   When is it a good time to
   begin talking about driving?
   Early, occasional    Ideally, the first conversations about safety should occur
         and candid     long before driving becomes a problem.
      conversations     Early, occasional and candid conversations establish a
 establish a pattern    pattern of open dialogue and can reinforce driving safety
    of open dialogue    issues without the strain of asking someone to change his or
   and can reinforce
                        her driving behaviors. Discussion at this point allows time for
                        the older adult to consider his or her driving skills and make
driving safety issues
                        appropriate modifications. Here are some conversation
without the strain of   openers:
    asking someone
                        “Health and safety first.”
to change his or her
                        When driving is placed within the larger context of other
   driving behaviors.   safety concerns, it may take the personal edge off the
                        conversation.

                        “Driving isn’t what it used to be.”
                        Family members of any age can find common ground by
                        talking about road conditions, such as faster, heavier traffic
                        that make driving more stressful. Restricting driving in order
                        to compensate for worsening driving conditions makes sense
                        for everyone, not just someone who may need to compensate
                        for declining abilities.

                        “Did you hear about the car accident in the news today?”
                        Use news reports to inform, not scare, older persons.
                        Headline news about accidents that involve older and
                        younger drivers can provide an opportunity to explore
                        your family member’s attitudes about unfit drivers and the
                        question of who is responsible for helping them decide
                        when to relinquish the keys.

                        “How did Granddad stop driving?”
                        This opener may provide an opportunity to reveal personal
                        feelings about driving and family intervention.




                                         Page 57                                          7
       What circumstances create
       opportunities for conversations
       about driving restrictions?
   According to     According to our survey, car accidents, near        information quickly. About 75 percent of
     our survey,    misses, self-regulation of driving, and health      older adults think that a significant change in
 car accidents,
                    changes provide opportunities to talk about         their health is a legitimate reason to have a
                    driving skills. Many older adults think that        discussion about driving.
   near misses,
                    family members should talk to them when a
  self-regulation                                                       “That was a close call yesterday. I worry about
                    potential problem arises. Here are suggestions
      of driving,
                                                                        your safety on the road.”
                    for starting frank discussions without
                                                                        Fifty percent of older adults said that having
     and health     sensationalizing difficult circumstances:
                                                                        a serious accident is an opportunity to start a
changes provide     “I’m glad that you’ve cut down on night driving.    conversation, while about 33 percent said a
  opportunities     I would never want you to drive when you’re not     minor accident or narrowly avoiding an acci-
         to talk    comfortable or feel that it’s too risky.”           dent should trigger a conversation. In situa-
   about driving
                    When adults modify their driving in small ways      tions where the older driver was not at fault,
                    without guidance from others, families should       families might want to discuss diminishing
          skills.
                    praise self-regulation as a positive step and not   ability to drive defensively. In all cases, these
                    discourage the driver’s actions. For example,       discussions are more productive if they are
                    don’t dismiss the older adult as a worrier and      not held at the accident scene.
                    discourage the driver who is limiting night-
                                                                        “I’m worried about your getting lost.”
                    driving by leaving a family gathering before
                                                                        Almost 70 percent of older adults say that
                    dark. Be supportive and express your willing-
                                                                        getting lost while driving could be cause for
                    ness to support their transportation needs.
                                                                        conversation. Getting lost in a familiar place
                    “Have you asked your doctor about the effects of    may suggest potentially serious cognitive
                    your new medication on your driving?”               health issues that could affect driving skills.
                    Many medications have sedative effects that         This may also be a good time to get a
                    can prevent a person from processing                doctor involved in the discussion.

                                                        Page 58                                                        8
      How do I prepare for
      serious conversations about
      limiting or stopping driving?
       Learn about the      Do your homework before you ask a family member to
       warning signs of     significantly restrict or stop driving.
      driving problems,     Get the facts. Learn about the warning signs of driving problems,
observe the older driver    observe your relative’s driving, and look for patterns of warning
             behind the     signs of future problems. In focus groups, people reported being
       wheel over time,
                            more willing to listen to those who had driven with them. See the
                            Warning Signs for Older Drivers on page 16.
 discuss your concerns
          with a doctor,    Observe the older driver behind the wheel over time. Has
 investigate alternative
                            the driver expressed personal concerns about driving safety?
                            Is the older driver limiting where and when he or she drives?
        transportation,
   and be supportive of     Discuss your concerns with a doctor and determine what infor-
        the older driver.
                            mation you need to provide, given your relative’s medical condi-
                            tion. Some doctors may take an active role in assessing a driver’s
                            skills and rendering an opinion; others will refer a concerned
                            patient to a driving rehabilitation specialist for assessment.

                            Investigate the alternatives for helping an older driver adjust to
                            driving limitations. Consider how to satisfy social and transporta-
                            tion needs when the older adult curtails or ceases driving.
                            The “Getting There” Worksheet on page 17 can help you assess
                            driving alternatives so that the older adult is not left house-bound.
                            The Transportation Cost Worksheet on page 19 can help you
                            calculate the current amount being spent on transportation.
                            Relatives may need to set aside time each week to meet the
                            transportation needs of an older relative. Consider increasing
                            the frequency of visits, outings, phone calls, letters, and e-mails.

                            Be Supportive. The transition from driver to passenger is not
                            always easy or smooth. Your support and understanding is
                            necessary before, during and after driving changes are made.

                            Expect to have several conversations to achieve a balance
                            between safety and independence. Men may require more repeat
                            conversations than women. Don’t be dissuaded by initial negative
                            reactions. During each conversation, share your genuine safety
                            concerns and desire to protect the driver’s best interests.


                                              Page 59                                               9
How can I encourage an older
adult to plan for and use
alternative transportation?
         Effective   Effective conversations encourage future planning and
    conversations    show respect for the older adult’s ability to make appropriate
       encourage
                     decisions. When you observe the older person modifying his
                     or her driving habits, use these opportunities to explore
   future planning
                     transportation options together to give the older adult time
 and show respect    to adjust to them.
           for the
     older adult’s   “If you don’t want to drive at night, we can arrange for
   ability to make
                     someone to pick you up.” Commend the older driver for being
                     cautious and help arrange transportation.
      appropriate
       decisions.    “Let’s take the bus so we don’t have to deal with the parking
                     downtown.” Practice using public transportation together
                     before it becomes a necessity. Remember that public
                     transportation may be difficult or impossible to use for
                     some older adults with physical or cognitive difficulties who
                     must limit their driving. In these cases, families are often the
                     first and only alternative transportation.

                     “You could save hundreds of dollars if you sold your car.”
                     Insurance, maintenance, depreciation, and gasoline costs
                     make owning and operating a car expensive. Even taxi services,
                     which provide door-to-door service, can be more economical.
                     Refer to the Transportation Cost Worksheet on page 19 to
                     understand the costs of driving alternatives.

                     “What if something happened and you couldn’t drive?
                     What would you do?” Ask what-if questions to encourage
                     advance planning.




                                Page 60                                                 10
          What if an older driver doesn’t
          realize that his or her driving
          is a serious problem?
    If driving skills   If driving skills continue to deteriorate after   physical harm to others, an accident can
       continue to      self-imposed restrictions, it is necessary to     pose enormous financial and legal risks.
  deteriorate after
                        have follow-up conversations. Additional          Families should tactfully mention this
                        conversations with family members, doctors        possibility, but not dramatize the point.
      self-imposed
                        or law enforcement officials may be neces-
      restrictions,     sary. Here are some more direct appeals to        “I’m afraid to let the grandchildren ride with you.”
    it is necessary     help persuade a high-risk driver:                 An older relative may realize the degree
  to have follow-up                                                       of concern when family members will not
    conversations.
                        “Even if you were not at fault in a collision,    ride with them. Protecting lives is more
                        you could be seriously injured or die.”           important than protecting feelings.
         Additional
                        Regardless of who is at fault, older adults are
     conversations      more likely to be injured or killed because       “Let’s talk with your doctor about this.”
        with family     they have less capacity to endure the physi-      Blame the poor health, not the driver.
 members, doctors       cal trauma of an accident. Pre-existing med-      Preferably, find out the doctor’s opinion
or law enforcement
                        ical conditions may complicate recovery or        before suggesting this step. The doctor
                        result in death.                                  might not agree with the family’s assessment
      officials may
                                                                          nor want to assume the role of determining
     be necessary.      “I know you would feel terrible if someone was    who should drive.
                        hurt when you were driving.”
                        Concern for others is often a stronger moti-
                        vation than concern for self. In addition to



                                                           Page 61                                                         11
      Is there a test that can determine
      if someone is a safe driver?
There are tests for reflexes,       There is no single, simple test to determine if someone is a safe
        vision, flexibility, and    driver. However, there are tests for reflexes, vision, flexibility,
            visual attention –
                                    and visual attention – all critical skills for driving. A doctor may
                                    refer the driver to a qualified specialist for an assessment of
 all critical skills for driving.
                                    driving skills. These tests last several hours and often include a
    Some older adults prefer        road test with an evaluator present.
assessments that give them
                 tips on being      Administered by rehabilitation centers, hospitals, and Veterans
        a better, safer driver.
                                    Administration Medical Centers, these tests can cost from $200
                                    to $1,000 and are seldom covered by insurance or Medicare.
                                    The Veterans Administration may offer free tests for eligible
                                    veterans.

                                    A formal assessment may seem threatening to an older
                                    driver, especially if it is either pass or fail. Some older adults
                                    prefer assessments that give them tips on being a better,
                                    safer driver.

                                    Drivers who pass the test will receive recommendations on
                                    improving skills, avoiding certain driving situations, useful
                                    equipment (e.g., wide range mirrors, pedal extensions), and an
                                    interval for re-testing. The results are shared with the driver
                                    and possibly with the driver’s physician, if requested. Results
                                    are not shared with a licensing authority unless so ordered
                                    by the court.
                                                Page 62                                                    12
   What if the driver has dementia?
    Families should     Some persons in early stages of dementia may have sufficient insight
          be vigilant   into their driving abilities to make adjustments. They should be
    about observing
                        given the opportunity to make decisions about driving, if safety is
                        not compromised.
    driving behavior.
Firsthand knowledge     Over time, such individuals will become incapable of accurately
  of driving behavior   assessing their driving skills. In progressive dementia, the disease will
   will help families   eventually rob the driver of skills necessary for safe driving. In these
  know if and when
                        cases, families and doctors must collaborate to protect the individual
                        and may need to take immediate unilateral action.
          they need
       to intervene.    Families of persons with dementia may not realize that getting lost in
                        familiar places is a serious warning sign. Persons who are confused
                        and forgetful may also lack the ability to respond appropriately to
                        ever-changing road conditions.

                        Families should be vigilant about observing driving behavior.
                        Firsthand knowledge of driving behavior will help families know if
                        and when they need to intervene. For more information on this
                        topic, see At the Crossroads: A Guide to Alzheimer’s Disease, Dementia
                        and Driving (www.thehartford.com/alzheimers).




                                                Page 63                                             13
What if a high-risk driver refuses
to stop driving?
       You may have     Some older drivers will not respond to constructive
         to consider    conversation. You may have to consider disabling the car,
   disabling the car,
                        filing down the keys, or taking away the car. Some older
                        drivers, however, find ways to work around these actions,
filing down the keys,
                        such as calling a mechanic and having a disabled car
or removing the car,    repaired. Strategies, such as not renewing a driver’s license,
  and speaking with     or canceling registration or insurance, alone may be
         the driver’s   ineffective. Remember, drivers may continue to drive
  doctor to schedule
                        without a driver’s license, car registration or insurance
                        coverage.
            a formal
driving assessment.     If you have not yet done so, speak with the older driver’s
                        doctor or schedule a formal driving assessment. Call your
                        state licensing agency or consult the Insurance Institute
                        for Highway Safety Web site (www.hwysafety.org)
                        to learn about testing in your state.




                                   Page 64                                               14
   Start the conversations today.
     With sensitivity    Limiting or giving up driving is a difficult decision for
 toward the feelings     older adults. Families can help individuals make these
     of older drivers,
                         difficult decisions by having periodic, frank discussions
                         about driving safety and health. Ideally, the transition
   families can help
                         from driver to passenger will happen gradually over time,
     the older driver    allowing all family members to adjust to new circumstances.
   make safe driving     Successful family conversations begin with good preparation
decisions and ensure     and caring communication.
   peace of mind for
                         With sensitivity toward the feelings of older drivers, families
    the entire family.
                         can help the older driver make safe driving decisions and
                         ensure peace of mind for the entire family.




                                                Page 65                                    15
FOR THE FAMILY




Warning Signs for Older Drivers
The driving behaviors listed below could cause safety problems. They are ranked from minor to serious. Many
of the less serious issues may be overcome with changes in driving behavior or physical fitness, while the more
serious behaviors may require your immediate action. Since driving ability seldom changes drastically in a short
time, you should be able to track changes over time to get a clear picture of overall driving ability.

Here’s how to use this list.
       • Observe driving over time, keeping notes to help you understand changes in driving ability.
       • Look for a pattern of warning signs and for an increase in the frequency of occurrence.


 Driving Behavior Warning Signs – When Noticed, How Often

1.   Decrease in confidence while driving.                          16. Uses a “copilot.”


2.   Difficulty turning to see when backing up.                     17. Bad judgment on making left hand turns.


3.   Riding the brake.                                              18. Near misses.


4.   Easily distracted while driving.                               19. Delayed response to unexpected situations.


5.   Other drivers often honk horns.                                20. Moving into wrong lane.


6.   Incorrect signaling.                                           21. Difficulty maintaining lane position.


7.   Parking inappropriately.                                       22. Confusion at exits.


8.   Hitting curbs.                                                 23. Ticketed moving violations or warnings.


9.   Scrapes or dents on the car, mailbox or garage.                24. Getting lost in familiar places.


10. Increased agitation or irritation when driving.                 25. Car accident.


11. Failure to notice important activity on the side of the road.   26. Failure to stop at stop sign or red light.


12. Failure to notice traffic signs.                                27. Confusing the gas and brake pedals.


13. Trouble navigating turns.                                       28. Stopping in traffic for no apparent reason.


14. Driving at inappropriate speeds.                                29. Other signs:


15. Not anticipating potential dangerous situations.



                                                           Page 66 www.thehar tford.com/talkwitholderdrivers          16
FOR THE FAMILY




“Getting There” Worksheet
Prior to talking to an older driver about limiting or             Questions to Ask
stopping driving, thought should be given to ways                  1. What programs are available in my area?
the driver can remain engaged in life’s activities. No               2.   Is there a cost?
single method of transportation is likely to meet all
                                                                     3.   What hours and days of the week does the
needs. This worksheet is designed to help you identify
                                                                          service run?
available transportation alternatives in your area.
                                                                     4.   What are the routes or areas of service?
Family/Friends                                                       5.   Are there limits to the number of rides in a
Family and friends are the top alternative to driving                     given time period?
for older adults. This mode of transportation
                                                                     6.   Is there any assistance available to people
may seem more familiar, comfortable and social to
                                                                          with physical or other health constraints?
many older adults. That said, there may be conflicting
feelings of burdening or inconveniencing others.                     7.   Is there assistance for people with bags, etc.?
Some older adults may want to do something in                        8.   Is pre-registration with the service required?
exchange for the ride.
                                                                     9.   Are wheelchair lifts available?
Questions to Ask
 1. Are people available to provide rides at the times            Notes:
    required?
  2.   To what extent are family or friends able or will-
       ing to provide rides.
  3.   Do people provide the rides willingly or do they
       resent having to adjust their schedules?
  4.   Is there something the older adult can “trade”
       for a ride (making dinner, taking the driver to
                                                                  Demand-Responsive Services or Paratransit
       lunch, paying for gas)?
                                                                  Often referred to as the Dial-a-Ride or Elderly and
                                                                  Disabled Transportation Service, these programs are
Notes:
                                                                  almost always subsidized by government funds and
                                                                  provide door-to-door service and offer rides by
                                                                  appointment. Fees or donations are common. Many
                                                                  use vans and offer accessible services for riders with
                                                                  special needs.
                                                                  Questions to Ask
                                                                   1. Is there a minimum age or other physical or
                                                                      cognitive criteria for using the service?
Local Programs that Offer Rides
These are locally developed programs, often spon-                    2.   How much does it cost?
sored by faith-based or non-profit organizations,                    3.   Can an account be set up in advance with
which provide rides for older adults. They may charge                     the service?
nominal fees or accept donations and often operate
                                                                     4.   How far in advance do reservations need
with the help of volunteer drivers.
                                                                          to be made?
                                                                   continued

                                                            Page 67 www.thehar tford.com/talkwitholderdrivers               17
FOR THE FAMILY




“Getting There” Worksheet (cont.)
Private Program Services                                       8. Will drivers provide assistance with bags,
Services such as adult day centers, housing programs,             packages, etc.?
stores, malls, or other businesses may offer transporta-       9. Can the service accommodate wheelchairs?
tion for program participants or customers.
                                                             Notes:
Questions to Ask
 1. What ride destinations are provided?
 2. Is there a cost?
 3. What hours does the service run?
 4. What are the routes?
 5. Is there any assistance available to people with
    physical or other health constraints?
 6. Is there assistance for people with bags, etc.?
 7. Is pre-registration with the service required?
 8. Are wheelchair lifts available?                          Mass Transit
                                                             Public transportation, where available, can be an
Notes:                                                       affordable option for some older adults.
                                                             Questions to Ask
                                                              1. How much does it cost?
                                                              2. Are there discounts for older/disabled people?
                                                              3. Can an account be set up in advance with the
                                                                 service? Or are there monthly passes?
                                                              4. What hours does the service run?
                                                              5. What geographic area does the service cover?
                                                              6. Will drivers provide assistance with bags,
Taxi/Car Service                                                 packages, etc.?
These private services offer flexible scheduling and          7. Can companions accompany the person on
charge a fee. Many older adults may perceive these               the service?
services as “expensive” or “a luxury” but they can cost       8. Are wheelchair lifts available?
much less than owning and maintaining a car. Some             9. Does the older adult have cognitive or physical
taxi/car services may be willing to set up accounts              limitations that prevent him or her from using
that allow other family members to pay for services.             this mode of transportation?
Questions to Ask
                                                             Notes:
 1. How much does it cost?
 2. How is the cost calculated?
 3. How long in advance should I call for a ride?
 4. Do you offer any guarantee on response time?
 5. Are there geographic limits to where you pro-
    vide service?
 6. Can an account be set up in advance with the
    service?
 7. How are tips handled with an account system?


                                                       Page 68 www.thehar tford.com/talkwitholderdrivers           18
FOR THE DRIVER




  Transportation Cost Worksheet
  Owning and operating a vehicle can be more expensive than you think! By writing down your actual
  expenses, you can get an idea of how much money could be available for alternative transportation if you
  were to stop driving.

  To determine the annual expense to own and operate a car, list all the related expenses below. Don’t forget
  to multiply by 12 for monthly expenses, or by 52 for weekly expenses. For less frequent expenses, such as
  tires, estimate the cost and divide by the number of years between expenses. Once you have the annual
  expense for owning and operating the vehicle, you can get a better idea of how much you are already
  spending on transportation.

   Vehicle Cost Per Year                                                                                                                            Annual Cost

   Car/Lease Payment

   Regular Operating Expenses
     • Gas........................................................................................................................................................................................
     • Washer Fluid ......................................................................................................................................................................
     • Parking ................................................................................................................................................................................
     • Tolls......................................................................................................................................................................................
     • Other....................................................................................................................................................................................

   Regular Maintenance
     • Oil Changes ........................................................................................................................................................................
     • Minor Tune-ups ..................................................................................................................................................................
     • Wiper Blades ......................................................................................................................................................................
     • Lights ..................................................................................................................................................................................
     • Car Wash/Wax ....................................................................................................................................................................
     • Other....................................................................................................................................................................................

   Long-Term Maintenance
   (estimate the cost and divide by the number of years between expenses)
      • Tires ....................................................................................................................................................................................
      • Brakes ..................................................................................................................................................................................
      • Major Tune-ups ..................................................................................................................................................................
      • Repair/Replace Parts ........................................................................................................................................................
      • Other....................................................................................................................................................................................

   Insurance – Annual Cost

   Motor Club/Roadside Assistance

   Registration/License Plate Fees

   License Fees

   Vehicle Inspection/Emissions Fees

                                                                                              Total Cost Per Year                        $


                                                                                           Page 69 www.thehar tford.com/talkwitholderdrivers                                                         19
Web Resources                                         Survey Data Collection
Hartford/MIT At the Crossroads: A Guide               In Spring 2002, we sent written questionnaires to
to Alzheimer’s Disease, Dementia & Driving            a sample of 7,200 home-dwelling adults aged 50
www.thehartford.com/alzheimers                        and older living in the United States. The sample
                                                      was stratified by age and was selected from a pool
MIT AgeLab                                            of participants in an ongoing consumer marketing
web.mit.edu/agelab                                    panel about whom we had some preliminary
                                                      demographic information. For the purposes of
AARP Driver Safety Program                            this study, drivers were considered to be people
www.aarp.org/drive                                    who were licensed to drive and had driven an
1-888-227-7669                                        automobile at least once in the previous 12 months.
                                                      Participants were offered a $1 incentive to complete
National Highway Traffic Safety Administration        the questionnaire. Of the total questionnaires
www.nhtsa.gov                                         sent, we had 3,824 returned for a 53 percent
                                                      response rate.
National Safety Council
www.nsc.org                                           To correct for some of the differences between the
www.TheDefensiveDrivingSchool.com                     sample and the population as a whole, the data are
                                                      weighted to 2001 Current Population Study quotas
Certified Driver Rehabilitation Specialists           on gender, age, region, household designation,
www.driver-ed.org                                     and household size. More precisely, the sample is
                                                      representative of adult drivers aged 50 and older
Eldercare Locator                                     who live in households headed by someone 50 or
www.eldercare.gov                                     older. Results reported here are based on the
                                                      weighted data.
Insurance Institute for Highway Safety
www.hwysafety.org

American Medical Association Guidelines for
                                                      The Hartford/MIT
Older Drivers
www.ama-assn.org/ama/pub/category/8925.html
                                                      AgeLab Partnership
                                                                             In 1999, The Hartford became
American Occupational Therapy Association                                    a founding sponsor of the
www.aota.org                                                                 MIT AgeLab, creating the
                                                      Safe Driving for a Lifetime partnership. Dr. Joseph
                                                      Coughlin of MIT and the Corporate Gerontology
                                                      Group at The Hartford are committed to producing
                                                      original research that can expand the understanding
                                                      of older drivers and their families as they deal with
                                                      changes in driving abilities. Through professional
                                                      meetings and public education, the Hartford/MIT
                                                      AgeLab partnership has successfully reached mil-
                                                      lions of people in the United States and across the
                                                      globe with high-quality, meaningful information to
                                                      guide important decisions about safe driving.

                                                 Page 70                                                      20
You can also visit us on the Web at:
www.thehartford.com/talkwitholderdrivers

To obtain additional copies of this free brochure,
use the convenient order form on the Web site, or
write to:                                                                      Safe Driving for a Lifetime




  The Hartford
  Family Conversations with
   Older Drivers
  200 Executive Boulevard                           We need to talk ...
  Southington, CT 06489                                 Family conversations with older drivers




For information on dementia and driving, visit
www.thehartford.com/alzheimers. To obtain a free
copy of the At the Crossroads: A Guide to Alzheimer’s
Disease, Dementia & Driving brochure, use the
convenient order form on the Web site, or write to:

  The Hartford                                                                Safe Driving for a Lifetime




  At the Crossroads
  200 Executive Boulevard
  Southington, CT 06489
                                                          At the Crossroads
                                                          A Guide to Alzheimer’s Disease,
                                                              Dementia & Driving




Both Web sites and both publications are also available
in Spanish.




This guide is designed to educate readers and assist them in analyzing
older driver safety. It is not intended to be an exhaustive source or to
relate to any particular driving situation. Readers are advised to con-
sult the necessary professionals to assist them in analyzing their driving
situation and to refer to the sources identified in the section entitled
“Web Resources” for additional information.


        Page 71
Page 72
Health, Functional Status & Older Driver Safety:
A Curriculum for State Highway Patrol Examiners & Officers                                                ______



Pre-Test Evaluation
1. Your gender:                  ___Male          ___Female

2. Your background:              ___Driver Examiner             ___State Trooper           ___Police Officer

3. Years of experience:          ___1-5 years                   ___5-10 years              ___10+ years

4. Approximately, what % of the persons you interact with professionally (i.e., in testing or traffic
stops) are older adults (65+ years old)? Circle your response below. If unsure, make your best guess.

           0%     5%      10%      20%     30%     40%        50%   60%     70%      80%    90%    100%



5. Circle “True” or “False” for each of the following statements. Make your best guess if unsure.

   a) A driver with Parkinson’s disease may have trouble quickly moving his
      foot from gas to brake.                                                              True   False
   b) A person with low contrast sensitivity should avoid night driving.                   True   False
   c) Approximately 15% of licensed drivers in Missouri are aged 65 and older.             True   False
   d) As a group, older drivers are more prone to accident than teen drivers.              True   False
   e) Form 4319 is restricted for use by police and troopers only.                         True   False
   f)    Glaucoma causes primarily a failure of central vision.                            True   False
   g) House Bill 1536 mandates that physicians report persons with Alzheimer’s
      disease for driver skills testing.                                                   True   False
   h) Left turns can be especially challenging for some older adults.                      True   False
   i)    Less than 10% of older drivers cited under HB-1536 retain a valid license         True   False
   j)    Males are more prone to crash and death across all ages.                          True   False
   k) Older drivers are involved more single-car crashes than teen drivers.                True   False
   l)    Older drivers are said to be “medically fit to drive” if they have no health
         conditions that may impact on key driving tasks.                                  True   False
   m) Peripheral neuropathy can make the brake pedal feel slippery.                        True   False
   n) Persons with dementia are often confused about time relationships.                   True   False
   o) Persons with dementia must retire from driving eventually.                           True   False
   p) Persons with dysnomia cannot understand that is said to them.                        True   False
   q) Persons with early dementia have recent memory loss.                                 True   False
   r)    Persons with moderate dementia are usually unsafe to drive.                       True   False
   s)    Someone with Kyphosis cannot see near objects.                                    True   False
   t)    The most common cause of memory loss in older adults is stroke.                   True   False
   u) Vehicle operation skills are the first to fail in persons with dementia.             True   False



        Please turn in this completed form to the presenter or at the registration desk. Thank you.

                                                    Page 73
Page 74
Health, Functional Status & Older Driver Safety:
A Curriculum for State Highway Patrol Examiners & Officers                                            ______



Post-Test Evaluation

Please rate today’s workshop on the following dimensions:

                                                                       POOR                       EXCELLENT

1. Overall quality of the presentation                                   1       2     3      4       5

2. Comprehensiveness of the presented information                        1       2     3      4       5

3. Applicability to your work situation & needs                          1       2     3      4       5

4. Quality of the handout materials                                      1       2     3      4       5



5. How likely are you to use the Cited Driver Worksheet or elements from it in your future
interactions with older drivers?

        ___ Unsure         ___ Not likely at all        ___ Somewhat likely            ___ Very likely



6. Circle “True” or “False” for each of the following statements. Make your best guess if unsure.

   a) A driver with Parkinson’s disease may have trouble quickly moving his
      foot from gas to brake.                                                          True   False
   b) A person with low contrast sensitivity should avoid night driving.               True   False
   c) Approximately 15% of licensed drivers in Missouri are aged 65 and older.         True   False
   d) As a group, older drivers are more prone to accident than teen drivers.          True   False
   e) Form 4319 is restricted for use by police and troopers only.                     True   False
   f)   Glaucoma causes primarily a failure of central vision.                         True   False
   g) House Bill 1536 mandates that physicians report persons with Alzheimer’s
      disease for driver skills testing.                                               True   False
   h) Left turns can be especially challenging for some older adults.                  True   False
   i)   Less than 10% of older drivers cited under HB-1536 retain a valid license      True   False
   j)   Males are more prone to crash and death across all ages.                       True   False
   k) Older drivers are involved more single-car crashes than teen drivers.            True   False
   l)   Older drivers are said to be “medically fit to drive” if they have no health
        conditions that may impact on key driving tasks.                               True   False
   m) Peripheral neuropathy can make the brake pedal feel slippery.                    True   False
   n) Persons with dementia are often confused about time relationships.               True   False
   o) Persons with dementia must retire from driving eventually.                       True   False


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                                                   Page 75
Health, Functional Status & Older Driver Safety:
A Curriculum for State Highway Patrol Examiners & Officers                                      ______


   p) Persons with dysnomia cannot understand that is said to them.              True   False
   q) Persons with early dementia have recent memory loss.                       True   False
   r)   Persons with moderate dementia are usually unsafe to drive.              True   False
   s)   Someone with Kyphosis cannot see near objects.                           True   False
   t)   The most common cause of memory loss in older adults is stroke.          True   False
   u) Vehicle operation skills are the first to fail in persons with dementia.   True   False



7. What did you like or appreciate about this training today? List examples.




8. What about today’s presentation could be improved when offered in the future?




9. Other comments?




   Please turn in this completed form to the presenter or at the registration desk. Thank you.




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