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					                                                                                       Objectives
                                                                 1. Prove importance of older driver assessment

                                                                 2. Highlight challenges of older driver
       The drive to keep older                                      assessment
            patients safe
                                                                 3. Review older driver assessment process &
                  CC Rounds                                         recommendations (CMA, AMA etc…)
        Dr. Heidi Schmaltz, Geriatrician
                                                                 4. Discuss dementia & driving
               February 1, 2006
                                                                 5. Identify useful tools & resources for older
                                                                    driver assessment & counseling




    Importance of Older Driver
           Assessment
                                                                      Car plows through market, killing 9
                                                                             Thursday, July 17, 2003 Posted: 1546 GMT (11:46 PM HKT)

                                                                    SANTA MONICA, California (CNN) --
                                                                    An 86-year-old man who drove his mid-size
                                                                    Buick through a crowded farmers‘ market
                                                                    …told police he couldn't stop and may have
                                                                    hit the accelerator instead of the brake…




                    Importance
• Aging population
  – older driver fatalities & injuries will triple in next 35y
                                                                        Challenges of Older Driver
• MVA’s lead cause accidental death 65 7
                                     - 4                                       Assessment
  – 2nd only to falls in 75- 84

• More collisions/ km than all but <25 yo
  – Lower mileage

• Higher fatality rate/ crash than other ages




                                                                                                                                       1
       Assessment Challenges 1                                   Assessment Challenges 2
                                                             • Aging physiology - Heterogeneity
• Older drivier characteristics
                                                                – Age alone is not enough!
                    -
  – Experience; “over learned” behavior                         – ↓peripheral vision; ↑reaction time; ↑adaptation
                                                                 time to glare/change in lighting
                     -
  – Less mileage; self restriction

  – More seatbelts & Less risky behavior                     • Aging vs. Disease
                                                                    -   o
                                                                – Co mrbidity
                                    - ehicle, left turns)
  – Most crashes intersections (multi v                         – Diagnosis alone not sufficient
                                                                – Fluctuations/ change over time




      Assessment Challenges 3                                     Assessment Challenges 4
                                                            • Complexity of Driving
  • Drugs affecting driving                                   – Multiple decisions/minute
     – Altered pharmacokinetics                               – Hierarchy of skills
                                                            • MDs assess only operational skills
     – Polypharmacy                                              • Cognitive/ physical capabilities req’d to operate vehicle
     – Increased sensitivity to CNS side effects              – NOT tactical skills
                                                                 • Decisions, behavior & attitudes while driving
        • Benzodiazepines
                                                              – NOT strategic skills
     – Remember OTCs & Alcohol                                   • Decisions & planning before driving
                                                              – NOT extrinsic risks




       Assessment Challenges 5                                    Assessment Challenges 6
            - atient relationship
  • Physician p                                              • Single biggest challenge:
  • Consequences driving cessation
                                                              NO reliable, clinically sensible, valid
  • Difficulties reinstating license
                                                                tools for screening/ assessment
  • Lack of confidence in assessment

  • Worried breach of confidentiality                            • All class III evidence (consensus)

  • “Not my job”




                                                                                                                               2
                                                           Process & Recommendations
                                                           for Older Driver Assessment




       Assessment Process 1                                      Assessment Process 2
                                                          • In AB, medical report required:
• Identify if medically unfit to drive
                                                            – To renew classes 1, 2, 4
  – Unsafe to drive due to medical conditions
  – Course/ prognosis                                       – If Code C (periodic satisfactory medical
  – Benefit from further assessment &/or treatment            report) or Code D (periodic vision report)

                                                            – By age
• Provincial requirements/ national standards                  • ≥75 years Q 5years
  – Personal vs. professional requirements                     • ≥ 80 years Q 2years
  – Car vs. other vehicles
                                                            – If medical condition affecting driving




    Recommendations – CMA                                     Recommendations - CMA
Determining Medical Fitness to Drive (2000)              Section 12: The aging driver (2 pages)
 – ~80 pages; Revision due 2006                            – Broad; no specific recommendations
 http://www.cma.ca/index.cfm/ci_id/18223/la_id/1.htm
                                                           – Watch for cognitive/ physical dysfunction
 – Thresholds of medical fitness by issue/system             affecting driving
    • Physical, mental, emotional fitness                     • Vigilant during regular evaluation for above factors
    • See CCS, Diabetes & CCMTA (seizures) for updates
 – Not an assessment approach or rules                     – Suggest
 – Public safety > confidentiality                            • MD may recommend road test or driving restrictions
                                                              • Not to ignore police reports of dangerous driving
 – Consider context




                                                                                                                       3
         Recommendations - CMA                               Recommendations - AMA
                                                         Physician’s Guide to Assessing and Counseling
Section 12 - Older Driver Factors to Consider                           Older Drivers (2003)
   1.    failing vision                                   http://www.ama-assn.org/ama/pub/category/10791.html (~200 pg)
   2.    hearing loss
   3.    slowing of perception                          Process of Assessment:
   4.    episodes of confusion & declining memory         1. Identify risk on history
   5.    loss of strength                                 2. Focused physical examination
   6.    arthritic joints                                 3. Treat identified causes of functional decline
   7.    COPD                                             4. Refer for further evaluation prn
   8.    potential for sudden changes in heart rhythm
                                                          5. Counsel : safe driving, restrictions, cessation
   9.    side effects of prescribed & OTC drugs
   10.   daily EtOH consumption                                   -     p    -
                                                          6. Follow u post cessation




                                                               Recommendations - AMA
     Recommendations - AMA
                                                        Driving History:
Red flags on history:                                       (Guide includes pt & family questionnaires)
1. Acute medical events, new presentation                  1. Driving pattern including passengers
   or unstable condition                                   2. Driving need; alternatives
2. Chronic medical conditions including                    3. Family concern re. driving safety
   those with unpredictable/ episodic events               4. Patient concerns/ decreased confidence
3. Medications including changes                           5. Accidents or near m- isses (2 years)
4. Symptoms of concern on review of                        6. Traffic tickets or warnings (2 years)
   systems                                                 7. Becoming lost
5. Driving history*                                        8. Poor night vision
                                                           9. Forgetfulness and confusion




     Recommendations - AMA                                     Recommendations - AMA
   Assess Driving Related Skills 1                                   ADReS 2
                                                        FUNCTION         TEST                      FURTHER Ax
FUNCTION         TEST                   FURTHER Ax                                                 THRESHOLD
                                        THRESHOLD
                                                        Motor speed      3m walking speed > 9 seconds
Visual Acuity Snellen E chart           <20/40          Motor ROM        Neck, shoulders,          Excessive pain,
Visual Fields Fields by                 Any defects                      elbows, fingers,          hesitation, very
              confrontation                                              ankles                    limited ROM
Cognition     Trail Making B            >180 seconds
                                                        Motor             Bilateral arms, R        <4/5
              Clock Drawing             Any errors      Strength           -
                                                                         (+/ L) leg




                                                                                                                          4
      Recommendation - CanDRIVE                                               Recommendations - SAFE DRIVE
  •   Cognition                                                           •   Safety record (from DMV)
  •   Acute or fluctuating illness                                        •   Attention skills
  •   Neuromusculoskeletal disease or neuro defects                       •   Family report
  •   Drugs                                                               •   Ethanol use
  •   Record
                                                                          •   Drugs
  •    - ar
      In c experience
      – Family & patient questionnaires provided                          •   Reaction time
  • Vision                                                                •   Intellectual impairment
  • Ethanol use                                                           •   Vision & visuospatial ability
                                                                          •   Executive functions
                   http://www.candrive.ca
                                                                              Wiseman & Souder. Geriatrics 1996; 51(7):36-45




                                                                                          Dementia & Driving
                                                                                               Dementia Definition
                                                                          1. Multiple cognitive deficits affecting:
                                                                                   -
                                                                               Short term memory, Language, Reasoning
               Dementia & Driving                                              Agnosia, Apraxia

                                                                          2. Significant social/occupational impairm’t &
                                                                             decline from previous

                                                                          3. Not during delirium episode or other
                                                                             psychiatric diagnosis




        Dementia & Driving - CMA                                                 Dementia & Driving - AMA
Section 13.5: Progressive dementia                                     • Driving ability & not dementia diagnosis important

  – Additional focused assessmt if cognitive impairment                • Consider & discuss risks for all patients with dementia
  – Support plan for driving cessation                                 • Focused medical assessment including:
  – Driving with known dementia risky                                     – driving history from family/ caregiver & assessment of
  – Reliance on MMSE score                                                  memory, attention, judgment, visuospatial
      • Ineligible to drive if <24/30 until further neuro assessment
                                                                       • If potentially impaired driving ability, then formal
      • Limits of MMSE                                                   assessment of driving skills
  – Poor judgment, reasoning ability, abstract thinking,
    & insight evaluated for driving ability even if ≥24/30             • Encourage pts with progressive dementia to plan early
                                                                         for driving cessation




                                                                                                                                     5
           Dementia & Driving
                                                                   Dementia & Driving - Misc
       American Academy Neurology
                                                            • Most AD pts stop driving <3y from dx
• Alzheimer pts increased risk crashes
                                                            • More complex cognitive skills (judgmt, speed
• CDR 1.0 (MMSE 19 2 unacceptable risk
                 - 5)                                         control, react to others) > driving mechanics

                                                            • Consider other cognitive or functional problems
                       - 9yo
• CDR 0.5 (MMSE 25) = 16 1 or BAC<.08%
  – Driving performance evaluation                          • Poor insight adds additional challenge
  – Reassess dementia & driving Q6mos
                                                            • Difficult extrapolating cognitive tests to driving
                                                              ability
• Further research re. other dx, risk factors, subgps
                                                                 – Drive Able preferred test (www.driveable.com)
    Dubinsky et al. (2000) Neurology 54(12): 2205 - 2211         – Driving toolkit (www.candrive.ca)




                                                                    After the Assessment:
                                                                Recommending Driving Cessation
                                                            • Document & explain assessment results/
                                                              recommendations
              After the Assessment                          • Prescription &/or letter
                                                            • Discuss transportation options
                                                                 – SW or Seniors outreach referral
                                                            •   Reinforce recommendations at future visits
                                                            •   Follow-up & monitor for depression
                                                            •   Report concerns to Driver Fitness Branch
                                                            •   Disable/ remove car




    Reporting Assessment in AB                                  Reporting: DriveAble sample letter
  • Discretionary                                           This patient has the following condition(s) likely to
      – Failure to meet published standard for fitness      significantly interfere with driving
                                                              Alcohol or drug abuse
      – Patients required to report their own conditions
                                                              Seizure(s) or loss of consciousness
      – Encouraged to report by CPSA                          Vision impairment or field deficits
                                                              Cognitive impairment
  • Protected from liability for reporting                    Dementia or Alzheimer Disease
      – Precedents for liability for NOT reporting            Stroke or head injury
                                                              Heart disease with pre-syncope, syncope
                                                              Uncontrolled diabetes or hypoglycemia
  • Driver Fitness & Monitoring Branch                        Unstable mental illness
      – Restrictions or asked to submit license               Uncontrolled or untreated sleep apnea or narcolepsy
      – Complex/ disputed case reviewed by Medical Review     Other__________________________________
        Board, who may ask for further evaluation




                                                                                                                    6
   Reporting: DriveAble sample letter                             After the Assessment:
                 cont’d.                                     If not recommending cessation
                                                         • Schedule follow-up assessment

    Situation is a serious road safety risk              • Encourage planning for driving cessation
    Road safety risk is unknown
    Driving assessment completed, DriveABLE
                                                         • Safe driving tips
  Report attached
    DriveABLE Assessment Recommended
    Patient is aware of this letter                      • AMA ‘refresher’ course for older drivers

  (form letter file available from DriveAble website;    • CanDrive self-evaluation CD-ROM (AMA)
  can be personalized/put on letterhead)




          After the Assessment
         Sample Safe Driving Tips
  • Always wear seatbelts
  • Plan all trips
     – familiar routes; avoid high s
                                 - peed/ dense traffic               Other resources
  • Avoid twilight/ dark & bad weather
  • Do not drive if tired or emotionally upset
  • Drive for short distances/periods only
  • Never drive after consuming alcohol
  • Use mirrors often; scan environment
  (Handouts available from AMA, CanDrive)




               Other resources
• Disease guidelines:                                              Thank you!
  – http://www.diabetes.ca
  – http://www.eyesite.ca
                                                                  Any questions?
  – http://www.css.ca (CVD);
                                                                     Contact info: Heidi Schmaltz
• Review article:
                                                               heidi.schmaltz@calgaryhealthregion.ca
                                        - 6
  – Hogan (2005) Can Fam Physician 51:362 38
                                                            (Additional references available upon request)




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