Assessment of Older Drivers by nikeborome

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									     The Elderly Driver:
   Functional Assessment
  Richard Marottoli, MD, MPH, VA CT and
             Yale University

   Shirley Neitch, MD, FACP, Hanshaw
 Geriatric Center, Marshall University, WV
Adapted from a satellite conference produced by
Department of Veterans Affairs Employee Education
Service and Office of Geriatrics and Extended Care, and
Consortia of Geriatric Education Centers.
Mr. Jones is an 83 year old widower sent
 for follow-up after hospital discharge

• PMH: HTN, hyperlipidemia, hip
  fracture, OA, cataracts
• Function
  – Lives in own home
  – Independent in l/B ADL, uses cane
  – Daughter visits twice/week
    • Straightens house
    • Brings food to reheat
               Driving

• 3-4 x/wk

• Mostly familiar places

• Minor crash 3 yrs ago

  – Rear-ended at stop sign

• No navigation problems
   Hospitalized 2 Weeks Ago

• Found on bathroom floor by daughter

• Awake but confused

• Unsure what happened, how

• ER: temp, +UA, renal insufficiency
  admitted for observation b/o ? LOC,
  hit head
          Hospital Course:
• Confusion resolved w/ IV fluids,
  antibiotics
• Head CT: Infarct of ? age
• Function: Needed assist w/transfers,
  walker for ambulation
• Disposition: STR; f/u appt. w/you
  regarding driving, living situation
• Home after 1 week at STR, returned to
  baseline mobility
     Types of Assessments

• Driving skills and behaviors can be
  assessed in different settings and at
  different levels of complexity:
  – DMVs
  – Rehabilitation Facilities
  – Local or Regional Assessment Clinics
  – Primary Care Provider Offices
   Types of Assessments
– “ADReS” Assessment of Driving-Related
  Skills
– available in Physician’s Guide to Assessing
  and Counseling Older Drivers developed by
  the American Medical Association in
  cooperation with the National Highway Traffic
  Safety Administration, September 2003,
  Chapter 3.
– Seven component testing protocol
– Much of the testing can be done by office
  staff
– Time required generally 10 min. or less
                 ADReS

• Seven Components:

  – Visual Fields     – Motor Strength

  – Visual Acuity     – Trail-Making
                        Test, Part B
  – Rapid Pace
    Walk              – Clock Drawing
                        Test
  – Range of Motion
                  ADReS

Component:
  Visual Fields
How Tested:
  Confrontation
Result Signaling Need for Intervention:
  Any field cut
                  ADReS

Component:
  Visual Acuity
How Tested:
  Snellen or Rosenbaum chart
Result Signaling Need for Intervention:
  Varies by state; most commonly, best
  corrected vision of 20/40 required
                 ADReS

Component:
  Rapid Pace Walk
How Tested:
  Mark 10 foot distance; Time patient
  walking 10 ft., turning, walking back
Result Signaling Need for Intervention:
  Time > 9 seconds
                   ADReS

Component:
   Range of Motion
How Tested:
  Neck rotation, finger curl, shoulder &
  elbow flexion, ankle plantar- &
  dorsiflexion ---Simulate driving position
Result Signaling Need for Intervention:
   Any clinically significant deficit
                 ADReS

Component:
  Motor Strength
How Tested:
  Shoulder, wrist, hand grip, hip, ankle
Result Signaling Need for Intervention:
  <4/5 in either upper extremity or right
  lower extremity
                  ADReS

Component:
  Trail-Making Test, Part B

How Tested:

  Standard form

Result Signaling Need for Intervention:

  > 180 seconds
                  ADReS

Component:
  Clock Drawing Test

How Tested:

  Standard form

Result Signaling Need for Intervention:
  Any abnormal element
         Visit Information
       (2 Weeks Post Discharge)

• Hx: No new complaints, feels fine

• Meds: Beta blocker, thiazide, statin

• Exam: BP, HR WNL

    Cataracts; OA changes hands/knees;
    good strength; independent transfers,
    stable slow gait with cane
          ADReS Findings

• Visual Fields: Intact
• Visual acuity: 20/40 ou
• Rapid pace walk: 8 sec (w/cane)
• ROM: Neck rotation, finger curl limited
• Strength: 4+ - 5/5
• Trails B: 135 sec
• Clock: # spacing slightly off
             Questions


1. What do you advise Mr. Jones
   regarding his driving? His living
   situation?

2. Are there other history, exam, or
   laboratory data that would be helpful
   at this point?
          Follow Up Visit
• 9 Months later (1 no show in interim)
• Accompanied by daughter who
  reports
  – More confused - oversees meds
  – House less clean, hygiene worse
  – Still drving - lost going to her house;
    no known crashes, but ? new scrapes/
    scratches on car
           Follow Up Visit

• Mr. J:
  – No functional changes
  – Increase in urinary frequency,
    occasional incontinence
• PE:
  – BP, HR higher compared with prior
    visits, otherwise unchanged except
    unkempt appearance, stains on clothes
          ADReS changes

• Rapid pace walk: 8.5 sec (8)

• Trails B: 165 sec (135)

• Clock: # spacing off, # on margin of
  clock, hand placement incorrect

• Fields, Acuity, ROM, strength
  unchanged
             Questions


1. What do you advise Mr. Jones
   regarding his driving? His living
   situation?

2. Are there other history, exam, or
   laboratory data that would be helpful
   at this point?

								
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