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?