Outline & Objectives Clinical Assessment of the Older Patient for Driving Fitness

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1 Outline & Objectives Clinical Assessment of the Older Patient for Driving Fitness Presented by: Linda Hill, MD, MPH Professor, UC San Diego School of Medicine A collaborative effort by the Division of Preventive Medicine and the Division of Trauma Part 1: Demographics and Safety Risks of Aging Identify conditions that may put patients at risk for unsafe driving Part 2: Screening and Interpretation Name the clinical screens to evaluate patients level of function for driving fitness Part 3: Managing Outcomes State referral and treatment options for patients who require further evaluation or are no longer fit to drive Part 4: Reporting Requirements Demonstrate familiarity with California DMV reporting methods and requirements Older Adults & Driving On average, older adults are dependent on alternative transportation after driving retirement Men for 7 years Women for 10 years Driving cessation results in 15% fewer trips to doctor 65% fewer trips for social, family and recreation purposes Decrease in number of friends and/or social network Decline in activity levels (Foley et al., 2002) Greater risk of worsening depressive symptoms Why Is This a Problem? Problems related to age can include Reduced vision Cognitive impairment Decreased strength Other medical conditions and medications can impair driving Fonda, S.J., et al. J Gerentol. 2001;56(6):S Foley DJ, et al. Am J Pub Health. 2002;92(8): Vision Changes with Aging Reduction in Visual Acuity Low vision or blindness between age 65 and 69 = 1.5% >80 years of age = 24% Reduction in Visual Fields Visual field loss in both eyes = crash rates 2x higher Nearly one in seven >65 display abnormal visual fields Cognitive Impairment Many conditions resulting in cognitive impairment are age related and are under diagnosed Prevalence rates rise significantly with age years: 2.4% years: 11% Greater than 85 years: % Congdon, et al. Arch Ophthalmol. 122, no 4 (April 2004) Johnson, C.A. and Keller, J.L., 1983 Lindsay et al., Canadian Journal of Psychiatry, 49, no 2 (February 2004): Burleigh 2002, Harwood 1997, Valcour 2000, Chodosh 2004.

Interpretation Name the clinical screens to evaluate patients level of function for driving fitness Part 3: Managing Outcomes State referral and treatment options for patients who require further

2 CA License Renewal Policy Medications Affect Driving Individuals 70 years of age and older Must renew license in person License is renewed for five years if vision and written tests are passed and there are no signs of cognitive impairment A limited term license may be issued for one to two years if a medical problem exists but is not severe enough to stop driving (e.g., mild dementia) california/renew license.php Various medications and polypharmacy can cause problems for drivers Anticonvulsants Antidepressants Antiemetics Antihistamines Anticholinergics Antihypertensives Antiparkinsonians Antipsychotics Anxiolytics Muscle relaxants Narcotic analgesics Stimulants Strengths of Older Drivers General characteristics of older drivers (Physically and cognitively intact) Take fewer risks More patient Possess greater life experience and knowledge of how actions impact others More compliant with the law Physician s Guide American Medical Association and National Highway Traffic Safety Administration (NHTSA) Physician s Guide to Assessing and Counseling Older Drivers Quick screening and referral tool Available at ama assn.org/go/olderdrivers AMA Screening Tools Assessments include 1. Visual Fields by Confrontation Testing 2. Visual Acuity 3. Rapid Pace Walk 4. Manual Test of Range of Motion 5. Manual Test of Motor Strength 6. Clock Drawing Test 7. Trail Making Test Visual Testing Test 1 Visual Fields Impaired peripheral vision can result in Failure to react to a hazard coming from the far left or right Failure to heed a stop light suspended over an intersection Weaving while negotiating a curve Driving too close to parked cars Test 2 Visual Acuity If corrected vision is worse than 20/40 = refer to a specialist 20/70 = recommend an on the road assessment 20/100 = advise the patient to stop driving

3 Frailty Testing Test 3 Rapid Pace Walk Testing for physical strength and balance Instruct patient to walk 10 feet, turn around, and walk back Test 4 Range of Motion Fingers, neck, shoulders, elbows and ankles Test 5 Motor Strength Shoulder adduction, abduction and flexion Wrist flexion and extension Hand grip strength Hip flexion and extension Ankle dorsiflexion and plantar flexion Cognitive Testing Test 7 Trail Making Test A time greater than 180 seconds requires further evaluation; dementia is a likely cause, but consider false positives Normal controls: average 81 seconds Mild Cognitive Impairment: average 136 seconds Alzheimer s disease: average 190 seconds UCSD Experience UCSD patients over age 65 were screened 73.5% passed 6.5% failed due to vision or frailty 11.3% failed due to cognitive impairment 8.7% did not complete the full screen 34.8% said they used a cell phone while driving Assessment Results Four possible outcomes 1) Pass 2) Fail: vision and/or frailty 3) Fail: cognitive/medical history Mandatory DMV Reporting 4) Incomplete: needs to repeat testing Hill L et al. Journal of Safety Research 2011;42(3): Management of PASSES Many older drivers have medical conditions and medications that could impair concentration, strength and cognition Help prolong driving and mobility Treat following evidence based guidelines Use the lowest effective dose of drugs Promote the general health guidelines No W/Up Management of FAILS FAIL Vision, Frailty, or Other Medical Condition Is the diagnosis confirmed? No Surrender license: discuss alternative transportation Yes Does the patient want to continue driving? Yes Treat manageable disease; consider DRS evaluation FAIL Cognitive Tests or Lapse of Consciousness Report to DPH and W/Up

Testing Test 7 Trail Making Test A time greater than 180 seconds requires further evaluation; dementia is a likely cause, but consider false positives Normal controls: average 81 seconds Mild

4 Who Can Help Occupational Therapy Generalists Driver Rehabilitation Specialists (DRS) Certified Driving Rehabilitation Specialist (CDRS) Certification through Association of Driver Rehabilitation Specialists (ADED) or (866) Specialty Certification in Driving & Community Mobility (SCDCM) Certification through American Occupational Therapy Association (AOTA) OT Generalist vs. DRS Clinical evaluations (cognitive, visual, perceptual, psychosocial, motor) Awareness of medical conditions, disabilities, and the aging process that may impact driving Generalist Specialist Behind-the-wheel assessments NO Passenger vehicle inspection NO Vehicle adaptive equipment NO Providing counseling on safe driving, alternate modes of transportation Driving Retirement Acknowledge that the patient has suffered a loss If necessary, assess the patient for symptoms of depression and make appropriate referrals Explain that driving retirement is for their safety and the safety of others Help the patient view the positives Discuss possible legal/financial consequences Send a follow up letter to the patient and family CA Title 17 Section Every physician and surgeon shall report every patient at least 14 years of age or older whom the physician and surgeon has diagnosed as having a case of a disorder characterized by lapses of consciousness. Lapse of Consciousness refers to conditions that involve Reduction of alertness or responsiveness to external stimuli Inability to perform one or more activities of daily living Impaired sensory motor function used to operate a motor vehicle dmv.ca.gov/pubs/vctop/appndxa/hlthsaf/hs htm Health & Safety Code Mandatory reporting of conditions that may progress in severity and are associated with lapses of consciousness Narcolepsy, sleep apnea Abnormal metabolic states hypoglycemia hyperglycemia Epilepsy Dementia, Alzheimer s disease Brain tumor Reporting Considerations Making the decision to report a patient may require physician discretion Factors to consider 1) Did a lapse in consciousness occur? 2) Is it related to an on going condition vs. a one time event?

5 Provider Liability Referral to DMV Physicians are considered negligent if they do not inform patients of medications and medical conditions that can impair driving Physicians may be held liable for civil damages if they clearly failed to report an impaired driver who causes a MVC Immunity is granted to the physician if the patient is reported prior to a MVC Document all referrals, recommendations, conversations, and reports (e.g., copy of a driver retirement letter and do not drive prescription) Driver Safety Office Initial Review No Action Medical Probation and/or Impose Safety Restrictions Suspend or Revoke License (Effective in Four Days) Provide Medical Evaluation Form (Due within 24 Days) Schedule a Re Examination DMV Decision Options Contact No Action Training, Research and Education for Driving Safety Review of Medical Evaluation Form Conduct Interview with Driver Schedule Re Examination Medical Probation or Safety Restrictions May involve a vision, written and driving test: evaluated on a case by case basis University of California, San Diego 9500 Gilman Dr. #0811 La Jolla, CA Tel: (858) Fax: (858) Suspend or Revoke 41 Website: TREDS.ucsd.edu TREDS@ucsd.edu 109

recommendations, conversations, and reports (e.g.

Law Enforcement s Identification and Referral of Medically Impaired Older Drivers

Presenters Law Enforcement s Identification and Referral of Medically Impaired Older Drivers Linda Hill, MD, MPH Department of Family and Preventive Medicine University of California, San Diego D. R. Ike