British Columbia Driver Fitness Handbook for Medical Professionals

Transcription

1 British Columbia Driver Fitness Handbook for Medical Professionals Ministry of Justice Office of the Superintendent of Motor Vehicles PO Box 9254 Stn Prov Gov Victoria BC V8W 9J2 Toll-Free: Fax: ii

2 Foreword We are pleased to present The BC Driver Fitness Handbook for Medical Professionals. The Handbook is a companion piece to the 2010 BC Guide in Determining Fitness to Drive. The Handbook was developed for the use of medical professionals who may have to consider a patient s fitness to drive and also to assist medical professionals faced with discussing driving ability with their patients. The Handbook provides medical professionals with the information that is required by the Office of the Superintendent of Motor Vehicles (OSMV) when determining a patient s fitness to drive. The Guide and the Handbook replace the 1997 BC Guide for Physicians in Determining Fitness to Drive a Motor Vehicle, 7th edition. While the Guide and Handbook represent a departure in how driver fitness policy is articulated in BC, they continue the 46 years of collaboration between the BC Medical Association (BCMA) and OSMV. The development of the Handbook is the result of a lengthy and intensive process. In March of 2006, OSMV, in partnership with the BCMA, launched the Guide to Drive Project. Over the course of four years, the BCMA played an integral role in the development of the medical condition guidelines as well as a decision-making framework for OSMV. The Handbook represents the BCMA s and OSMV s continuing commitment to anchor driver fitness determinations on the best-evidence available, reflecting a continuous commitment to public safety, while allowing the maximum driving privilege possible. Stephanie Melvin Deputy Superintendent Ministry of Justice Office of the Superintendent of Motor Vehicles PO Box 9254 Stn Prov Gov Victoria BC V8W 9J2 Toll-Free: Fax: iii

3 Quick Link Table of Contents (Click on any link to go to the corresponding chapter) Note: the Medical Condition Chapters are numbered to mirror the full text version of the 2010 BC Guide in Determining Fitness to Drive and therefore begin at Chapter 11. Chapter 11: Diabetes - Hypoglycemia Chapter 12: Peripheral Vascular Diseases Chapter 13: Musculoskeletal Conditions Chapter 14: Chronic Renal Disease Chapter 15: Respiratory Diseases Chapter 16: Vestibular Disorders Chapter 17: Cardiovascular Disease and Disorders Chapter 18: Hearing Loss Chapter 19: Psychiatric Disorders Chapter 20: Cerebrovascular Disease Chapter 21: Vision Impairment Chapter 22: Syncope Chapter 23: Seizures and Epilepsy Chapter 24: Neurological Disorders Chapter 25: Traumatic Brain Injury Chapter 26: Intracranial Tumours Chapter 27: Cognitive Impairment including Dementia Chapter 28: Sleep Disorders Chapter 29: Prescription and Over-The-Counter Drugs Chapter 30: General Debility and Lack of Stamina iv

4 Detailed Table of Contents (Click to go to the corresponding page) Foreword... iii Detailed Table of Contents... v Introduction How this handbook is organized...1 Chapter 1: Background Purpose of this handbook OSMV s changing approach to driver fitness Research evidence-based Functions necessary for driving Functional ability and driving outcomes...2 Table 1 Cognitive functions needed for driving...3 Table 2 Motor functions needed for driving...5 Table 3 Sensory functions needed for driving Functional assessments...7 Table 4 Functional Assessment Overview Driver Fitness Program overview...9 Screening...9 Assessment Determination Reconsideration Chapter 2: The role of medical professionals in the Driver Fitness Program Introduction Reporting under section 230 of the MVA Conducting assessments and providing results Driver s medical examination (DMER) Diabetic driver medical examination Specialist assessments Cognitive Screening Tests and DriveABLE Transient impairments Part 2: Medical Conditions Chapter 3: Introduction to the Medical Condition Chapters Purpose of the medical condition chapters Source of the medical condition chapters Source of the medical condition guidelines Format of the medical condition chapters Medical conditions at-a-glance Chapter 11: Diabetes - Hypoglycemia Overview Diabetes and adverse driving outcomes Effect of diabetes and hypoglycemia on functional ability to drive v

5 Medical Condition Guidelines Private and commercial drivers with Type 2 diabetes that is not treated with insulin or insulin secretagogues Private and commercial drivers with Type 2 diabetes that is treated with insulin secretagogues Private drivers with diabetes treated with insulin Commercial drivers with diabetes treated with insulin Private drivers who have an episode of severe hypoglycemia Private drivers who have an episode of hypoglycemia unawareness Private drivers who have persistent hypoglycemia unawareness Commercial drivers who have an episode of severe hypoglycemia Commercial drivers who have an episode of hypoglycemia unawareness Commercial drivers who have persistent hypoglycemia unawareness Chapter 12: Peripheral Vascular Diseases Overview Peripheral vascular diseases and adverse driving outcomes Effect of peripheral vascular diseases on functional ability to drive Peripheral arterial disease Abdominal aortic aneurysm and aortic dissection Deep vein thrombosis Medical Condition Guidelines Private and commercial drivers with peripheral arterial disease Private drivers who have an aneurysm or dissection Private and commercial drivers who have had surgery for an aneurysm or dissection Commercial drivers who have an aneurysm or dissection Private and commercial drivers who have deep vein thrombosis Chapter 13: Musculoskeletal Conditions Overview Musculoskeletal conditions and adverse driving outcomes Effect of musculoskeletal conditions on functional ability to drive Medical Condition Guidelines Private and commercial drivers who have lost a limb Private & commercial drivers who have a chronic musculoskeletal condition Chapter 14: Chronic Renal Disease Overview Chronic renal disease and adverse driving outcomes Effect of chronic renal disease on functional ability to drive Chronic renal disease Dialysis General debility and stamina Medical condition guidelines Private and commercial drivers with stage 1 or 2 renal disease Private and commercial drivers with stage 3 or 4 renal disease vi

6 14.8 Private drivers with end-stage renal disease Commercial drivers with end-stage renal disease Private and commercial drivers who have had a renal transplant Chapter 15: Respiratory Diseases Overview Chronic obstructive pulmonary disease and adverse driving outcomes Effect of chronic obstructive pulmonary disease on functional ability to drive Medical Condition Guidelines Private and commercial drivers with mild impairment Private drivers with moderate impairment Commercial drivers with moderate impairment Private drivers with severe impairment Commercial drivers with severe impairment or requiring supplemental oxygen Private drivers requiring supplemental oxygen Private and commercial drivers who have had a permanent tracheostomy Chapter 16: Vestibular Disorders Overview Vestibular disorders and adverse driving outcomes Effect of vestibular disorders on functional ability to drive Medical Condition Guidelines Private and commercial drivers with recurrent episodes that occur with warning symptoms Private and commercial drivers with recurrent episodes that occur without warning symptoms Private and commercial drivers with drop attacks Private and commercial drivers who experience a single episode of vestibular dysfunction Private and commercial drivers with vestibular disorders resulting in persistent impairment Chapter 17: Cardiovascular Disease and Disorders Overview Cardiovascular disease and adverse driving outcomes Effect of cardiovascular disease on functional ability to drive Episodic impairment Persistent impairment Policy rationale Medical Condition Guidelines Private and commercial drivers with congenital heart defects Private drivers with coronary artery disease Commercial drivers with coronary artery disease Private and commercial drivers with asymptomatic coronary artery disease or stable angina Private drivers who have had CABG surgery Commercial drivers who have had CABG surgery vii

7 17.13 Private and commercial drivers who have experienced cardiac arrest Private and commercial drivers who have premature atrial or ventricular contractions Private drivers who have ventricular fibrillation with no reversible cause Commercial drivers who have ventricular fibrillation with no reversible cause Private and commercial drivers who have hemodynamically unstablevt Private drivers who have sustained VT and a LVEF of <30%with no associated impaired level of consciousness Private drivers who have sustained VT and a LVEF of > 30% Commercial drivers who have sustained VT and a LVEF of <30% Commercial drivers who have sustained VT and a LVEF of > 30% Private and commercial drivers who have non-sustained VT Private and commercial drivers who have had paroxysmal SVT, AF or AFL with NO associated impaired level of consciousness Private and commercial drivers who have had paroxysmal SVT, AF or AFL associated WITH impaired level of consciousness Private and commercial drivers who have persistent or permanent paroxysmal SVT, AF or AFL Private and commercial drivers who have sinus node dysfunction Private drivers with atrioventricular (AV) or intraventricular block Commercial drivers with atrioventricular (AV) or intraventricular block Private drivers with permanent pacemakers Commercial drivers with permanent pacemakers Private drivers who have declined an ICD or have an ICD implanted as primary prophylaxis Private drivers who have an ICD implanted as secondary prophylaxis for sustained VT Private drivers where ICD therapy (shock or ATP) has been delivered Private drivers who have an ICD implanted as secondary prophylaxis for VF or VT Commercial drivers who have declined an ICD or have an ICD implanted as primary or secondary prophylaxis Private drivers with inherited heart disease Commercial drivers with inherited heart disease Private drivers with medically treated valvular heart disease Commercial drivers with medically treated aortic stenosis or sclerosis Commercial drivers with medically treated aortic or mitral regurgitation or mitral stenosis Private drivers with surgically treated valvular heart disease Commercial drivers with surgically treated valvular heart disease Private drivers with mitral valve prolapse Commercial drivers with mitral valve prolapse Private drivers with congestive heart failure Private drivers with Left Ventricular Assist Device (LVAD) viii

8 17.46 Commercial drivers with congestive heart failure Private drivers with left ventricular dysfunction or cardiomyopathy Commercial drivers with left ventricular dysfunction or cardiomyopathy Private drivers with a heart transplant Commercial drivers with a heart transplant Private drivers with hypertrophic cardiomyopathy Commercial drivers with hypertrophic cardiomyopathy Syncope Private and commercial drivers with hypertension CCS recommendations regarding transient conditions Waiting periods Chapter 18: Hearing Loss Overview Hearing loss and adverse driving outcomes Effect of hearing loss on functional ability to drive Medical Condition Guidelines Private drivers with hearing loss Commercial drivers with hearing loss Chapter 19: Psychiatric Disorders Overview Psychiatric disorders and adverse driving outcomes Effect of psychiatric disorders on functional ability to drive The role of insight Mood disorders - Major Depressive Disorder, Bipolar Disorder, Dysthymia (Axis I) Anxiety disorders (Axis I) Schizophrenia (Axis I) Personality disorders (Axis II) Pharmacological treatment Medical Condition Guidelines Private & commercial drivers with a psychiatric disorder or psychotic episode Chapter 20: Cerebrovascular Disease Overview Cerebrovascular disease and adverse driving outcomes Effect of cerebrovascular disease on functional ability to drive Transient ischemic attack Cerebrovascular accident Cerebral aneurysm Medical Condition Guidelines Private and commercial drivers who have had a TIA Private and commercial drivers who have had a CVA Private and commercial drivers with a cerebral aneurysm that requires repair Private drivers who have had surgery to repair a cerebral aneurysm Commercial drivers who have had surgery to repair a cerebral aneurysm ix

9 Chapter 21: Vision Impairment Overview Vision impairments and adverse driving outcomes: Myopia, hyperopia, astigmatism, and presbyopia (refractive errors) and low vision Monocular vision Impaired contrast sensitivity Dark adaptation and glare recovery Visual field loss including hemianopia Diplopia and Nystagmus Cataracts Diabetic retinopathy Glaucoma Age-related macular degeneration (ARMD) and retinitis Pigmentosa Effect of vision impairments on functional ability to drive Condition Guidelines Private drivers with impaired visual acuity Commercial drivers with impaired visual acuity Private drivers with visual field loss Commercial drivers with visual field loss Private drivers with a loss of stereoscopic depth perception or monocularity Commercial drivers with loss of stereoscopic depth perception or monocularity Private and commercial drivers with diplopia Private and commercial drivers with impaired colour vision Recommended procedures for testing visual functions Visual acuity Visual field Diplopia Contrast sensitivity Depth perception Dark adaptation and glare recovery Chapter 22: Syncope Overview Syncope and adverse driving outcomes Effect of syncope on functional ability to drive Policy rationale Medical Condition Guidelines Private drivers who have had a single episode of syncope Private drivers with syncope with a treated or reversible cause Private drivers with recurrent typical vasovagal syncope or situational syncope Private drivers with recurrent atypical vasovagal syncope or unexplained syncope x

10 22.11 Commercial drivers who have had a single episode of typical vasovagal syncope Commercial drivers with syncope with a treated or reversible cause Commercial drivers with recurrent situational syncope Commercial drivers with atypical vasovagal syncope, unexplained syncope or recurrent typical vasovagal syncope Chapter 23: Seizures and Epilepsy Overview Seizures and epilepsy and adverse driving outcomes Effect of seizures and epilepsy on functional ability to drive Policy rationale Medical Condition Guidelines Private and commercial drivers with provoked seizures caused by a structural brain abnormality Private and commercial drivers with provoked seizures with no structural brain abnormality Private and commercial drivers with alcohol-related provoked seizures Private drivers with single unprovoked seizure Commercial drivers with single unprovoked seizure Private drivers with epilepsy Private drivers who have epileptic seizures while asleep or upon awakening Private drivers with epilepsy who experience simple partial seizures Private drivers who have had surgery for epilepsy Private drivers with epilepsy who change medication Commercial drivers with epilepsy Commercial drivers with epilepsy who change medication Chapter 24: Neurological Disorders Overview Neurological disorders and adverse driving outcomes Multiple sclerosis Parkinson s disease Cerebral palsy Medical Condition Guidelines Private and commercial drivers with a neurological disorder Chapter 25: Traumatic Brain Injury Overview Traumatic brain injury and adverse driving outcomes Effect of traumatic brain injury on functional ability to drive Medical Condition Guidelines Private and commercial drivers with a traumatic brain injury Chapter 26: Intracranial Tumours Overview Intracranial tumours and adverse driving outcomes Effect of intracranial tumours on functional ability to drive xi

11 Medical Condition Guidelines Private and commercial drivers with an intracranial tumour Chapter 27: Cognitive Impairment including Dementia Overview Dementia Mild cognitive impairment Delirium Cognitive impairment, dementia and adverse driving outcomes Effect of cognitive impairment and dementia on functional ability to drive Medical Condition Guidelines Private and commercial drivers with cognitive impairment or dementia Chapter 28: Sleep Disorders Overview Sleep disorders and adverse driving outcomes Effect of sleep disorders on functional ability to drive Medical Condition Guidelines Private and commercial drivers with untreated OSA Private and commercial drivers with treated OSA Private drivers with narcolepsy Commercial drivers with narcolepsy Chapter 29: Prescription and Over-The-Counter Drugs Overview Psychotropic drugs and adverse driving outcomes: Opioids Antidepressants Antiepileptics Antihistamines Antipsychotics Non-steroidal anti-inflammatories Sedatives and hypnotics Stimulants (for ADHD) Effect of psychotropic drugs on functional ability to drive: Opioids Antidepressants Antiepileptics Antihistamines Beta-blockers Antipsychotics Non-steroidal anti-inflammatories Sedatives and hypnotics Stimulants (for ADHD) Medical Condition Guidelines Private and commercial drivers who use psychotropic drugs xii

12 Chapter 30: General Debility and Lack of Stamina Overview General debility Lack of stamina Effect of general debility and lack of stamina on functional ability to drive Medical Condition Guidelines Private and commercial drivers with frailty, weakness or general debility Private and commercial drivers with a lack of stamina xiii

13 Chapter 1: Background Introduction 1.1 How this handbook is organized The Handbook consists of two parts. The first part, Background, explains the purpose of the Handbook, new developments that have influenced OSMV s approach to driver fitness, outlines the functions necessary for driving, and provides an overview of the Driver Fitness program. Part Two of the Handbook, the Medical Condition Chapters, provides information on medical conditions that may have an impact on fitness to drive and identifies the information that medical professionals should provide to OSMV about individuals who have those medical conditions. The Medical Condition Chapters are numbered to mirror the full text version of the 2010 BC Guide in Determining Fitness to Drive and therefore begin at Chapter Purpose of this handbook This handbook will replace the 1997 Guide for Physicians in Determining Fitness to Drive a Motor Vehicle, 7th edition. The Handbook is for the use of medical professionals who may have to consider a patient s fitness to drive and provide information about a patient to the Office of the Superintendent of Motor Vehicles (OSMV). The Handbook identifies medical conditions that may affect fitness to drive and the information that medical professionals should provide to OSMV about individuals who have those medical conditions. It is not the purpose of this handbook to provide medical advice or direct medical professionals in the provision of medical care. In conjunction with this handbook, OSMV has published the 2010 BC Guide in Determining Fitness to Drive, a Policy and Procedures Manual that guides OSMV staff in making driver fitness determinations. Much of the content of this handbook is drawn from that manual. In particular, the individual medical condition chapters in this handbook are derived from the medical condition chapters in the 2010 BC Guide. 1.3 OSMV s changing approach to driver fitness The guidelines in the 1997 Guide were based on a diagnostic model for determining driver fitness. That is, guidelines were based primarily on the medical condition and the presumed group characteristics of people with that condition rather than on how the medical condition affected the functions necessary for driving on an individual basis. In terms of an evidentiary basis, the 1997 Guide reflected the consensus opinion of practicing physicians including members of specialty sections within the BCMA. 1

14 Since the 1997 edition, three developments have had a significant impact on driver fitness policy in BC: A Supreme Court of Canada decision established the requirement to individually assess drivers. OSMV has adopted a functional approach to driver fitness Research evidence-based OSMV has increased its emphasis on using research evidence, where it exists, as the basis of its driver fitness policies. This information has been drawn from an integrative literature review performed by Dr. Bonnie Dobbs. See s.3.2 OSMV assesses the impact of a medical condition on the functions necessary for driving when making driver fitness determinations. This section of the handbook will describe the functions necessary for driving, and the assessment tools that can be used to assess the impact of a medical condition on these functions Functions necessary for driving The functions necessary for driving can be categorized as either cognitive, motor, or sensory (vision). Within each category, the functions that are most relevant to the driving task are described in the Tables below. Although the functions necessary for driving are described individually, driving is a complex perceptualmotor skill which usually takes place in a complex environment and which requires the functions to operate together Functional ability and driving outcomes Cognitive: Individuals with progressive or irreversible declines in cognitive function cannot compensate for a cognitive impairment. Motor: Research on motor functions and driving indicates considerable variability in the association between the different motor functions and driving outcomes. Overall, the research suggests that a significant level of impairment in motor functions is needed before driving performance is affected to an unsafe level. Sensory vision: Results from studies investigating the relationship between visual abilities and driving performance are, for the most part, equivocal. It may be, as suggested for motor abilities, that a significant level of visual impairment is needed before driving performance is affected. 2

15 Table 1 Cognitive functions needed for driving Cognitive Function Description Example in the driving context Divided attention the ability to attend to two or more stimuli at the same time attending to the roadway ahead while being able to identify stimuli in the periphery Selective attention Sustained attention (vigilance) Short-term or passive memory Working memory (the active component of short-term memory) Long term memory Choice/ complex reaction time the ability to selectively attend to one or more important stimuli while ignoring competing distractions the capacity to maintain an attentional activity over a period of time the temporary storage of information, or the brief retention of information, that is currently being processed in a person's mind the ability to manipulate information with time constraints/taking in and updating information memory for personal events (autobiographical memory) and general world knowledge (semantic memory) the time taken to respond differentially to two or more stimuli or events isolating the traffic light from among other environmental stimuli attending to the roadway ahead over an extended period of time remembering roadway sign information such as that related to freeway exits or construction areas; signs related to caution ahead, etc. processing environmental information related to the driving task on a busy freeway. knowing: your way from home to the grocery store the meaning of traffic signs, and the rules of the road. responding when a cat darts onto the edge of the road at the same time a pedestrian steps onto the roadway 3

16 Cognitive Function Description Example in the driving context Tracking Visuospatial abilities the ability to visually follow a stimulus that is moving or sequentially appearing in different locations processes dependent on vision such as the recognition of objects, the ability to mentally rotate objects and determinations of relationships between stimuli based on size or color visually following other cars on the road understanding where a tree and other objects are in relation to the car. Executive functioning (see also central executive functioning below) Central executive functioning (see also executive functioning above) Visual information processing those capabilities that enable an individual to successfully engage in independent, purposeful, and self-serving behaviours. Disturbances in executive functioning are characterized by disturbed attention, increased distractibility, deficits in self-awareness, and preservative behaviour. that part of working memory that is responsible for supervising many cognitive processes including encoding (inputting information from the external world), storing information in memory, and retrieving information from memory. Central executive (CE) functioning includes abilities such as planning and organization, reasoning and problem solving, conceptual thought, and decision making. CE functioning is critical for the successful completion of tasks that involve planning or decision making and that are complex in nature the processing of visual information beyond the perceptual level (e.g., recognizing and identifying objects and decision making related to those objects). Visual information processing involves higher order cognitive processing. However, because of the visual component, references to visual information processing often are included within the visual domain. making a left turn at an uncontrolled intersection. 4

17 Table 2 Motor functions needed for driving Motor functions (including sensorimotor) 1 Function Description Example in the driving context Coordination the ability to execute smooth, accurate, controlled movements executing a left hand turn; shifting gears, etc. Dexterity Gross motor abilities Range of motion Strength Flexibility readiness and grace in physical activity; especially skill and ease in using the hands gross range of motion and strength of the upper and lower extremities, grip strength, proprioception, and fine and gross motor coordination. the degree of movement a joint has when it is extended, flexed, and rotated through all of its possible movements the amount of strength a muscle can produce the ability to move joints and muscles through their full inserting keys into the ignition; operating vehicle controls, etc. Range of motion of the extremities (e.g., ankle extension and flexion) is needed to reach the gas pedal and brake and upper body range of motion (e.g., shoulder and elbow flexion) is necessary for turning the steering wheel. Range of motion of the head and neck is necessary for looking at the side and rear for vehicles and for identifying obstacles at the side of the road or cars approaching from a side street. lowering the brake pedal getting in and out of the car, operating vehicle controls, fastening the seat belt 1 Sensorimotor functions are a combination of sensory and motor functioning and are considered as a subset of motor functions. Sensorimotor functions are, for the most part, reflexive or automatic, e.g., the response to your hand being placed on a hot stove or the ability to sit upright. 5

18 Motor functions (including sensorimotor) 1 Function Description Example in the driving context Reaction time range of motion. Muscle strength and flexibility often go hand in hand. the amount of time taken to respond to a stimulus depressing the brake pedal in response to a child running out on the roadway, swerving to avoid an animal on the road. 1 Sensorimotor functions are a combination of sensory and motor functioning and are considered as a subset of motor functions. Sensorimotor functions are, for the most part, reflexive or automatic, e.g., the response to your hand being placed on a hot stove or the ability to sit upright. Table 3 Sensory functions needed for driving Sensory functions Function Description Example in the driving context Acuity Visual field Contrast sensitivity Glare recovery Perception the spatial resolving ability of the visual system, e.g., the smallest size detail that a person can see. an individual s entire spatial area of vision when fixation is stable, i.e., the extent of the area that an individual can see with their eyes held in a fixated position. the ability to perceive differences between an object and its background, e.g., the ability detect a gray object on a white background or to see a white object on a light gray background. the process in which the eyes recover visual sensitivity following exposure to a source of glare the process of acquiring, interpreting, selecting, and organizing sensory information reading directional signs seeing cars approaching from the left or right seeing traffic lights or cars at night adapting to the reflection of the sun from a car dashboard or oncoming headlights when driving at night 6

19 1.4.4 Functional assessments Consistent with its functional approach to driving fitness, OSMV will request an assessment of an individual s functional ability to drive whenever that information is necessary in order to make a driving fitness determination. A functional assessment is any kind of assessment that involves direct observation or measurement of the functions necessary for driving. Whether or not a functional assessment is appropriate depends upon whether a medical condition results in a persistent or an episodic impairment. Persistent impairment is an ongoing or continuous impairment to a function necessary for driving. The potential impacts of persistent impairments on the functions necessary for driving are generally measurable, testable and observable. Although the condition may be progressive, the progression is usually slow and sudden deterioration is unlikely. Persistent impairments may be stable, e.g. loss of leg, or progressive, e.g. arthritis. Episodic impairment is the result of a medical condition that does not have any ongoing measurable, testable or observable impact on the functions necessary for driving but that may result in an unpredictable sudden or episodic impairment. Episodic impairments generally result in sudden incapacitation. For example, the medical condition that gives rise to the impairment may be testable, e.g. the size of an abdominal aortic aneurysm, or known, e.g. epilepsy, but the precipitating event that negatively impacts the functional ability to drive, e.g. the rupture of the aneurysm or an epileptic seizure, is not predictable. The source of the potential impairment is known and the inevitability of functional impairment is known in the event that the episodic impairment occurs, but when it will occur is not known. 7

20 Table 4 Functional Assessment Overview Driving function Cognitive Motor (including sensorimotor) Sensory: hearing Functional assessments Cognitive screening tools such as the; MOCA, MMSE, SIMARD-MD, Trails A or B DriveABLE assessment (in-office and road tests) Occupational therapist (OT) or driver rehabilitation specialist assessment which may include an in-office assessment and/or a road test Audiogram (hearing report) Sensory: vision Examination of Visual Functions (EVF) Visual Field Test (VFT) OT or driver rehabilitation specialist assessment which may include both an in-office assessment and a road test 8

21 1.5 Driver Fitness Program overview The Motor Vehicle Act (MVA) gives OSMV the authority to examine an individual s fitness and ability to drive safely, impose restrictions and conditions on a licence and cancel licences if an individual is not fit to drive. OSMV exercises this authority through its Driver Fitness Program. The flowcharts on the following pages highlight the four key activities of the Driver Fitness Program: Screening, Assessment, Determination, and Reconsideration. Screening identifies individuals who have a known or possible medical condition that may impair their functional ability to drive, commercial drivers and aging drivers. Note: DMER is the acronym for Driver Medical Examination Report 9

22 Assessment is the process of collecting information required to make a driver fitness determination. The key assessment used for driver fitness determinations is a driver s medical examination completed by an individual s general practitioner and documented on the Driver Medical Examination Report (DMER). A variety of other assessments may also be required, such as specialist examinations or road tests. 10

23 Determination involves reviewing: the information obtained from assessments any other relevant file information, such as driving history, and the medical condition guidelines outlined in Part 2 of this Handbook and determining whether an individual is fit to drive. 11

24 Reconsideration is the process of reviewing a driver fitness determination upon request of an individual who was found not fit to drive, or who has had restrictions or conditions imposed. 12

25 Chapter 2: The role of medical professionals in the Driver Fitness Program 2.1 Introduction For the purpose of this document a medical professional is defined as a registered psychologist, optometrist, opthamologist, nurse practitioner or medical practitioner. Medical professionals play a key role in the Driver Fitness Program. Medical professionals participate in screening by reporting to OSMV if a patient has a medical condition or functional impairment that may affect driving. Medical professionals participate in assessment by conducting assessments of patients and providing assessments results to OSMV. Medical professionals also provide a diagnosis, or working diagnosis, so that the guidelines may be applied. While driver fitness determinations rely heavily on information provided by medical professionals, the responsibility for determining whether an individual is fit to drive rests with OSMV. 2.2 Reporting under section 230 of the MVA Under section 230 of the MVA, registered psychologists, optometrists, medical practitioners, and nurse practitioners must report to OSMV if: a patient has a medical condition that makes it dangerous to the patient, or to the public, for the patient to drive a motor vehicle, and continues to drive after the psychologist, optometrist, medical practitioner or nurse practitioner warns the patient of the danger. When reporting a condition to OSMV, medical professionals are requested to complete, in full, the Report of a Condition Affecting Fitness and Ability to Drive form and fax it to OSMV at Conducting assessments and providing results Medical professionals conduct assessments of drivers and fax the results of those assessments to OSMV at Medical professionals primarily conduct medical, rather than functional assessments. A medical assessment is any kind of assessment that provides information regarding an individual s medical condition and/or their response to, or compliance with, treatment. This includes assessments such as ultrasounds, blood tests and other medical tests that are not specifically requested by OSMV, but are often submitted by medical professionals and provide useful information regarding an individual s medical condition. The following sections will describe the various assessments that OSMV may request from medical professionals and provide direction on transient impairments. 13

26 2.3.1 Driver s medical examination (DMER) Each medical condition chapter in this handbook will indicate the information that OSMV requires in order to make a driver fitness determination for an individual with that medical condition. Medical professionals should ensure that this information is included on the DMER, or attached to the DMER those medical or functional assessments that provide the necessary information Diabetic driver medical examination Commercial drivers with diabetes who are treated with insulin are required to submit a Diabetic Package annually to OSMV. Part of this package is the Doctor s Report on Commercial Driver with Diabetes on Insulin, which must be completed by their treating physician Specialist assessments Specialist assessments are assessments performed by medical professionals with a specialization in a particular area of medicine. Many individuals are assessed by specialists during the course of the diagnosis and treatment of a medical condition and OSMV may request and obtain copies of those assessments from the medical professional who submitted the DMER. However, in some cases, a specialist assessment is not medically necessary, but will provide further information that is required in order for OSMV to make a determination of driver fitness. In this situation, if there is no specialist assessment on file, and the medical professional has indicated that a specialist assessment is not medically necessary, OSMV will request a specialist assessment. Details of the information that is required from the specialist will be clearly stated in the request Cognitive Screening Tests and DriveABLE Cognitive screening tools such as, the MOCA, MMSE, SIMARD MD, Trails A or Trails Bmay be used in the clinical evaluation of any individual to help identify possible cognitive impairment as it relates to driving. OSMV requests that medical professionals complete cognitive tests such as MOCA, MMSE, SIMARD MD, Trails A or Trails B anytime that it is noted as required in the Medical Condition Guidelines. Medical professionals should also complete a cognitive screening test such as MOCA, MMSE, SIMARD-MD, Trails A or Trails B on any patient who is at risk for developing a cognitive impairment, or where 14

27 there has been any doubt raised as to their cognitive status. The results of the test should be submitted to OSMV when completing a Drivers Medical Examination Report, or via a Report of a Condition Affecting Fitness and Ability to Drive. The DriveABLE evaluation for medically at-risk drivers was developed through science to provide evidence-based decisions about fitness-to-drive. DriveABLE is OSMV s functional driving evaluation of choice for individuals whose cognitive abilities are in the indeterminate range. On-road evaluations provided by ICBC are not designed for, and nor are they appropriate for, the assessment of individuals who are experiencing any type of cognitive decline Transient impairments Transient impairment means a temporary impairment of the functional ability to drive where there is little or no likelihood of a recurring episodic, or ongoing persistent, impairment. Examples of transient impairments are: the after-effects of some surgeries, e.g. the time to recover from the anaesthetic and the surgery itself fractures and casts, post-orthopedic surgery concussions eye surgery, e.g. cataract surgery use of orthopaedic braces (including neck), and cardiac inflammation and infections. Medical professionals do not need to report transient impairments to OSMV. Because the impairment is only temporary, OSMV does not need to know when a driver has experienced a transient impairment. In these situations, medical professionals are best able to advise patients whether they should be driving and, if not, when they can resume driving. The Canadian Medical Association (CMA) Guide for Physicians when Determining Fitness to Drive (2012) contains guidelines for medical professionals for many transient impairments associated with a range of medical conditions. 15

28 Part: 2 Medical Conditions Chapter 3: Introduction to the Medical Condition Chapters 3.1 Purpose of the medical condition chapters The medical condition chapters in this part of the handbook will: - identify what conditions may have an impact on an individual s fitness to drive - highlight the risk of impairment and crash associated with certain medical conditions - present OSMV guidelines for determining fitness to drive of an individual with the identified medical condition, and - identify the information that medical professionals should submit to OSMV for an individual with the identified medical condition. 3.2 Source of the medical condition chapters The medical condition chapters are based primarily on an integrative literature review by Dr. Bonnie Dobbs. In that review, Dr. Dobbs used a multi-step process to critically evaluate and compile evidence from published research studies on the effects of medical conditions on driving and/or the effects of medical conditions on functional abilities needed for driving (e.g., sensory, motor, and cognitive). The integrative review chapters are currently being integrated into a Medical Conditions and Driving book to be published by Dr. Dobbs in the future. (Further information about Dr. Dobbs can be found on pages ii and 4 of the 2010 BC Guide in Determining Fitness to Drive.) 3.3 Source of the medical condition guidelines The medical condition guidelines were drafted by OSMV, with review and input from a variety of subject matter experts and stakeholders. Wherever possible, OSMV has incorporated current driver fitness research into the medical condition guidelines to ensure that they are based on the best evidence possible. Nonetheless, because of the paucity of evidence for many medical conditions, reliance on expert opinion is a necessary component of the medical condition guidelines. 16

29 3.4 Format of the medical condition chapters Each of the medical condition chapters follows a similar format: The Overview lists the medical conditions which are included in the chapter. Adverse driving Outcomes provides an outline of what research, if any, was found by Dr. Bonnie Dobbs in her review of the scientific literature. Effect on functional ability to drive and assessment approach which includes a table that indicates: o whether the condition results in an episodic or persistent impairment o the functional abilities that are affected by the medical condition, and o the assessment tools that may be used to assess the level of impairment for each functional ability affected. Medical condition guidelines include the general guidelines that OSMV uses to determine fitness to drive for an individual with the identified medical conditions. The guidelines are presented in table form. The number of tables depends upon the number of medical conditions included in the chapter. The top row of each table indicates the medical condition(s) and licence class to which the guidelines in the table apply. The tables are divided into two columns. The column on the left lists the medical condition guidelines. There may be different guidelines for private and commercial drivers. The column heading will indicate to which group of drivers the guidelines apply. The column on the right lists the information that is required from medical professionals in order for OSMV to apply the guidelines and make a driver fitness determination for an individual with the identified medical condition. It also includes any information that OSMV requires in order to determine whether an individual who is currently fit to drive should be scheduled for reassessment in the future. 17

30 3.5 Medical conditions at-a-glance For each major medical condition identified in the medical condition chapters, the following table identifies: whether the resulting impairment is persistent or episodic what functions(s) are impaired, and whether the condition also commonly results in a lack of stamina or general debility. The following abbreviations are used in the table: Cog means cognitive SI means sudden incapacitation, and GD means general debility. Chapter and Condition Impairment Function impaired Other Persistent Episodic Motor Cog Sensory All Stam /SI ina GD Sensorimotor Vision Hearing 11. Diabetes Hypoglycemia X 12. Peripheral arterial disease - X severe claudication 12. AAA X 12. Aortic dissection X 12. DVT Pulmonary embolism X 13. Musculoskeletal X 14. Renal diseases X 15. Respiratory diseases X 16. Vestibular disorders X X 17. Cardiovascular diseases X X 18. Hearing loss X 19. Psychiatric disorders X 20. Cerebrovascular diseases X 21. Vision impairment X 22. Syncope X 23. Seizures and epilepsy X 24. MS, Cerebral Palsy, X Parkinson s 25. Traumatic brain injuries X X 26. Intracranial tumours X X 27. Cognitive impairment X including dementia 28. Sleep apnea X X 28. Narcolepsy X X The preceding is a truncated version of the first ten chapters of the 2010 BC Guide in Determining Fitness to Drive. The full text version of the Guide can be viewed by opening the above link. 18

31 The Medical Condition Chapters and Guidelines that follow are numbered to mirror the full text version of the 2010 Guide and therefore begin at Chapter 11. Chapter 11: Diabetes - Hypoglycemia Overview This chapter contains guidelines for individuals with diabetes. Diabetes and adverse driving outcomes Although there is some variability in results of research on drivers with diabetes, there is clear evidence to show that both private and commercial drivers with diabetes are at an increased risk of motor vehicle crashes. It has been shown that diabetes treatment modality is an important consideration in determination of risk for drivers. Study results consistently indicate that individuals taking insulin have an elevated risk of crashes. Some studies have also shown an elevated risk of crash for drivers with type 2 diabetes who are treated with a combination of oral antihyperglycemics (secretagogues and non-secretagogues). Those treated by diet alone or with a single oral antihyperglycemic agent have shown no elevated risk of crash. A relationship between hypoglycemia and crashes has also been found. Despite a lack of data from studies of large samples of people with diabetes, a number of small studies have shown a relationship between hypoglycemic reactions and motor vehicle crashes. While research has established clear links between diabetes, hypoglycemia and motor vehicle crashes, the variable results of these studies indicate that decisions about driving should be based on assessment of individual medical history and circumstances including: treatment modality incidence of hypoglycemia incidence of hypoglycemia unawareness, and presence of chronic complications of diabetes. 19

32 Effect of diabetes and hypoglycemia on functional ability to drive For individuals with diabetes, both acute and chronic complications of the disease may affect fitness to drive. Hyperglycemia may cause blurred vision, confusion, and eventually diabetic coma. For the purposes of this handbook, these are considered transient impairments. The neuroglycopenic symptoms associated with severe hypoglycemia can significantly impair the sensory, motor, and cognitive functions required for driving. There are studies that suggest that mild hypoglycemia may also impair these functions. While it is clear that the risk of hypoglycemia is an important consideration when assessing the fitness of drivers with diabetes, research indicates that the chronic complications of diabetes are more likely to be responsible for impaired fitness to drive than episodic incidents of hypoglycemia. Over time, people with diabetes often develop co-morbidities caused by their prolonged exposure to hyperglycemia. These complications of diabetes include retinopathy, neuropathy, nephropathy, cardiovascular disease, and peripheral vascular disease. Therefore, the effect of chronic complications always must be considered when assessing fitness to drive for people with diabetes. Condition Type of driving impairment and assessment approach Primary functional ability affected Assessment tools Severe hypoglycemia Episodic impairment: Medical assessment likelihood of impairment All sudden incapacitation Driver s Medical Examination Report Doctor s Medical Report Re Diabetic Driver Driver s Diabetes Questionnaire 20