THE ELDERLY or IMPAIRED DRIVER

Transcription

1 THE ELDERLY or IMPAIRED DRIVER

2 WARNING In a Cochrane review of driving assessments for maintaining mobility and safety in demented drivers The authors concluded that the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents

3 ELDERLY DRIVER FACTS 1. # of elderly drivers is rapidly increasing and they are driving further: By 2020 there may be 38 million older(>70) licensed drivers on the road. By 2030 almost ¼ drivers on highway will be > or =65 2. In a survey of 2,422 adults 50 and older, 86 percent reported that driving was their usual mode of transportation. Within this group, driving was the usual method of transportation for 85 percent of participants 75 to79, 78 percent of participants 80 to 84, 60 percent of participant s 85 and older. 3. Driving cessation is inevitable for many and can be associated with negative outcomes: Social isolation Decreased out-of-home activities iti Increase in depressive sx 4. Many older drivers self-regulate their driving behavior. a y ode d e s se egu ate t e d g be a o many avoid night-time driving, avoid left hand turns, decrease mileage; however, not true for all and MVA/mile driven increases starting at age 65

4 4. Crash rate for older drivers is in part related to physical &/or mental changes associated with aging &/or disease: elder crashes tend to be related to inattention or slowed speed of visual processing: often multiple vehicle events at intersections with left hand turns 5. Physicians can influence their patients decisions to modify or stop driving & can also help their patients maintain safe driving skills. 6. Driving abilities share many attributes that are necessary for successful ambulation, such as adequate visual, cognitive, and motor function. In fact, a history of falls has been associated with an increased risk of motor vehicle crash.

5 Many pts will stop when we tell them; we can keep them on road longer by managing their diseases such as arthritis, cataracts, or discontinuing sedating medications. W d t b f t t d i i l f t d i i h b We need to be aware of state driving laws, refer to driving rehab specialists, recommend driving restrictions, and refer to State authorities when appropriate

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7 Assessing Patients for Driving Safety History: Questions for Caregivers Has the patient had any motor vehicle crashes? Has the patient had any "near misses"? Has the patient had any tickets? Has the patient been pulled over by police? Have you noticed a change in the patient's driving behaviors from baseline? Since the last examination? Has the patient had difficulty staying in a lane? Does the patient have difficulty following the rules of the road? Do other drivers honk at the patient? Are there scratches on the vehicle? Has the patient gotten lost in familiar areas? Is the patient vigilant in scanning for vehicles/pedestrians?

8 resources/public-health/promoting-healthy-rces/lifestyles/geriatric-health/older-driver-safety/assessingcounseling-older-drivers.page

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10 A condition in which a person who suffers from a disability seems unaware of the existence of his or her disability

11 Physical Examination: Assessment for Comorbid Conditions That Can Further Reduce Capacity Visual: cataracts, diabetic retinopathy, macular degeneration, glaucoma Cognitive: sleep apnea, multiple sclerosis, Parkinson disease, psychiatric disease, diabetes Motor: degenerative joint disease, muscle weakness, neuropathy Medication review: assessment for sedating agents Antihistamines Antipsychotics Tricyclic antidepressants Bowel / bladder antispasmodics Benzodiazepines Muscle relaxants Barbiturates

12 Functional Assessment: Assessment of Instrumental Activities of Daily Living Food preparation, finances, telephone, medications, shopping, housekeeping, laundry Inability to do IADL can be a red flag that driving is impaired

13 1. Screen for red flags: medical illnesses, medications that may impair driving 2. Ask about new onset impaired driving behaviors 3. Ask driving-related functional skills in pts that are at increased risk 4. Treat any underlying causes of functional decline 5. Refer appropriate p (if need eval &/or adaptive training) pts to driver rehab specialist 6. Counsel pts: safe driving behavior, restrictions, cessation, &/or alternative transportation options 7. F/U to see if made changes; eval for depression and social isolation

14 IS THE PATIENT AT INCREASED RISK FOR UNSAFE DRIVING? 1. Observe pt at office visit? Impaired personal care? Impaired ambulation or getting into or out of chair?difficulty with visual tasks? Impaired attention, memory, language, expression, or comprehension 2. Be alert to red flags: any condition, medication, or sx that can affect driving-see next slide 3. If pt or family asks if they are safe to drive, identify reason for the concern 4. Ask how much pt drives, what problems they have with driving, are you a safe driver?, have you ever gotten lost while driving, any tickets, any near crashes?

15 RED FLAGS Acute events: mi, cva, arrhythmia, syncope, seizure, surgery, delirium, new sedating meds Pt or family member s concern Interaction of chronic medical conditions on their function: vision,c-v, neurologic, dm, arthritis Intermittent/unpredictable events: syncope, angina,tia, hypoglycemia, sleep attacks medications

16 ASSESSING FUNCTIONAL ABILITY VISION, COGNITION, MOTOR/SOMATOSENSORY FUNCTION VISION ACUITY various states require >20/40 or <20/70 SNELLEN CHART for distance, ROSENBAUM CHART for near vision VISUAL FIELDS confrontation COGNITION: memory, short, long term, working memory visual perception processing, search, visuospatial skills selective and divided attn executive skills: sequencing, planning, judgment, decision making language vigilance if cognitively impaired, do not rely on copilot: if can t drive without copilot, should not drive

17 ADReS ASSESSMENT OF DRIVING-RELATED SKILLS Seven Components: Visual Fields Motor Strengthth Visual Acuity Rapid Pace Walk Range of Motion Trail Making Test, Part B Clock Drawing Test

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

19 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

20 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

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

22 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

23 ADReS Component: Trail-Making Test, Part B How Tested: Standard form Result Signaling Need for Intervention: > 180 seconds

24 TRAILMAKING TEST PART B is a good test for general cognitive function poor performance correlates with poor driving Assesses working memory, visual processing, visuospatial skills, selective & divided attention, psychomotor coordination

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26 ADReS Component: Clock Drawing Test How Tested: Standard form Result Signaling Need for Intervention: Any abnormal element

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29 DRIVER REHAB SPECIALIST plan, develop, coordinate, implements driving services for disabled pts They evaluate pt, often have computer programs that predict safety, can do on road functional assessment, recommend arrange adaptive equipment Generally the cost is out of pocket we do have this available at the VA through OT LOCATE outside driver rehab specialist: d or

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31 Counseling pt who is no longer safe to drive Physicians have an ethical responsibility to protect the patient s safety through eval of their driving behavior, and when all options have been exhausted to rec driving i cessation Advice i from MD is the most frequently cited reason that a pt stops driving Explain why, and discuss pts thoughts and feelings but don t get into dispute or long explanation document in chart Need to assess impairments that might adversely affect driving abilities: Must be able to identify and document: physical and mental impairments that clearly relate to ability to drive Driver must pose a clear risk to public safety Before reporting: need candid discussion, advise of options, negotiate workable plan --? Need rehab or OT, or only drive during daytime,etc

32 Discuss state t reporting requirements Protect confidentiality: only minimum amount of info reported and appropriate security measures used in handling the information Explore transportation alternatives and give pt resources to explore alternatives social worker can help Encourage family/caregiver assistance: good websites: www. nfcacares.org If family member not there, communicate to family member if pt does not have capacity

33 HIPPA has a regulation that allows for reporting information that includes pt s protected health info when it is in the public interest. Not all states protect health providers when they report. However, some states require you to report. AMA policy: states that it is desirable and ethical to notify DMV If pt continues to drive and you know it: ask pt why and if they understand the law and legal, financial consequences; if cognitively impaired, notify family can notify DMV

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35 MEDICAL CONDITIONS THAT CAN AFFECT DRIVING SEE AMA Physician's Guide to Assessing and Counseling Older Drivers Specifically chapter 9 goes into detail about most medical conditions Some common salient points 3 mo after last seizure, symptomatic ti VT 4 wks after median sternotomy or 8 wks after heart transplant After AICD implantation: (from AHA) for primary prevention: recovery from operation(at least 1 wk) for secondary prevention : 6 months See also JAMA VOL 303 #16, 4/28/10 CLINICIAN S CORNER GOOD ARTICLE + MANY RESOURCES LISTED

36 Practice Parameter update: Evaluation and management of driving risk in dementia Neurology :

37 Table 1: Summary of recent studies on dementia and driving performance. Author, Year Study design Study population Alzheimers Disease (AD) Ott BR, 2008 [47] Prospective cohort 52 patients with AD (CDR = 0.5) versus 32 patients with AD (CDR = 1) Assessment method ORT Key findings Median time to driving restriction due to failure on road test, at-fault motor vehicle accident or dementia progression was 605 days for CDR = 0.5 and 324 days for CDR = 1 Duchek JM, 2003 [55] Prospective cohort 21 patients with AD (CDR 0.5), 29 with AD (CDR 1.0) and 58 elderly controls ORT At baseline, 41% of subjects with CDR = 1 versus 14% with CDR = 0.5 versus 3% with CDR = 0 were judged as unsafe drivers. Mean time of follow-up until persons were judged as unsafe was <3 months for CDR = 1, 10 months for CDR = 0.5 and 14 months for CDR = 0 Dawson JD, 2009 [46] Cross sectional 40 subjects with AD (mean MMSE 26.5 ± 2.5) versus 115 elderly controls ORT Subjects with AD committed 80% more safety errors than controls. Lane observance errors were more common in drivers with AD Frittelli C, 2009 [42] Cross sectional 20 patients with AD (mean MMSE 22 ± 4) versus 19 agematched controls Driving simulator AD patients showed a higher number of lane violations and a longer mean latency in visual reaction time compared to controls Whelihan WM, 2005 [80] Cross sectional 23 patients with AD (CDR = 0.5) versus 23 age-matched controls ORT Patients yielded significantly higher values on a weighted assessment score, meaning poorer driving performance Frontotemporal Dementia (FTD) De Simone V, 2007 [31] Cross sectional 15 subjects with FTD versus 15 controls matched for age, gender and education Driving simulator FTD patients committed significantly more safety errors, the most important being speed violations, offroad accidents, collisions and ignored stop signs CDR = Clinical dementia rating; ORT = On-the-road Test; MMSE = Mini-Mental State Examination.

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39 1. Generally mmse by itself does not predict driving safety MMSE<24 is possibly useful 2. 76% of pts with mild dementia still pass ORDT(on the road driving test) 3. CDR is useful for for identifying pts at increased risk for unsafe driving; however a substantial # of drivers with CDR still pass ORDT 4. Pt s rating of their ability to drive is not useful; caregiver s assessment is probably useful

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41 For pts with dementia, consider the following characteristics useful for identifying pts at increased risk for unsafe driving CDR scale LEVEL A Caregiver s rating of pt s ability as marginal or unsafe LEVEL B LEVEL C: hx of traffic citations hx of crashes reduced driving mileage self reported situational avoidance MMSE<24 Aggressive or impulsive personality characteristics

42 For demented pts, consider the following characteristics NOT useful for identifying unsafe driving LEVEL A: A pts self rating of safe driving i ability LEVEL C: Lack of situational avoidance LEVEL U: insufficient evidence to support or refute the benefit of n/p testing, after controlling for the prescence and severity of dementia

43 Ability of Neuropsychological Tests and Test Batteries to Predict Performance on Road Testsa Carr, D. B. et al. JAMA 2010;303: Copyright restrictions may apply.

44 SAMPLE ALGORITHM FOR EVALUATING DRIVING COMPETENCE SAMPLE ALGORITHM FOR EVALUATING DRIVING COMPETENCE AND RISK MANGEMENT IN PTS WITH DEMENTIA

45 Figure 114"> Iverson, D. J. et al. Neurology 2010;74:

46 Approach to Evaluating Older Adults With Cognitive Impairment or Dementia Carr, D. B. et al. JAMA 2010;303: Copyright restrictions may apply.

47 AM I A SAFE DRIVER? I get lost while driving i My friends or family are worried about my driving Other cars appear from nowhere I have trouble finding and reading signs in time to respond to them Other drivers drive too fast Other drivers honk at me Driving stresses me out After driving, I feel tired I feel sleepy while driving I ve had more near misses lately Busy intersects bother me Left hand turns make me nervous The glare from oncoming headlights bother me Medication makes me dizzy or drowsy I have trouble turning steering wheel or pushing down the foot pedal I have trouble looking over my shoulder while I back up

48 I have been stopped by police for me driving People will no longer ride with me Ih have trouble backing up I ve had at fault accidents in the past yr I am too cautious while driving I sometimes forget to use my mirrors or signals I sometimes forget to check for oncoming traffic I have more trouble parking If + response to any, your safety may be at risk

49 STEPS FAMILY MEMBERS CAN TAKE TO ENSURE DEMENTED PTS DON T DRIVE 1. Ask md to rx driving cessation orally and in writing 2. Ask md to use medical conditions other than dementia as the reason: slow reflexes, impaired vision, 3. Use contract 4. Hide, file down or replace car keys with ones that won t start car 5. Remove car or don t repair 6. Disable vehicle 7. Ask family lawyer to discuss with pt, family ramifications of continued driving

50 Consider using a handout like the Hartford s We Need to Talk which can be accessed at the following website; rochure/brochure.htm or writing the Hartford and requesting brochures at;the a; HartfordWe Need to Talk200 Executive BoulevardSouthington, CT If concerned about your relative s driving

51 Expert Recommendations of Professional Societies and Consensus Meetings

52 REFERENCES UP TO DATE JAMA 2010;303(16): PHYSICIAN S GUIDE TO Assessing and Counseling Older Drivers,2010, AMA Swiss Medical Weekly 2011;140:w13136 ;4 33 ACP PIER Cochrane Database Syst Rev 2009 Jan 21; (1) CD JAMA 2011; 305 (10) Circulation 3/6/ Neurology 2010;74: More information for patients and caregivers: see APPENDIX B of AMA guide