THE ASSESSMENT OF FITNESSTODRIVE IN PERSONS WITH DEMENTIA Dr' Frank Molnar, Division of Geriatric Me

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THE ASSESSMENT OF FITNESS-TO-DRIVE IN PERSONS
WITH DEMENTIADr. Frank Molnar, Division of
Geriatric Medicine, University of Ottawa
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Conflict of interests

• None
• No Pharmaceutical Industry support
• More relevant to driving no Automotive
  Insurance Industry support
• Honorarium donated to the University of Ottawa,
  Division of Geriatric Medicine Academic Rounds
  fund

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Objectives

• To describe the scope of the problem of unfit
  drivers that will impact on the medical system
• To highlight the complexity of the assessment of
  fitness to drive
• To provide practical approaches for assessing
  fitness to drive in persons with dementia
• To describe what happens after an assessment

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Driving

• The Scope of the Problem

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The Aging Driving Population
1986-1996
Percent Change
16-19 20-24 25-44 45-59 60-69
70-79 80
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The U-Shaped Curve MVC / Km
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Projections
Source LÉcuyer et al. (2006). Transport Canada
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A Major Public Health Concern

• When involved in a crash, seniors are over 4
  times more likely to be seriously injured and
  hospitalized than are drivers 16-24 years of age.
• Treatment of injuries to seniors is more costly,
  recovery slower, less complete.
• Majority of crash-injured seniors were driving
  the vehicle.
• Most (3 of 4) crashes involving older drivers are
  multiple vehicle crashes (e.g. merging into
  traffic, left hand turns across oncoming
  traffic).

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Assessment of Fitness-to-Drive

• The Complexity of the
• Medical Driving Evaluation

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It is Not Age

• Medical conditions and medications are the
  primary cause of declines in older driver
  competence.
• Can make even the best of drivers unsafe to
  drive.
• Can affect drivers of any age Increasingly
  likely as we age due to the cumulative effect of
  multiple diseases.
• Not presence but severity and/or instability of
  conditions /- high doses and/or changing doses
  of medications
• Medical community best placed to first recognize
  possibly impairing medical conditions.

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Medical Conditions

• Any medical condition or medication that results
  in a change of physical, sensory, mental or
  emotional abilities has the potential to
  compromise driving performance.
• Physical weakness slow / limited movement
• Sensory vision loss limited feeling in limbs
• Cognitive/Perceptual slowed thinking decreased
  attention
• Emotional anxiety, panic reactions

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Hierarchical Model of Driving
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Realistic Conclusions

• No screening or assessment protocol will ever
  predict 100 of risk of Motor Vehicle Crash (MVC)
• Only test stable intrinsic features
• operational gt tactical, strategic
• Miss new or fluctuating illness
• Cannot predict extrinsic factors
• weather, other drivers, road conditions, car
• Full complexity cannot be fully addressed with
  time available in front-line clinical settings
• Therefore objective is to improve not to perfect
  the assessment of fitness to drive

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Increased Risk of an At-Fault Crash
7.6
5.0
5.0
Risk of an At-Fault Crash
2.8
3.0
2.5
2.1
2.2
1.8
Epilepsy
Psychiatric
Pulmonary
Diabetes
Visual Acuity
BAC .08
Cognitive
Neuological
Cardiovascular
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Assessment of Fitness-to-Drive

• DEMENTIA DRIVING
• The Facts

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Estimated Numbers of Drivers with Dementia in
Ontario1
98,032
34,105
32,373
30,642
24,083
21,803
14,909
1 from Hopkins, et al., (2004)
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The Scope of the Problem

• Hopkins

2.5 of the elderly are DDs (demented drivers)
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BUT

• The diagnosis of dementia does not automatically
  mean no driving (some people with mild dementia
  can drive albeit for a limited period of time
  before they must hang up the keys)
• The diagnosis of dementia does mean
• You must ask if the person is still driving
• You must assess and document driving safety and
  follow your provincial reporting requirements

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Consensus statements

• Swedish (1997)
• Australian Geriatrics Society (2001)
• American Academy of Neurologists (2000)
• AMA and Canadian Medical Association guidelines

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http//www.cma.ca/index.cfm/ci_id/18223/la_id/1.ht
m
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Conclusions of Consensus statements (cont)

• Recognize limitations of data
• those with moderate to severe dementia should not
  drive (CMA Moderate 1 ADL or 2 iADLs impaired
  due to cognition)
• individual assessment for those with mild
  dementia
• periodic follow-up is required (every 6 - 12
  months)
• gold standard is comprehensive on-road
  assessment

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Expert / Consensus Guidelines

• Limitations of Guidelines
• Based on expert opinion recommend tests such as
  MMSE, Clock Drawing, Trails B
• Lack of operating instructions (i.e. guidance
  regarding how to interpret the results of the
  tests)
• Do not provide guidance regarding HOW physicians
  are to apply such tests (e.g. how to respond to
  different scores, what cut-offs to use, errors
  automatic failure )

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Operating instructions Lack of evidence-based
cut-offs

• Clinical Utility of Office-Based Cognitive
  Predictors of Fitness to Drive in Persons with
  Dementia A Systematic Review.
• (Molnar, Marshall, Man-Son-Hing et al.,
  JAGS 2006 5418091824)
• No cognitive tests that could potentially be used
  in an office-setting had cut-off scores validated
  in persons with dementia!

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Assessing Dementia and Driving

• Start by asking older patients if they drive!
• Seems simple but most MDs do not ask (too busy,
  fear of opening Pandoras box... Lack of
  awareness does not provide legal protection)
• Keep in mind that driving capacity depends on a
  GLOBAL CLINICAL PICTURE
• including cognition, function, physical
  abilities, medical conditions, behavior, driving
  record .
• Many patients will be more comfortable with the
  idea of driving cessation if the decision is made
  for physical reasons (e.g. loss of vision,
  syncope etc.)

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Review medical conditions that when severe,
poorly controlled or changing rapidly can impact
on driving (would you get in a car with them
based on these findings?)

• 3Ds Dementia / Delirium / Depression
• Diabetes
• vision and hearing
• cardiac disease
• Stroke
• Parkinsons
• Arthritis
• Sleep apnea

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Getting the most out of cognitive tests
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Test Specific Cognitive Domains

• Judgment Test response to situation (fire,
  yellow light)
• Visuospatial MMSE (Pentagons)
• Clock Drawing
• Executive function Trails A and B
• Clock Drawing
• Animal-naming (1minute)

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Applying Trichotomization

• Given the results of the cognitive test would you
  get in the car with the patient driving (or would
  you let a loved one drive with them)?
• Yes
• Uncertain
• Absolutely not

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The MMSE

• The MMSE can provide a rough framework for
  assessing driving safety. Unless you feel a low
  score is due to a language barrier, low education
  or sensory deficits, patients scoring under 20
  are likely unsafe to drive.
• Higher scores are more difficult to interpret.
• Trichotomization (obviously unsafe, uncertain
  safety, obviously safe) approach may be helpful

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Clock Drawing Test

• A test of Executive Function and Visuospatial
  function
• Gestalt method The good, the bad or the ugly
• Once again Trichotomization (obviously unsafe,
  uncertain safety, obviously safe) approach may be
  helpful

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Trail Making A and B (available at www.rgpeo.com).

• Trail Making A
• Unsafe gt2 minutes or 2 or more errors
• Trail Making B (Trichotomization)
• Safe lt2 minutes and lt2 errors (0 or 1 error)
• Unsure 23 minutes or 2 errors (consider
  qualitative dynamic information regarding how the
  test was performedslowness, hesitation, anxiety
  or panic attacks, impulsive or perseverative
  behaviour, lack of focus, multiple corrections,
  forgetting instructions, inability to understand
  test, etc.)
• Unsafe gt3 minutes or 3 or more errors
• The longer the patient takes and the more errors
  they make, the more certain you can be that they
  are unsafe

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Applying these ideas in the context of a
systematic approach

• Geriatrics and Aging article
• Approaches based on clinical acumen (experience
  and opinion)
• 10-Minute Office-Based Dementia and Driving
  Checklist (will review)
• CANDRIVE acronym (see article)

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10-Minute Office-Based Dementia and Driving
Checklist

• 1. Dementia Type
• Generally unsafe
• Lewy Body dementia
• fluctuations, hallucinations, visuospatial
  problems
• Frontotemporal dementias
• if associated behaviour or judgment issues

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10-Minute Office-Based Dementia and Driving
Checklist

• 2. Functional Impact of the Dementia
• Consider ADLs and IADLs as a hierarchy with
  Driving being at the top as the highest level
  IADL (the only one where fractions of a second
  can result in accidental death)
• According to CMA guidelines and Canadian
  Consensus Guidelines on Dementia, persons with
  dementia are unsafe to drive if
• Impairment of gt1 IADL due to cognition (IADL
  mnemonic SHAFT)
• Shopping,
• Housework/Hobbies,
• Accounting,
• Food,
• Telephone / Tools
• OR impairment of 1 or more personal ADLs due to
  cognition (ADL mnemonic DEATH
• Dressing,
• Eating,
• Ambulation,
• Transfers,
• Hygiene

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10-Minute Office-Based Dementia and Driving
Checklist

• 3. Family Concerns - ask in a room separate from
  the patient
• If family feels the patient is safe/unsafe (make
  sure family has recently been in the car with the
  person driving).
• The granddaughter questionWould you feel it was
  safe if a 5-year-old granddaughter was in the car
  alone with the person driving? (Often different
  response from familys answer to previous
  question)
• Generally if the family feels the person is
  unsafe to drive, they are unsafe. If the family
  feels the person is safe to drive, they may still
  be unsafe as family may be unaware or may be
  protecting the patient.

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Ask Family Specific Questions - Signs of a
Potential Problem

• Collisions and/or damage to the car
• Getting lost
• Near-misses with vehicles, pedestrians
• Confusing the gas and brake
• Traffic tickets
• Missing stop signs/lights stopping for green
  light
• Deferring right of way
• Not observing during lane changes/ merging
• Others honking/irritated with the driver
• Needing a co-pilot (cannot compensate for
  emergencies)

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10-Minute Office-Based Dementia and Driving
Checklist

• 4. Visuospatial Issues
• Intersecting pentagons/clock-drawing test
• if major abnormalities, likely unsafe.

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10-Minute Office-Based Dementia and Driving
Checklist

• 5. Physical Inability to Operate a Car (Often a
  physical reason is better accepted).
• musculoskeletal problems, weakness/multiple
  medical conditions affecting
• neck turn,
• use of steering wheel/pedals,
• ability to move feet rapidly
• ability to feel the gas / brake pedals,
• level of consciousness
• cardiac/neurological problems (episodic spells).

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10-Minute Office-Based Dementia and Driving
Checklist

• 6. Vision/Visual Fields
• Significant problems including visual acuity,
  field of vision.

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10-Minute Office-Based Dementia and Driving
Checklist

• 7. Drugs (If associated with side
  effectsdrowsiness, slow reaction time, lack of
  focus)
• especially high doses or changing doses
• Alcohol, benzodiazepines, narcotics,
  neuroleptics, sedatives, anticonvulsants
• Anticholinergicsantiparkinsonian drugs, muscle
  relaxants, tricyclic antidepressants,
  antihistamine (OTC), antiemetics, antipruritics,
  antispasmodics, others (next slide)

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Reference List of Drugs with Anticholinergic
Effects

• Miscellaneous
• Flexeril
• Lomotil
• Rythmodan
• Tagamet
• Digoxin
• Lasix

• Antidepressants
• Antipsychotics
• Antihistamines/
• Antipruritics
• Antiparkinsonian
• Antispasmotics
• Antiemetics

The medications in the miscellaneous category
have been shown to have anticholinergic
properties by radioimmunoassay but are
less anticholinergic than the other medications
listed. However, they may add to total
anticholinergic load.
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10-Minute Office-Based Dementia and Driving
Checklist

• 8. Trail Making A and B (available at
  www.rgpeo.com).
• Trail Making A
• Unsafe gt2 minutes or 2 or more errors
• Trail Making B
• Safe lt2 minutes and lt2 errors (0 or 1 error)
• Unsure 23 minutes or 2 errors (consider
  qualitative dynamic information regarding how the
  test was performedslowness, hesitation, anxiety
  or panic attacks, impulsive or perseverative
  behaviour, lack of focus, multiple corrections,
  forgetting instructions, inability to understand
  test, etc.)
• Unsafe gt3 minutes or 3 or more errors
• The longer the patient takes and the more errors
  they make, the more certain you can be that they
  are unsafe

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Trails A
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Trails B
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Trails A B
Trails A and B are tests of memory, visuospatial,
attention and executive function. Any errors or
scoring below the 10th percentile in the time
taken raises concerns about driving safety.
Norms for Trails A and B by age (in seconds) and
education
Trails A performance decreases with age but is
NOT affected by education
Trails B performance decreases with age AND
with education
Although this test does help determine who should
not be driving, passing Trails AB does not
necessarily mean that the patient is safe to drive
TN Tombaugh Arch clin neuropsychol 200419.pg
203-14
(Failure error(s) or time lt10th percentile)
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10-Minute Office-Based Dementia and Driving
Checklist

• 9. Ruler Drop Reaction Time Test (Accident
  Analysis and Prevention 200739105663.)
• The bottom end of a 12 inch (30-cm) ruler is
  placed between thumb and index finger (1/2 inch
  (1 cm) apart) ? let go and person tries to catch
  ruler (normal 6-9 inches (1522 cm) abnormal
  2 failed trials out of 3trials
• No validated norms / cut-offs

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Reaction Time

• If you notice slow reactions on routine clinical
  interaction (history, physical examination) the
  patient may already be too slow to drive and
  merits further dynamic (i.e. timed) testing.
• Stroke(s), delirium, depression, Parkinsons
• Look at Trails A and B
• May need on-road if trails A and B do not answer
  the question

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10-Minute Office-Based Dementia and Driving
Checklist

• 10. Judgment/Insight - ask the person
• What would you do if you were driving and saw a
  ball roll out on the street ahead of you?
• With your diagnosis of dementia, do you think at
  some time you will need to stop driving?
• Other ideas/ scenarios?

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Other RED FLAGS

• Delusions
• Disinhibition
• Hallucinations
• Impulsiveness

• Agitation
• Anxiety
• Apathy
• Depression

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After the Assessment

• Outcomes of Assessment
• Reporting duties
• Further testing
• Disclosure Techniques telling the patient

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Physician assessment of person with dementia
Patient not safe
Uncertain safety
Patient safe
Discuss with patient and family
Discuss with patient and family
At some time driving cessation will be necessary
Provincial Ministry of Transport notification
Patient wishes to continue driving ? referral to
specialist or specialized on-road driving
evaluation report to Ministry of Transportation
Suggest driving training and self-limitation
Patient notification (letter), copy for chart
or
Book six- tonine-month follow-upto reassess
driving safety report to Ministry of
Transportation
Patient decides to stop driving report to
Ministry of Transport notification
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How to Report

• Mild dementia (no concerns re. driving)
• Patient has mild dementia with MMSE ___, Trails
  B ___. I have not noted any evidence to suggest
  they are not fit to drive but feel they should be
  re-evaluated every __ months.
• Frequency (6 or 12 months based on clinical
  judgment
• Warn family to notify you if they note cognitive
  change or signs of delirium
• Would report if there is a risk patient will not
  return for follow-up
• Do not forget to advise the patient to start
  planning for eventual driving cessation

• Moderate to severe dementia
• Patient is not safe to drive due to the
  following findings_______________________________
  _________________________________________________
  
• Q? How much information can we disclose?
• If potentially litigious then only include the
  findings of the testing.
• If patient tells you that you cannot report them
  then write patient will not provide consent to
  forward my findings

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Disclosure unfit to drive

• Refer to Geriatrics and Aging article
  http//www.geriatricsandaging.ca/fmi/xsl/article.x
  sl?-layArticle-recid2003-find-find

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Notification About Driving Safety

• Name _________________________________
•  Date __________________________________
•  Address ________________________________________
  _________________________________
•   
• You have undergone assessment for
  memory/cognitive problems. It has been found by
  comprehensive assessment that you have
  ________________________ dementia. The severity
  is _________________.
•  
• Even with mild dementia, compared to people your
  age, you have an 8 times risk of a car accident
  in the next year. Even with mild dementia, the
  risk of a serious car accident is 50 within 2
  years of diagnosis.
• Additional factors in your health assessment
  raising concerns about driving safety include
•  _________________________________________________
  _________________________
•  _________________________________________________
  _________________________
•  _________________________________________________
  _________________________
•  _________________________________________________
  ________________________
•  
• As your doctor, I have a legal responsibility to
  report potentially unsafe drivers to the Ministry
  of Transport. Even with a previous safe driving
  record, your risk of a car accident is too great
  to continue driving. Your safety and the safety
  of others are too important.
•  
• ___________________________ M.D.
  __________________________ Witness

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Fitness to drive unclear Further Assessment
Required

• Notify jurisdictional authorities as per
  provincial reporting requirements
• Report
• Fitness to drive unclear more testing needed
• or
• Deficits may be temporary (e.g. delirium)
  requires follow-up

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Specialized Driving Assessment

• Cognitive tests (Neuropsychologist, OT)
• can assess the more obviously impaired
• do not refer to specialty dementia clinics if the
  only issue is driving (inadequate resources)
• Driving Simulator Evaluation
• not fully acceptable for ultimately determining
  fitness to drive
• can give insight to the evaluator for the on-road
  assessment
• On-Road Assessment (OT / Driving Instructor)
• Present Gold Standard
• Expensive warn patient that need to repeat
  every 6 months (and have to pay each time)

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Key Learning Points

• If dementia is diagnosed, driving must be asked
  about, formally assessed, and documented.
• Physicians can perform a comprehensive driving
  safety clinical evaluation in approximately 15 to
  20 minutes.
• If you are unsure of safety, refer to specialized
  assessment or specialized on-road testing.
• In dementia, driving safety must be reassessed
  every 6 to 12 months.

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Resources

• Alzheimer Knowledge Exchange
• www.drivinganddementia.org
• Geriatrics and Aging (leading Geriatric
  CME journal)
• www.geriatricsandaging.ca
• CMA Determining Medical Fitness to Drive A
  Guide for Physicians. Canadian Medical
  Association Drivers Guide 7th edition.
• www.cma.ca/index.cfm/ci_id/18223/la_id/1.htm
• Driving and Dementia Tool Kit for Family
  Physicians (Dementia Network of Ottawa-Carleton)
• www.rgpeo.com or www.CanDRIVE.ca
• US Physicians guide to Assessing an Counseling
  Older drivers
• http//www.nhtsa.dot.gov/people/injury/olddrive/Ol
  derDriversBook/pages/Introduction.html

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Clinical Scenario

• You have found a patient unfit to drive and have
  informed them and their family. The patient says
  you are not permitted to send their medical
  information to the ministry of transportation or
  they will sue you and call the college. What do
  you do?

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Clinical Scenario

• A patient is in your office who is clearly unfit
  to drive home. MMSE 16/30. You tell them they
  should not drive home but they refuse to comply.
  You feel they are an imminent threat to public
  safety. What do you do?

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Clinical Scenario - OCFP

• You receive a report from a Sleep Specialist
  which reads The findings of the sleep study
  indicate your patient may be unsafe to drive. I
  recommend you report them to the Ministry of
  Transportation
• What do you do?