Promoting Older Driver Safety in Missouri: Education

1
Promoting Older Driver Safety in
MissouriEducation Outcomes

• Jacqueline Rogers, Missouri Department of
  Transportation
• Tom Meuser, PhD, University of Missouri St.
  Louis
• David Carr, MD, Washington University School of
  Medicine

2
Agenda

• MODOT Division of Highway Safety (Rogers)
• Missouri Statistics
• Gathering Stakeholders from Five Key Communities
• Education Blitz
• Educating Driver Examiners, Troopers, Police
  Officers (Meuser)
• HB-1536 Evaluation Enhancing DOR Medical Review
• Older Driver Safety Pamphlet for Missouri (Carr)
• Clinical Evaluation, Screening, Driver Fitness
• Questions?

3
Older Drivers Have Fewer Crashes
Crashes per 100,000 drivers
(Source NCSA, 2000)
4
Driver Fatality Rate(per 100 million VMT)
Fatality Rate
Driver Age Group
Source FARS 2001 and NHTSA 2001
5
US Population By Segment (Squaring the U.S.
Population Pyramid 1950-2030)
Age
85
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
1950
1980
2030
2000
(227,658,000)
(150,216,000)
(267,955,000)
(304,807,000)
6
Whats Happening in Missouri?
7
Missouri Traffic Crashes

• 3,186 disabling injuries involving an older
  driver
• 42 (1,349) were the older driver
• 543 fatalities involving an older driver
• 60 (328) were the older driver
• 16 of the fatalities involve an older driver

8
Types of Crashes
1. Unsignalized Intersections 34
2. Commercial Motor Vehicle 16
3. Pedestrians 12
4. Signalized Intersections 5. Following Too Close 24 30
9
Develop Statewide Program

• GOALS
• Reduce deaths and injuries related to traffic
  crashes involving older drivers
• Keep people driving safely as long as we can
• Participate in National Demonstration Project
• Develop Statewide Network of Partners

10
Model for Older Driver Program Activities
11
National Demonstration Project

• Focus on Five Communities
• Columbia, Springfield, Cape Girardeau, St. Louis,
  and KC
• Implement Five Core Programs
• DriveWell
• AMA Physicians Module
• Roadwise Review
• CarFit
• Law Enforcement Module

12

• Four hour training
• Discuss issues related to older driver safety and
  community mobility
• Toolkit that provides resources for local use
• Trained 95 people

13
Assessing Counseling the Older Driver

• Washington University provided Training
• Trained 212 people

14
Roadwise Review

• Worked with AAA
• Distributed approximately 125 copies of the
  self-assessment tool statewide
• Can be accessed on the web at www.aaa.com

15
CarFit Program

• Community events
• Fit people to their vehicles
• Trained 75 people

16
Law Enforcement Module

• Trained approximately 500 people
• St. Louis County Municipal Police Academy
• Law Enforcement Traffic Safety Advisory Councils
  Annual Conference
• Missouri State Highway Patrol, Driver Examiners
  Training

17
Other Accomplishments

• Created a display
• Created print ads
• Created a brochure
• Database of over 200 contacts
• Received a variety of media coverage across the
  state
• Provided an article in the TRB Newsletter
• Held statewide older driver workshops
• MoDOT/FHWA sponsored older driver workshop for
  engineers

18

• Tom Meuser, PhD
• University of Missouri St. Louis

19
Two Older Drivers
A focus on functional health status recognizes
that we age differently on an individual level.
20
Medical Conditions Crash Risk
Many of these conditions are more prevalent in
older adults.
21
Medical Fitness to Drive

• Medical Fitness to Drive (MFD) is applicable to
  all age groups, but is especially relevant for
  older adults.
• A number of studies indicate that certain
  age-related medical conditions may impair driving
  ability and thereby elevate crash risk.
• The management and reporting of MFD concerns is a
  voluntary process in most states.
• The first responsibility for addressing MFD
  concerns resides with the individual driver. Many
  States require drivers to notify the DMV of
  health conditions that may impair driving safety.
• Most States allow health professionals, law
  enforcement personnel, and others to report
  potentially unfit drivers for re-testing and
  possible license revocation. A few, such as
  California, mandate such reporting where dementia
  and other conditions are concerned.

22
Driving Mobility ContinuumDrawing the Fitness
Line
Mild or Reversible
Serious Permanent
23
St. Louis Team

• Investigators
• Tom Meuser, PhD, UM St. Louis (formerly with
  WU)
• Dave Carr, MD, Washington University
• Gudmundur Ulfarsson, PhD, University of Iceland
  (formerly with WU)
• Pat Niewoehner, OTR/L, CDRS, St. Louis VA Medical
  Center
• Peggy Barco, OTR/L, DRS, Washington University
  Center for Head Injury Services
• Marla Berg-Weger, PhD, Saint Louis University
• Past Student Other Assistants
• Joon-Ki Kim, Washington University
• Tom Epplin-Zapf, Washington University
• Matthew Minn, Southern Illinois University
• Jessica Lester, Washington University
• Jami Croston, MSOT, Washington University
• Katie MacLean, MSW, Alzheimers Association, St.
  Louis Chapter
• Emily Kissel, Washington University
• Mimi Hilburg Annie Harmon, University of
  Missouri St. Louis
• Donna Keller, former part-time on-site data
  assistant

And many others
24
Active in Driving Education Research

• Education
• Dementia Driving Workshops
• Highway Patrol Curriculum
• Missouri Senior Driver Pamplet
• AMA Older Drivers Project
• CarFit, DriveWell
• Mobility Counseling Project
• Local, Regional National Talks

• Research
• Beliefs of Stakeholders
• Validation of Training Curricula
• Dementia Driver Fitness
• Stroke Driver Fitness
• Older Driver Evaluation Mobility Clinic with
  On-Road Testing

25
Education
26
Health, Functional Status Older Driver Safety

• A Curriculum for State Highway Patrol Examiners
  Officers

27
Learning Objectives

• At the end, you will understand
• Older driver safety statistics in Missouri.
• How age-related changes in health and functional
  status may impair driving ability and increase
  crash risk.
• An approach to observing and describing such
  changes in older drivers.
• How to document such changes in support of a
  citation and the license review process.
• Complete pre-test questionnaire now, if required,
  and hand it in to the presenter. Thank you!

28
Case Example Traffic Stop

• Mr. Jim Greene, age 73, was pulled over by State
  Trooper for weaving and driving through a stop
  sign.
• Mr. Greene has lived in Florissant, Missouri, for
  just the past two years, after moving here from
  Madison, Wisconsin, to live closer to his
  children.
• He wears glasses, but does not report a vision
  problem.
• He seems mildly confused, forgetful and rather
  irritated/embarrassed to have been stopped.

29
(No Transcript)
30
Form 4319 (page 1)
31
Form 4319 (page 2)
32
Case Example Driving Skills Test

• Mrs. Mary Brown, age 74, was cited by the
  Director of Revenue to take a Driver Skills Test.
• She is a retired factory worker and lifelong
  resident of Florissant, MO.
• She reports a minor problem with her distance
  vision (I think I need new glasses, but I still
  see OK)
• She is quite anxious about being tested, but
  tries her best to be cooperative during the
  examination.

33
(No Transcript)
34
Narrative on Form 232

• Mrs. Brown was a pleasant, willing participant
  in the driving skills test. She appeared
  moderately anxious, as evidenced by rapid
  breathing, high pitched tone of voice, and many
  comments on her performance.
• She wore glasses, but appeared to have
  difficulty seeing both near and far objects. For
  example, she misread her driver license number
  and she could not read signs on nearby buildings.
  She reported being at the Hazelwood test
  facility, and she stated her name, address and
  phone number without difficulty. She gave the
  correct date and time.
• She walked to her vehicle, entered it, and
  fastened her seatbelt properly. She pointed
  correctly to controls named by the Examiner, and
  she named common objects giving incorrect names
  initially, but self-corrected later.
• During testing, she frequently drove too close
  to the curb and parked cars. She appeared
  confused when asked to parallel park between
  cones, and asked three times to explain what I
  wanted her to do. I discontinued this maneuver
  after a few minutes. At the last intersection on
  the course, she appeared not to see the stop sign
  and continued driving until I instructed her to
  stop. She failed due to excessive points.

35
Missouris Voluntary Reporting Law

• Passed by the MO Legislature in 1998 following a
  significant lobbying effort by CARD, WU,
  Alzheimers Assoc, other organizations.
• Not age or disease specific.
• Intended to promote reporting of impaired drivers
  by health professionals, particularly physicians.
• Forms allow for a range of health and addiction
  conditions to be reported.
• Similar to voluntary laws in 45 other states.
• Has never been formally evaluated.

36
Driver Condition ReportDownloadable from
http//dor.mo.gov/mvdl/drivers/forms/
37
Project Details

• Private University (x2) Private Foundation
  State Government Collaboration
• Characterize the functional impact and efficacy
  of HB-1536 for the medically impaired older
  driver in Missouri
• Goal to capture data for all reported
  individuals, aged 50, reported between 2001
  2005.
• A clear understanding of how the Missouri law
  works and its efficacy will have broad
  implications for state policy, traffic safety,
  public education, and the well-being of medically
  impaired older drivers.
• Our project will also provide a basis for future
  inter-state comparisons and national policymaking.

38
Missouri Reporting Process

• Once reported, the older adult must negotiate
  each step (hurdle) in the process to retain a
  valid license.
• Failure to submit a physician statement (Hurdle
  1) leads to license revocation in all cases.

39
What did we expect coming into this?

• Most reported drivers would be evaluated by a
  physician.
• Half or more would be referred on and complete
  on-road testing.
• A quarter or more would pass and retain a valid
  license to drive.
• A quarter or so would have a positive crash
  history.
• A quarter or more would have a positive citation
  history.
• A substantial number would show evidence of
  ongoing driving subsequent to license revocation.

40
Reporting Trends over Time
Why might reports from license office staff be
going down?
41
Annual Crash Rates
42
Combined Frequency of Medical Conditions (n
4,100 cases from which microfilmed documents
were reviewed)

• Dementia / Cognitive Impairment 45
• Vision Condition 31
• Musculoskeletal / Neuromuscular 28
• Disorders of Consciousness 16
• Cardiac / Cardiovascular 12
• Brain Insult, Tumor or Stroke 10
• Psychiatric Condition 8
• Alcohol / Drug Abuse 3

43
Summary of Outcomes
44
MODOT-Funded Project2008-2009

• Follow-up project with the Missouri DOR to apply
  findings from the HB-1536 evaluation effort to
  improve current forms and system.
• Single Form for Reporting from All Stakeholders
• Incorporate best practices from other States
  into a new Physicians Statement (Form 1528)
• Enhance education provided to License Office
  Staffers

45
Issues

• States rely significantly on physician input in
  deciding questions of medical fitness to drive
  and whether someone should have license
  restrictions or be de-licensed (permanently or
  temporarily).
• Few physicians are trained to make such
  determinations, however, and many do not view
  driving as within their medical purview.
• Some States, such as California, provide
  significant guidance to physicians concerning the
  medical review process, whereas others provide
  very little.
• The quality of physician input in Missouri has
  been mixed at best.

46
Physician Statement
47
Best Practices Project

• We are in the process of collecting medical
  review forms and supporting documents from all US
  States, Canadian Provinces, and from other
  countries (UK, Australia).
• We need to develop a means to rate these forms in
  terms of the guidance they provide to physicians,
  their comprehensiveness, ease of use, etc.

48
We will also be improving training provided to
license office clerks
In Missouri, DMV clerks are encouraged to be on
the lookout for impaired drivers and to report
those they consider to be a safety risk.
49

• David Carr, MD
• Washington University
• School of Medicine

50
Disclosures Carr

• Funding Support (Past Year)
• National Institute on Aging (NIA)
• AAA Foundation Traffic Safety
• Missouri Department of Transportation
• LongerLife Foundation
• Consulting Relationships
• American Medical Association (AMA)
• ADEPT
• SeniorSMART
• AAA Foundation Traffic Safety
• Speakers Bureau
• St. Louis Alzheimers Association
• Drug Industry Sponsored Trials
• Elan
• Investment/Stock/Equity None

51
Transportation Safety Handout for Older Adults

• Final Report Submitted to
• Missouri Department of Transportation
• Highway Safety Division Oct 23, 2007
• Dr. Gudmundur Freyr Ulfarsson
• Assistant Professor of Civil Engineering
• Washington University
• School of Engineering and Applied Science
• Dr. David B. Carr
• Associate Professor of Medicine and Neurology
• Washington University School of Medicine

52
AGING DEMOGRAPHICS

• Older Adults
• 2007
• 36 Million Older Adults over age 65 yrs (12 US)
• 28 Million Licensed Drivers over 65 yrs (15 US)
• 2050
• 86 Million Older Adults over age 65 yrs (21 US)
• 66 Million Licensed Drivers over age 65 (25 US)
• Chronic Disease
• General Population
• 25 million people or about 1/10 citizens
• 1.7 million die each year
• Older adults
• 50 affected over age 65 years
• 37 report disease is severe
• 16 require assistance

53
OBJECTIVES

• To develop a transportation safety pamphlet
• -for older drivers
• -based on crash statistics in Missouri
• -based on common medical conditions
• The booklet
• - reviews the risk factors for injury
• -enhances knowledge of vehicular/environmental
  risk factors
• -enables older adults to take steps to address
  impairments
• -provides materials in a format that was easy to
  understand

54
METHODOLOGY

• Pre-pamphlet Focus Groups
• Little insight
• The Missouri Crash Statistics
• Focus on Older Drivers
• Medical Literature
• Focus on conditions that are associated with risk
• Draft Pamphlet Design
• Based on Literature
• Pre and Post Focus Groups
• Further modification
• MoDOT input and Graphic Design Team

55
CONTENT CRASHES

• Behavioral Suggestions
• Vehicle adjustments and service
• Avoid alcohol or drowsy driving
• Use seatbelt and avoid cellphones!
• Environmental Suggestions
• Weather
• Intersections
• Parking/Driveways
• Turning

56
CONTENT MEDICAL INFO

• Conditions
• Vision
• Cognition
• Motor
• Areas
• Common medical conditions
• Symptoms related to common diseases

57
Fitness-to-Drive in Older Adults with Dementia

• Investigators
• Washington University at St. Louis
• David B. Carr, MD
• Associate Professor of Medicine/Neurology
• Clinical Director, Division of Geriatrics and
• Nutritional Science, ADRC
• Peggy Barco, MS, OTR/L, BSW
• Instructor
• Program of Occupational Therapy
• Funded by MoDOT
• Division of Highway Safety
• Report due Oct 30, 2008

• Collaborators
• Washington University at St. Louis
• Annie Johnson, Project Coordinator
• Holly Hollingsworth, PhD Statistician
• Jami Croston, OT Graduate Student
• The Rehabilitation Institute of St. Louis
• Kathy Dolan, OTR/L
• Pat Storie, COTA
• Independent Drivers, LLC
• Steve Ice, OTR/L
• Jefferson Barracks, VA
• Pat Niewoehner, OTR/L

Local Advisory Panel Tom Meuser, PhD, Marla
Berg-Weger, PhD External Advisory Panel Linda
Hunt, PhD, Loren Staplin PhD, Dr. G. Ulfarrson
58
Why Alzheimers Disease?
4 Million AD Cases TodayOver 14 Million
Projected Within a Generation
16
14.3
14
11.3
12
10
8.7
Millions
8
6.8
5.8
6
4
4
2
0
Year
59
Driving and non-DAT Dementia
Alzheimers Disease
Temporal profile laboratory results
Behavior, Language
EPS, Visual Hallucinations
Stroke, Focal Signs
Frontotemporal dementias
Rapidly evolving dementias
Lewy body dementia
Vascular dementia
60
WHAT IS THE PROBLEM?

• We currently have no brief, simple, office-based
  instrument that would predict the ability to pass
  a performance-based road test in medically
  impaired drivers, particularly those with
  cognitive impairment.
• Often, the final "arbiter" in the decision to
  drive is whether the impaired driver can pass an
  on road test.
• Road tests are expensive, time consuming, and
  may need to be repeated over time in individuals
  with progressive conditions.
• There is also the safety concern for the driving
  instructors (OT's/SHP officers) and the welfare
  of the public when administrating these tests.

61
BACKGROUND

• Medical Fitness-to-Drive (MFD) study in Missouri
  indicates dementia an issue
• 20 of drivers over age 80 demonstrated
  significant cognitive impairment at license
  renewal in one study
• Larger population-based studies that are able to
  identify cognitively impaired drivers by brief
  cognitive screens have found modest increases in
  crash rates
• At higher levels of cognitive impairment,
  previous studies from our Center have indicated
  that many older adults are unable to pass a road
  test.

62
BACKGROUND cont.

• Current Approaches
• Heterogeneous vs. Homogenous Groups
• One test vs. Multiple tests
• Various Outcome Measures
• Candidate Tests
• Vision Tests
• Traffic Sign Tests
• Knowledge Tests
• Road Tests

63
OBJECTIVES

• Develop a first tier screen for fitness-to- drive
  testing in older adults with dementia (Year 1)
• Primary goal is to reduce the number of road
  tests performed by the highway patrol
• Secondary goal is to develop screening tools for
  caregivers and for health professionals
• Study different types of dementia (Year 2)
• Build a database that can be adopted by others
• Recommend further validation with prospective
  studies examining at-fault crash data

64
PRELIMINARY RESULTS

• Each participant was screened via telephone.
• As of Oct 22nd, 2008 86 participants were
  screened.
• 27 were excluded for the following reasons
• 9 informants stated they were not interested or
  refused
• 4 specifically stated concerns about being
  reported to the DMV
• 3 had driving evaluations in the past year
• 2 did not have an active license
• 2 did not meet criteria for a dementing illness
• 2 did not have a physician diagnosis of dementia
• 2 participants refused
• 1 participant had state testing
• 1 participant admitted to the nursing home
• 1 raised concern for a lawsuit

65
DEMOGRAPHICS

• 59 driving evaluations of participants with a
  diagnosis of dementia have been studied to date.
• The demographic characteristics of this sample
  are as follows 74.310.3 age in years, 54 Male,
  18 African American, 14.62.9 years of
  education, have averaged 56.210.8 years of
  driving, and drive an average of 5.2 1.9 days
  per week.
• Informants that provided information on the
  participants included spouses (61), adult
  children (32) and friends/relatives (7).
• GOAL 200 participants with dementia from
  TRISL/VA sites

66
TOOLS FOR HIGHWAY PATROL(N59)

• To date, our participants have been able to name
  correctly 7.4 3.0 road signs (out of 12),
  provide the correct meaning of the sign on
  average 7.42.2, and obtain an average score of
  9.4 2.8 out of 13 questions on our written
  examination.
• This data will be compared to on-road performance
  as our sample size increases.
• These tests have been easy to administer, take
  minimal time by the examiner, have some face
  validity and may be potentially acceptable to the
  older adult and family as a proxy for safe
  driving.
• Continue to modify scoring rules

67
TOOLS FOR CAREGIVERS(N59)

• The Functional Activity Questionnaire (FAQ)
• Scores range from 0-30, each of ten items scored
  0-3.
• It has been well validated in the geriatric
  literature.
• It assesses performance of IADL
• The FAQ was completed by mail.
• Informants 6.86.8
• Participants 2.53.1
• Driving Behaviors
• A checklist was provided by mail
• Informants 2.53.1
• Participants .91.4

68
TOOLS FOR OTsDRIVING CLINICS TRISL(N59)

• Contrast Sensitivity (1.6.2 LogMARs)
• Reaction time right foot (.82.7 secs)
• Rapid Pace Walk (7.71.9 secs)
• Short Blessed Test (8.97)
• Trails A (61.140.8 secs)
• Trails B (195.389.9 secs)
• Clock Drawing Task (5.12.4)
• Maze Test (46.225.7)
• UFOV (334.5159.6 msec)

69
DRIVING CLINICS VAMC(N61)
70
Driving Outcomes

• Crashes
• (4 Crash rate per year)
• Road Tests
• (56 failure rate)
• Simulators
• Questionnaire
• Cessation
• Others

71
Statistical Methods

• Independent variables continuous, categorical
• Dependent variables continuous, categorical
• Use t-tests for continuous, chi-square for
  categorical
• Inter-rater and intra-rater reliability and
  perhaps measures of test stability
• Determine unadjusted correlations with pass/fail
• Stepwise logistic regression for those variables
  that were significant, along with important
  demographics
• Models will be created to determine the
  combinations of independent variables that best
  predict road test failure
• ROC curves to be created with the AUC to reflect
  graphically and quantitatively the ability of the
  model to discriminate those that fail from those
  that pass

72
Expanded Fitness-to-Drive Study

• Create a set of standards for driving evaluations
  (OTs)
• History (DHQ, Destinations, etc)
• Physical Exam (DHI, Muscle Strength, etc)
• On-the-road performance testing (WURT, DMV, etc)
• Recruit DMV/Driving Clinics across the state
• Urban
• Rural
• Create a common data base shared by sites
• Desktop
• Web-based
• Develop disease specific fitness-to-drive models
• Diseases Dementia, CVA, other
• Outcomes Road Test, Cessation, Crashes, At-fault
  Crashes

Pre-proposal sent into AAAFTS and pending 11/08
73
Acknowledgments

• AAA
• Michael Wright
• CARD
• Shel Suroff
• Alzheimers Association
• Katie McLean
• MoDOT/Highway Safety
• Leanna Depue
• Jackie Rogers
• Highway Patrol
• Captain Gary Moore
• Ron Beck
• External Advisors/Collaborators
• Linda Hunt
• Pacific University
• Loren Staplin
• Transanalytics
• Gudmundur Ulfarsson
• University of Iceland

• WUSM
• Participants and their families
• Peggy Barco
• JoAnn Wilson
• Ann Johnson
• Jami Croston
• Holly Hollingsworth
• ADRC and MDC staff
• UMSL
• Tom Meuser
• Jefferson Barracks VAMC
• Pat Niewoehner
• Independent Drivers
• Steve Ice
• TRISL
• Kathy Dolan
• Patricia Storie
• SLU
• Marla Berg-Weger