DriveWise®: Lessons learned from a hospital based driving clinic Margaret O’Connor PhD/ABPP Beth Israel Deaconess Medical Center Harvard Medical School

Driving: A Right or Privilege? Most pervasive marker of self esteem American culture “in love” with the automobile; the car is celebrated in song, art, movies, music Well defined entry but no system to exit

Mandatory Vs. Voluntary Reporting Most states - voluntary Oregon, CA, Utah, and PA mandatory reporting dementia 30 states -immunity to physicians

MASS RMV Reporting Procedures No Immunity or Legal Protection Self reporting state: driver’s responsibility MDs not mandated but encouraged No Immunity or Legal Protection RMV Follow Up If general public, medical clearance requested If MD or law enforcement- imminent threat voluntary surrender in 10 days Anonymity not guaranteed Person must file written request for identification of reporter

THE OVER 90 CROWD Hollis, Lee, Kapust, Phillips, Wolkin & O’Connor (2013) 88 patients 27 (90-97); 61 (80-87) Drivers age 90+ at no greater driving risk than those 10 years younger Made similar types and frequency of on road errors Age, in and of itself, does not predict poor driving!

Which Lobes are Key For Driving? Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352: 692-9

Does Age Or A Diagnosis Of Dementia Preclude Safe Driving? Procedural memory ages well Heterogeneity in dementia Let’s be fair: balance autonomy and safety Does the driving risk for mild dementia exceed the crash rate of 16-19 year old males? Need for evidence based solutions…gives the patient their “day in court”

American Academy of Neurology Practice Parameter (Dubinsky et al One Class I and several Class II studies: increased crash risk in AD CDR 0.5 risk ~ 16-19 yo or BAC <.08% CDR 1 - greater than society tolerates CDR of 1 - discontinue driving (Standard) CDR of 0.5 – driving exam (Guideline) Reassessment every six months (Standard)

STEP 4: Rating Dementia Severity

Predictive Screening Tests MMSE <24 - unsafe (Odenheimer, 1994; O’Connor et al, 2010) >24 - not signficant (DeRaedt 2001; Grace et al. 2005) MoCA <18 - unsafe driving (Hollis et al, 2014) TMTB - 3 X 3 rule versus 180” TMTA > 50”; TMTB > 126” (Duncanson et al., 2015) Errors - TMTA - NS; TMTB = 3 (Duncanson et al., 2015) Clinical Dementia Rating Scale (CDR) Brown et al., 2005: 46% CDR 0.5,41% CDR 1 passed

Limitations: Outcome Measures Crash rate: low frequency event, under reporting (memory loss, less citations) Simulator studies: expensive, cumbersome, motion sickness Road tests: subjective, limited driving (no hazardous situations, etc)

DRIVEWISE Beth Israel Deaconess Medical Center Division of Cognitive Neurology Beth Israel Deaconess Medical Center 617- 667- 4074

Driving Assessment Process Referral Social Work Evaluation Occupational Therapy Evaluation Team Meeting Road Evaluation Feedback Session w/ Social Work

Who are the clients? Over 700 individuals tested over 15 years Patients with underlying medical, cognitive or psychiatric problems that may impair driving safety A range of diagnoses: Alzheimer’s disease, MS, Parkinsons, ALS, Stroke, post ECT, bipolar, orthopedic problems, brain tumors Ages: 17-97

Demographics Breakdown by Age

The Social Work Assessment Sign consent form Take psychosocial/driving history Begin to anticipate negative consequences Administer MoCA; complete 4C’s Set up feedback session at which time good/bad news delivered in detailed letter

Montreal Cognitive Assessment (MoCA) Visuospatial/executive, naming, memory, attention, language, abstraction & orientation (Nazzredine et al, 2005)

THE 4 C’S Crash/ Citation (family) Concern Clinical Status Cognition 1 2 3 4 No Crashes 1+ fender bender Major Citation Crash(es) None Mild concern Moderate concern Extreme concern Good health Mild medical Moderate medical Severe medical Intact Mild decline Moderate decline Severe decline

Occupational Therapy Evaluation Three key domains of driving are assessed Vision Cognition Physical Function Standardized On Road Evaluation 21

Vision Testing Visual acuity- 20/40 or better, Daytime only restrictions available Visual Field- 120 degrees of lateral field at eye level Tracking Depth perception Contrast Sensitivity

Folstein MF, Folstein SE, McHugh PR., 1975 Mini-Mental State Examination (MMSE) Orientation, recognition, calculation, recall, and language Folstein MF, Folstein SE, McHugh PR., 1975 MMSE

MoCA vs MMSE in the prediction of driving test outcome 92 adult drivers Neither test predictive for cognitively intact For dementia MoCA was a better predictor As MoCA score decreased by 1 point, person was 1.36 times more likely to fail MoCA ‘cut score” of 18 or less

Useful Field of View Test Measures the size of the visual field in which one can process rapidly presented, increasingly complex information with a single glance Relies on cognitive function as well as visual function

Useful Field of View Test (Ball et al, 1988) Test 1 Measures speed identifying a single object. 27

UFOV Test 2 Measures speed dividing attention between two objects.

Trail Making Tests Sensitive to divided attention Divided attention is known to be important for safe driving Reitan, 1955 Trail Making Test Part B

Physical Assessment 30 Strength and range of motion Coordination Sensation Functional control Mobility Brake reaction time 30

On Road Evaluation The ‘gold standard’ for assessing driver safety Standardized assessment based on the Washington University Road Test - presents a variety of driving challenges (Hunt et al, 1997) OT and CDI both separately score driving performance Evaluation is only a ‘snapshot’ of driving

On Road Evaluation Starting and securing the car Following instructions and road signs Visual awareness Positioning & lane control Maneuvers Responding to obstacles & situations Speed control Problem solving

Outcomes of the Evaluations Individuals can either pass, fail, or be referred for remediation. The decision was not made for a handful of cases.

Breaking Bad News Techniques Enlist family support Take time and allow for silences Focus on history of resilience Define independence broadly Focus on actual driving errors Discuss safety for self and others Medicalize the problem Monitor for mood changes

Driving Cessation Older adults who have relinquished their license make fewer trips and engage in fewer activities They experience greater health problems, including a higher incidences of depression Although rides may be available, ‘discretionary travel’ for social and recreational needs is often reduced Family members struggle to ‘pick up the slack’ (Sutts & Wilkins, 2003; Perkison et al, 2005).

Transportation Alternatives 73 % of U.S. adults age 65+ live in areas with little or no access to public transportation; 30% live alone In urban areas adults over 65 make only 6% of trips by mass transit and less than 1% by taxi Public transportation is often inaccessible to those older adults with mobility or memory impairments. (Taylor, & Tripodes, 2001).