Medically At-Risk Drivers Gina C. Pervall, MD Chief, Medical Advisory Board MDOT MVA BIAMD - March 2018

Disclosure I have no financial interest or affiliation with any entity producing, marketing, re-selling or distributing healthcare goods or services consumed by, or used on patients.

Objectives Identify medically at-risk drivers Understand MVA’s referral and review process for medically at-risk drivers Knowledge of testing and assessments used by the Medical Advisory Board for fitness-to-drive Resources

Maryland Drivers Maryland has more than 4.3 million licensed drivers Largest group of licensed drivers is 50 – 59 years old More than 17% of Maryland drivers are 65 years & older Start with some stats 50-59 age group grown by 36% since 2000 90 and older grown over 2 times since 2000 = 20,000 drivers

Baby Boomers are those born between 1946 and 1964

Driving after Brain Injury 70% individuals with TBI return to driving 63% individuals with severe TBI were involved in subsequent crashes Bivona, et al. 2012 Study included drivers who were non-licensed before prior injury and drivers with and without driver rehab

Driving after Brain Injury CVA – No increased accident rate TBI – Accident rate two-times higher compared to general population Lack of adequate compensation for cognitive deficits Premorbid conditions Shanke, et al. 2008 Study in Norway was follow up of accident rate and driving patters 6-9 years after brain injury Young at time of TBI Medication

Driving after Brain Injury Individuals with TBI who received driver rehabilitation had no higher rate of accidents compared to control group Schultheis, et al. 2012 5 year after injury study

Medically Fit Driver A safe driver has the ability reason, remember, and react quickly to any driving hazard, or to avoid a collision. First, to identify medically at risk, we need to define a safe driver: These 3 points in response to driving hazards and to avoid collisions. As a result of a variety of factors, drivers may be considered “unsafe” when they are unable to accomplish these tasks….Medical factors

Warning Signs of Unfit Driver Getting lost Not observant Accidents/Near misses Drifting across lanes Slow to make decisions Poor distance judging Driving too fast/slow Parking difficulties Not seeing signs, forgetting backing up

Medical Risk Factors Physical/Functional Limitations Mental/Cognitive Limitations Visual Impairments Impairing Medications Any one or combination of these can impact attention, reaction and recognition of hazardous situations or changing traffic conditions. ALL can be impacted with a brain injury

Brain Injury & Driving Disruptions Physical Impairments Decreased Strength Poor Coordination Decreased Reflexes Decreased Reaction Time Need strength and muscle control to physically operate a car Poor hand-eye coordination Following a brain injury, motor skills may be compromised due to weakness, hemiparalysis, ataxia, rigidity

Brain Injury & Driving Disruptions Cognitive Impairments Memory Deficit Poor Divided Attention Decreased Information Processing Speed Poor Judgement/Insight Easily distracted, unable to recognize hazards, unable to multi-task Remember rules of the road Prone to more risk-taking behavior, labile mood Poor awareness of driving problems, unable to recognize driving errors

Brain Injury & Driving Disruptions Cognitive Impairments cont. Inability to concentrate over long periods Poor problem solving Lack of awareness/insight Easily distracted, unable to recognize hazards, unable to multi-task Remember rules of the road Prone to more risk-taking behavior, labile mood Poor awareness of driving problems, unable to recognize driving errors

Brain Injury & Driving Disruptions Visual Impairments Blurred Vision Double Vision Visual Field Deficit Variety of problems, most common listed Acuity and field – CVA hemianopia Also, decreased VA, nystagmus,

Brain Injury & Driving Disruptions Medications Narcotics Benzodiazepines Anticonvulsants Antidepressants Prescription & over-the-counter medications BOTH can affect ability to drive safely Sedation, dizziness, lightheadedness May forget to take a crucial medication

MD Vehicle Law§16-118 The Administrator may appoint a Medical Advisory Board of qualified physicians and optometrists to enable the Administration to comply properly with the provisions of this title regarding the physical and mental condition of individuals who seek to drive on highways in this State. Individual medical reviews 85% with medical reviews kept their license (average of 60% of people with mod to sever brain injuries return to driving after injury)

Medical Advisory Board Comprised of physicians from various specialties Reviews medical information of individuals with conditions that can impact their ability to safely drive Assesses medical fitness to drive Provides advice and recommendations to MVA Does not make the final decision regarding driving privileges since 1947 Functional and cognitive ability 85% with medical reviews kept their license

COMAR 11.17.03.02 Physical and Mental Condition Any physician and other person authorized to diagnose, detect, or treat a disorder that: is characterized by lapse of consciousness; or Results in corrected visual acuity that files to comply with the vision requirements…” Physician and driver requirement - Physician reports refers to transportation law MD Vehicle Law§16-119 Physician reports are confidential. Apart from the psychologist and psychiatrist privilege, there is no physician-patient privilege in Maryland. No civil/criminal action may not be brought against a physician who makes a report.

Lapse of Consciousness Confusion Epilepsy Narcolepsy Hypoglycemia Cardiovascular Disease Cerebrovascular Disease Alcoholism Drug Addiction

COMAR 11.17.03.02-1 A licensee or an applicant for a driver’s license shall notify the Administration if the licensee or applicant is diagnosed with a “reportable condition”… Physical and Mental Condition Physician reports refers to transportation law

Reportable Conditions Diabetes Epilepsy Seizure Heart Condition (LOC) Stroke Dizzy/Fainting/Blackout Traumatic Brain Injury Sleep Disorder Weakness/Shaking/Numbness Loss of Limb/Function Sleep Disorder Dementia Mental Health Condition Schizophrenia Alcohol Use Problem Drug Use Problem Corrected minimum Visual Acuity worse than 20/70 Field of Vision less than 110 degrees Summary: Lapse of Consciousness, Impaired Motor Skills, Impaired Cognition or Judgment, Poor Visual Acuity

Medical Review Process Law Enforcement, Healthcare Professionals, Branch Referrals, Self-Report, Court Referrals, Concerned Citizens

MVA Functional Capacity Test Rapid walk - lower limb mobility Useful Field of View (UFOV®) - divided attention Delayed Recall - memory Motor Free Visual Perception Test (MVPT) - spatial relationships Trails B - visual search and sequencing, information processing speed, attention switching Screening - Details FCT Article 2006, Karlene Ball “Performance-based cognitive measures are predictive of future at –fault MVCs in older adults… High-risk older drivers can be identified through brief, performance-based measures administered in an MVA setting.”

Useful Field of View (UFOV) Quantifies visual field over which driver can process rapidly presented visual information Most studied relative to predictive validity for on the road driving performance, predictive of attention and visaul processing skills for on the road performance in people with moderate to severe TBI 25

Motor Free Visual Perception Test Assess spatial relationships, visual memory and discrimination

Motor Free Visual Perception Test

Trails B Executive functioning: visual motor tracking, divided attention 30

FCT Results No Deficit Mild Deficit Moderate - Severe Deficit No further testing/MVA Drive Test Mild Deficit MVA Drive Test Moderate - Severe Deficit OT/Driver Rehab On and off the road evaluations. OT/Driver Rehab Specialist. Difficult to assess in research: routes not standard, traffic fluctuations Physical: Visual acuity, FOV, Neck ROM, Extremities, reaction time. Cognitive: decision making, reaction time, judgment, reasoning, visual spatial skills, attention. BTW: test of mechanical operation Note: research does not support simulators

OT/Driver Rehab Assessments Clinical Evaluation Medical History Physical Functioning Cognitive Functioning Behind-the-Wheel Evaluation Objective Clarification Immediate Feedback Guidance On and off the road evaluations. OT/Driver Rehab Specialist. Difficult to assess in research: routes not standard, traffic fluctuations Physical: Visual acuity, FOV, Neck ROM, Extremities, reaction time. Cognitive: decision making, reaction time, judgment, reasoning, visual spatial skills, attention. BTW: test of mechanical operation Note: research does not support simulators

OT/Driver Rehab Report No Deficits Driving Deficits with Potential to Compensate Retraining Vehicle modification Geographical restriction Daylight only driving Retire Two part comprehensive driving evaluations: one part in clinic and the second part behind the wheel of a car. AE: hand controls, spinner knob, left foot accelerator

MAB Review Medical Information MVA Screening/ Testing Referral Reports Physician report, LOC affidavit, treatment report, etc. MVA Screening/ Testing Functional Capacity Test (FCT), Vision, Law, Drive Test Referral Reports OT/Driver Rehab Assessment

MAB Recommendation Qualified to Drive WITHOUT Stipulations Approved for driving and case closed. Qualified to Drive WITH Stipulations Approved with restrictions, adaptive equipment, periodic monitoring. Not Qualified to Drive Temporary/permanent suspension of driver’s license.

Resources Driver Assessments: at Home, the MVA, & by Professionals http://www.mva.maryland.gov/safety/older/driver-self-assessment-tools.htm Functional Capacity Test Screening http://www.mva.maryland.gov/safety/older/fct-screening.htm Referring Drivers to MVA Medical Review Process http://www.mva.maryland.gov/referringdrivers.htm Safety for Older & Medically At-Risk Drivers http://www.mva.maryland.gov/safety/older/older-driver-safety-safe-mobility.htm Safety for Older & Medically At-Risk Drivers: Comprehensive. Download MD Resource Guide for Aging Drivers, Several links – safety, rehab programs, transitioning Referring Drivers to MVA Medical Review Process: Video for Maryland police officers on how to spot drivers who may not drive safely because of cognitive or physical problems.

Driver Wellness and Safety Medical Advisory Board 410 768 7513 DWSMED@mdot.state.md.us Medical Advisory Board 410 768 7371 MAB@mdot.state.md.us

Case Review

30 year old healthy man was operating a fork lift during snow removal duty for his employer. The equipment malfunctioned causing the driver to be catapulted forward, hitting his head and cracking the windshield for the forklift. Brief LOC. Complained of headache, dizziness and confusion. Imaging in ER negative. Diagnosed with concussion and discharged from ER with recommendation for rest, analgesic for headache, and follow up with PCP.

Scenario 1 – Self-Report Health Questionnaire Physician’s Report LOC Affidavit No deficits – close case PR concerns – FCT or OTC

Scenario 2 – Physician’s Report Health Questionnaire LOC Affidavit FCT/MVA Drive Test OT/Driver Rehab Assessment

Scenario 3 – OT/Driver Rehab Report Favorable Unfavorable Health Questionnaire LOC Affidavit MVA Drive Test Restrictions Driver Rehab Suspension

Scenario 4 – Law Enforcement Report Emergency Suspension Health Questionnaire Physician’s Report LOC Affidavit FCT/MVA Drive Test OT/Driver Rehab