Driving Licence Assessment Panel

Speakers Dr Satish Karunakaran Consultant Psychiatrist Dr Yong Mong Tan Consultant Endocrinologist Dr Craig Costello Consultant Neurologist Dr Dharmesh Anand Consultant Cardiologist

Driving in Neurology Dr Craig Costello MBBS FRACP North Queensland Neurology

Driving Complex multifaceted highly skilled task Encompasses all parts neurological system Temporary intermittent or chronic conditions Personal and public safety (risk) Balance of ones privilege to drive Rights and responsibilities

Temporary TIA / Stroke with resolution of deficit Cause orientated Time for preventative medications to have effect Altered consciousness rare Vision is the trap

Progressive Dementia Parkinson's and similar syndromes Peripheral neuropathy (often stable) Transitional Mindful of symptoms that cause concern

Epilepsy Comprehensive but gaps in guidelines Straightforward Complex - neurologists lose sleep over Explanation and reassurance Further opinion

Work together GP / Specialist / Relatives Practical driving assessment No decision maker QT (conflict) Syncope

Diabetes and Driving

Case presentation Male 55y, holds commercial drivers R, MC, UD x 30 yrs Type 1 diabetes since 1976, suffered 2 episodes of hypoglycemia requiring ambulance attendance. ED advised no driving till assessed by an endocrinologist. Could not afford without licence. Medications: Humalog with meals, Levemir simvastatin Home glucose mostly 5-8 at different times, a few <4 post BF and afternoon. Qs we must ask? Examination was essentially normal- what should we examine for? Biochem: HbA1c 6.7%, others normal

Assessing people with diabetes for driverslicence Remember it has significant medico-legal implications- do it professionally Major areas of concern are hypoglycemia, hypoglycemia unawareness, diabetes complications and related areas of CVD, OSA In my practice, at booking I require patients to have: 1. a current eye review, preferably filled in Eye Section 2. provide at least 3 weeks home glucose readings 3. pre warned may not pass the assessment consider use of 3 month provisional approval pending further review to improve compliance, assist hardship and defuse anger.

Heart and Driving Dr. Dharmesh Anand MD DNB FRACP FCSANZ Consultant Cardiologist TTH & Mater Hospital

55 year truck driver 55 year truck driver Clearance to drive (Conditional Licence) Clearance to drive (Conditional Licence) BG: BG: – NSTEMI 2007; DES in LAD, POBA Diagonal in Brisbane; Minor disease in RCA, LCX – Normal LV systolic function – 2 EST negative since – Smoker – Hypertension – Hypercholesterolemia – Obesity – Nil symptoms

Conditional licence with annual review (PCI/CABG/Angina/ Known CAD, HF, Heart Transplant, HCM) there is a satisfactory response to treatment; and there is an exercise tolerance of 90% of the age/sex predicted exercise capacity according to the Bruce protocol (or equivalent exercise test protocol) ; and there is no evidence of severe ischaemia, i.e. less than 2 mm ST segment depression on an exercise ECG or a reversible regional wall abnormality on an exercise stress echocardiogram or absence of a large defect on a stress perfusion scan; and there is an ejection fraction of 40% or over; and there are minimal symptoms relevant to driving (chest pain, palpitations, breathlessness)

What Next ? Exercise Stress Test Exercise Stress Echo Dobutamine Stress Echo CT Coronary angiogram Coronary Angiogram No testing Specialist Cardiologist Referral MPS 11 minutes on the Bruce protocol reaching a peak heart rate of 148 bpm which was 80% of maximum predicted heart rate. There were no symptoms. The ejection fraction was 64%. There was equivocal evidence of small reversible ischaemia in the RCA territory.

June 2012 Anterior NSTEMI with dynamic anterolateral ST depression Emergent coronary angiography revealed proximal occlusion LAD instent, treated 2X DES in LAD (P) & (M). RCA has proximal to mid long stenosis 70-80% at most in moderate size vessel LVEF 30% Occipital CVA (Homonymous hemianopia); AF

July 2012 : Presyncope Most difficult and needs Cardiologist review (Holter ECG, Echo, Function testing, EP studies) Cardiac arrhythmias (4 wk-3 mo), Vasovagal syncope (24 hrs for private vehicle) to are the extreme ends of the spectrum Blackouts of unknown aetiology : Non-driving periods (6 mo for private to 5 yrs for commercial vehicles) Cardiology Review No driving for 3 months Holter ECG; Negative ESE : LVEF 45%, Negative, Exercised for 11 mins Stopped smoking OK from cardiology

SUMMARY NTC guidelines are comprehensive and detailed in most cases (MI, CABG, PCI etc.) NTC guidelines are comprehensive and detailed in most cases (MI, CABG, PCI etc.) Non-Driving periods have to be clearly documented Non-Driving periods have to be clearly documented For conditional licence For conditional licence – Functional testing preferred over coronary imaging – Exercise Stress Echo to be preferred – Careful of cumulative radiation dosage before ordering MPS Cardiologist review in complicated cases Cardiologist review in complicated cases – Blackout of unknown aetiology – Suspected cardiac arrhythmias – Hypertrophic cardiomyopathy – Adult congenital heart disease – Cardiac defibrillator – Aortic aneurysm