The Elderly Driver: Functional Assessment Richard Marottoli, MD, MPH, VA CT and Yale University Shirley Neitch, MD, FACP, Hanshaw Geriatric Center, Marshall University, WV Adapted from a satellite conference produced by Department of Veterans Affairs Employee Education Service and Office of Geriatrics and Extended Care, and Consortia of Geriatric Education Centers. Richard Marottoli, MD, MPH, VA CT and Yale University Shirley Neitch, MD, FACP, Hanshaw Geriatric Center, Marshall University, WV Adapted from a satellite conference produced by Department of Veterans Affairs Employee Education Service and Office of Geriatrics and Extended Care, and Consortia of Geriatric Education Centers.

Mr. Jones is an 83 year old widower sent for follow-up after hospital discharge PMH: HTN, hyperlipidemia, hip fracture, OA, cataracts Function –Lives in own home –Independent in l/B ADL, uses cane –Daughter visits twice/week Straightens house Brings food to reheat PMH: HTN, hyperlipidemia, hip fracture, OA, cataracts Function –Lives in own home –Independent in l/B ADL, uses cane –Daughter visits twice/week Straightens house Brings food to reheat

Driving 3-4 x/wk Mostly familiar places Minor crash 3 yrs ago –Rear-ended at stop sign No navigation problems 3-4 x/wk Mostly familiar places Minor crash 3 yrs ago –Rear-ended at stop sign No navigation problems

Hospitalized 2 Weeks Ago Found on bathroom floor by daughter Awake but confused Unsure what happened, how ER: temp, +UA, renal insufficiency admitted for observation b/o ? LOC, hit head Found on bathroom floor by daughter Awake but confused Unsure what happened, how ER: temp, +UA, renal insufficiency admitted for observation b/o ? LOC, hit head

Hospital Course: Confusion resolved w/ IV fluids, antibiotics Head CT: Infarct of ? age Function: Needed assist w/transfers, walker for ambulation Disposition: STR; f/u appt. w/you regarding driving, living situation Home after 1 week at STR, returned to baseline mobility Confusion resolved w/ IV fluids, antibiotics Head CT: Infarct of ? age Function: Needed assist w/transfers, walker for ambulation Disposition: STR; f/u appt. w/you regarding driving, living situation Home after 1 week at STR, returned to baseline mobility

Types of Assessments Driving skills and behaviors can be assessed in different settings and at different levels of complexity: –DMVs –Rehabilitation Facilities –Local or Regional Assessment Clinics –Primary Care Provider Offices Driving skills and behaviors can be assessed in different settings and at different levels of complexity: –DMVs –Rehabilitation Facilities –Local or Regional Assessment Clinics –Primary Care Provider Offices

Types of Assessments –“ADReS” Assessment of Driving-Related Skills –available in Physician’s Guide to Assessing and Counseling Older Drivers developed by the American Medical Association in cooperation with the National Highway Traffic Safety Administration, September 2003, Chapter 3. –Seven component testing protocol –Much of the testing can be done by office staff –Time required generally 10 min. or less –“ADReS” Assessment of Driving-Related Skills –available in Physician’s Guide to Assessing and Counseling Older Drivers developed by the American Medical Association in cooperation with the National Highway Traffic Safety Administration, September 2003, Chapter 3. –Seven component testing protocol –Much of the testing can be done by office staff –Time required generally 10 min. or less

ADReS –Visual Fields –Visual Acuity –Rapid Pace Walk –Range of Motion –Visual Fields –Visual Acuity –Rapid Pace Walk –Range of Motion –Motor Strength –Trail-Making Test, Part B –Clock Drawing Test Seven Components:

ADReS Component: Visual Fields How Tested: Confrontation Result Signaling Need for Intervention: Any field cut

ADReS Component: Visual Acuity How Tested: Snellen or Rosenbaum chart Result Signaling Need for Intervention: Varies by state; most commonly, best corrected vision of 20/40 required

ADReS Component: Rapid Pace Walk How Tested: Mark 10 foot distance; Time patient walking 10 ft., turning, walking back Result Signaling Need for Intervention: Time > 9 seconds

ADReS Component: Range of Motion How Tested: Neck rotation, finger curl, shoulder & elbow flexion, ankle plantar- & dorsiflexion ---Simulate driving position Result Signaling Need for Intervention: Any clinically significant deficit

ADReS Component: Motor Strength How Tested: Shoulder, wrist, hand grip, hip, ankle Result Signaling Need for Intervention: <4/5 in either upper extremity or right lower extremity

ADReS Component: Trail-Making Test, Part B How Tested: Standard form Result Signaling Need for Intervention: > 180 seconds

ADReS Component: Clock Drawing Test How Tested: Standard form Result Signaling Need for Intervention: Any abnormal element

Visit Information (2 Weeks Post Discharge) Hx: No new complaints, feels fine Meds: Beta blocker, thiazide, statin Exam: BP, HR WNL Cataracts; OA changes hands/knees; good strength; independent transfers, stable slow gait with cane Hx: No new complaints, feels fine Meds: Beta blocker, thiazide, statin Exam: BP, HR WNL Cataracts; OA changes hands/knees; good strength; independent transfers, stable slow gait with cane

ADReS Findings Visual Fields: Intact Visual acuity: 20/40 ou Rapid pace walk: 8 sec (w/cane) ROM: Neck rotation, finger curl limited Strength: /5 Trails B: 135 sec Clock: # spacing slightly off Visual Fields: Intact Visual acuity: 20/40 ou Rapid pace walk: 8 sec (w/cane) ROM: Neck rotation, finger curl limited Strength: /5 Trails B: 135 sec Clock: # spacing slightly off

Questions 1.What do you advise Mr. Jones regarding his driving? His living situation? 2.Are there other history, exam, or laboratory data that would be helpful at this point? 1.What do you advise Mr. Jones regarding his driving? His living situation? 2.Are there other history, exam, or laboratory data that would be helpful at this point?

Follow Up Visit 9 Months later (1 no show in interim) Accompanied by daughter who reports –More confused - oversees meds –House less clean, hygiene worse –Still drving - lost going to her house; no known crashes, but ? new scrapes/ scratches on car 9 Months later (1 no show in interim) Accompanied by daughter who reports –More confused - oversees meds –House less clean, hygiene worse –Still drving - lost going to her house; no known crashes, but ? new scrapes/ scratches on car

Follow Up Visit Mr. J: –No functional changes –Increase in urinary frequency, occasional incontinence PE: –BP, HR higher compared with prior visits, otherwise unchanged except unkempt appearance, stains on clothes Mr. J: –No functional changes –Increase in urinary frequency, occasional incontinence PE: –BP, HR higher compared with prior visits, otherwise unchanged except unkempt appearance, stains on clothes

ADReS changes Rapid pace walk: 8.5 sec (8) Trails B: 165 sec (135) Clock: # spacing off, # on margin of clock, hand placement incorrect Fields, Acuity, ROM, strength unchanged Rapid pace walk: 8.5 sec (8) Trails B: 165 sec (135) Clock: # spacing off, # on margin of clock, hand placement incorrect Fields, Acuity, ROM, strength unchanged

Questions 1.What do you advise Mr. Jones regarding his driving? His living situation? 2.Are there other history, exam, or laboratory data that would be helpful at this point? 1.What do you advise Mr. Jones regarding his driving? His living situation? 2.Are there other history, exam, or laboratory data that would be helpful at this point?