+ The Older Driver Debra Bynum, MD Division of Geriatric Medicine 2010

+ Cases… Mrs. Simon, a 67-year-old woman with type 2 diabetes mellitus and hypertension, mentions during a routine check- up that she almost hit a car while making a left-hand turn when driving two weeks ago. Although she was uninjured, she has been anxious about driving since that episode. Her daughter has called your office expressing concern about her mother’s driving abilities. Mrs. Simons admits to feeling less confident when driving and wants to know if you think she should stop driving. What is your opinion?

+ Cases… Mr. Evans, a 72-year-old man with coronary artery disease and CHF, arrives for an office visit after fainting yesterday and reports “light- headedness” for two weeks. You notice that his heartbeat is irregular. You perform a careful history and physical, and order some tests to determine the cause of his atrial fibrillation. When you ask him to schedule a follow-up for next week, he tells you he cannot come because he is about to embark on a two-day road trip to visit his daughter and newborn grandson. Would you address the driving issue and if so, how? What would you communicate to the patient?

+ Driving: Autonomy and Power

+ ACOVE-3 Quality Indicators Pertaining to Assessment If a vulnerable older adult has newly diagnosed dementia, then one of the following should occur (consistent with state law) Patient advised not to drive a motor vehicle Referral to the Department of Motor Vehicles to test driving ability Referred to a driver’s safety course that includes assessment of driving ability

+ Risk Factors for MVA in older adults… Poor visual acuity (<20/40) Poor visual contrast sensitivity Dementia Visual spatial deficits Visual attention problems Impaired neck and trunk rotation Poor motor coordination and speed of movement Alcohol and narcotics Medications (antidepressants, antipsychotics, antihistamines, benzodiazepines, muscle relaxants)

+ Facts from AMA site… Fact #1: The number of older adult drivers is growing rapidly and they are driving longer distances.

+ Fact #2: Driving cessation is inevitable for many and can be associated with negative outcomes.

+ Fact #3: Many older drivers successfully self-regulate their driving behavior. But motor vehicle crash rates per mile driven begin to increase at age 65 (despite overall less crashes) Older drivers may reduce their mileage by eliminating long trips, but local roads may have more hazards. Decreasing mileage may not always proportionately decrease safety risks -- “low mileage” drivers (e.g., less than 3,000 miles per year) may actually be the group that is most “at- risk”

+ Type of crashes Compared with younger drivers whose car crashes are often due to inexperience or risky behaviors, older driver crashes tend to be related to inattention or slowed speed of visual processing. Older driver crashes are often multiple- vehicle events that occur at intersections and involve left-hand turns.

+ Fact #5: Physicians can influence their patients’ decisions to modify or stop driving

+ Downsides to recommendation to stop driving Decreased activity Depression Limited access to resources (especially if person is also a caregiver)

+ Assessment of Driving-Related Skills (ADReS) three key functions for safe driving are (1) vision (2) cognition (3) motor/somatosensory function

+ Vision Visual acuity Visual fields Contrast sensitivity

+ Cognitive ability Memory—short-term, long-term, and working memory Visual perception, visual processing, visual search, and visuospatial skills Selective and divided attention Executive skills (sequencing, planning, judgment, decision making) Language Vigilance.

+ Cognitive assessment Clock drawing Trails B recent Maryland Pilot Older Driver Study (MaryPODS) that found an association with Trails B performance and at-fault crashes in a cohort of older adults utilized only the practice trial of Trails B prior to the full test.

+ Motor and Somatosensory Rapid Pace Walk Manual test of range of motion Manual test of motor strength Proprioception

+ ADReS: Summary Recommended sequence: Visual Fields by Confrontation Testing Snellen E Chart Rapid Pace Walk—Mark a 10-foot distance on the floor. With the patient already standing at the 20-foot mark, have him/her walk to the 10-foot mark, then back Manual Test of Range of Motion— This is performed when the patient has returned to the examination room Manual Test of Motor Strength Clock Drawing Test Trail Making Test, Part B

+ Recommendations: Visual acuity: 20/40-20/70: consider further assessment 20/70-20/100: recommend on road assessment < 20/100: needs specialty and road assessment

+ Cognition Intervention recommended if either one abnormal Trail Making part B greater than 3 minutes This test may have greatest correlation with recent/future crashes Clock drawing Assessment of visual spatial functioning

+ Evaluating driving risk in patients with Dementia: evidence based review Recognition that MMSE has no correlation and low sensitivity for identifying unsafe drivers Neurology 2010; 74:

+ Conclusions from evidence review… Clinical Dementia Rating (CDR) is established as useful for identifying patients at increased risk for unsafe driving Recognition that still a significant number of patients with CDR will be found to be safe drivers with On Road Driving Test (ORDT)

+ CDR Categories: Memory Orientation Judgment and problem saving Community affairs Home and hobbies Personal care Scoring 0-2 (2 more severe)

+ MMSE If <24, MAY be helpful Over 24, not helpful at all

+ Other indicators… Caregiver’s rating of marginal or unsafe driving is helpful Patient’s self-rating of safe is NOT useful

+ Other indicators…. History of crash in the past 1-5 years Traffic citation in past 2-3 years History of crash is likely more useful in identifying patients at risk for future crashes than the presence of mild dementia alone…

+ Decreased mileage Reduced driving mileage is likely associated with INCREASED risk of poor driving Self reported avoidance may be useful in identifying at risk drivers The absence of self avoidance/decreased mileage is NOT helpful in indentifying safe drivers

+ Personality characteristics… Aggressive or impulsive personality traits may be associated with increased risk

+ Neuropsychological Predictors of Driving Errors in Older Adults JAGS 2010: Found that the strongest predictor of age related decline in driving performance was composite measure of cognitive abilities Short term memory NOT associated with performance Highest predictor of problems: test components involving visuospatial and visuomotor abilities

+ Hearing Impairment and ability to drive JAGS 2010: Older adults with poor hearing had more difficulty in driving in presence of visual or auditory distracters than older adults with normal hearing

+ 4 C’s: Crash History, Family Concerns, Clinical Condition, Cognitive Function JAGS C’s: Interview Based Screening tool to identify at-risk drivers Study in JAGS evaluated effectiveness when compared to standardized driving performance test

+ 4 Cs Screening Tool Crash/CitationConcern (family report) Clinical Status (medical history) Cognition (family report and clinical impressions) 1. No crashes/citation 1. No concerns1. Overall good health 1. Intact cognition 2. One or more fender benders 2. Mild concerns (family has talked with patient about safety) 2. Medical condition/mild impact on vision, attention, motor (frailty, arthritis, neuropathy) 2. Mild cognitive decline/intact daily function 3. Citation for dangerous violation 3. Moderate concerns: family restricts patient from driving with passengers 3. Medical issues: moderate impact on vision, attention, motor (stroke, early alzheimers, parkinson’s) 3. Moderate cognitive decline: decline in daily functions 4.Crash or crashes4. Extreme concerns: family wants patient to stop driving immediately 4. Medical issues/severe impact on vision, attention, motor 4. Severe cognitive decline/dependenc e on others for daily function

+ 4 C’s Screening Tool Family Concerns most highly associated with at risk driving behavior on Road Performance Testing…. Prior crashes and clinical condition not predictive 95% of marginal or unsafe drivers had 4C score of 9-16

+ Review: Possible Indicators of at – risk driving… History of traffic citations History of crashes Reduced driving mileage Self-reported situational avoidance MMSE score <24 Visuospatial difficulty on cognitive testing Aggressive or impulsive personality characteristics Hearing deficit 4 Cs: Especially FAMILY CONCERNS

+ Summary: Assessment – Who is at risk? History of traffic citations History of crashes Reduced driving mileage Self-reported situational avoidance MMSE score <24 Aggressive or impulsive personality Family Concerned

+ Summary: Assessment Cognitive testing with visuspatial testing 4 Cs screening tool Address family concerns strongly Visual and hearing assessments (visual fields) Manual testing of ROM and motor strength Rapid pace walk Referral to On Road Driving Assessment