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

2. 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

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

4. 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

6. 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!

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

8. 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 year old males?
Need for evidence based solutions…gives the patient their “day in court”

9. 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 ~ 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)

10. STEP 4: Rating Dementia Severity

11. 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

12. 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)

14. DRIVEWISE Beth Israel Deaconess Medical Center
Division of Cognitive Neurology
Beth Israel Deaconess Medical Center

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

16. 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

17. Demographics
Breakdown by Age

18. 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

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

20. THE 4 C’S Crash/ Citation (family) Concern Clinical Status Cognition 12 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

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

22. 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

24. 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

25. 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

26. 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

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

28. UFOV Test 2 Measures speed dividing attention between two objects.

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

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

31. 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

32. 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

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

34. 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

35. 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).

36. 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).