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

2. 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.

3. 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

4. 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

5. Baby Boomers are those born between 1946 and 1964

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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,

16. 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

17. 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)

18. 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

19. 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.

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

21. COMAR
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

22. 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

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

24. 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.”

25. 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

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

29. Motor Free Visual Perception Test

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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. Resources Driver Assessments: at Home, the MVA, & by Professionals
Functional Capacity Test Screening
Referring Drivers to MVA Medical Review Process
Safety for Older & Medically At-Risk Drivers
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.

38. Driver Wellness and Safety Medical Advisory Board
Medical Advisory Board

39. Case Review

40. 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.

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

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

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

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