Driving in Dementia. Tel Aviv University Spring 2016 Mark Rapoport, MD, FRCPC Associate Professor, Dep t of Psychiatry

Transcription

1 Driving in Dementia Tel Aviv University Spring 2016 Mark Rapoport, MD, FRCPC Associate Professor, Dep t of Psychiatry

2 With appreciation Disclosures CIHR Alzheimer Society of Canada Brain Canada/Chagnon Family PSI No industry funding Acknowledgments Gary Naglie Shawn Marshall Frank Molnar Carla Zucchero- Sarracini Duncan Cameron The Candrive Group

3 None Disclosures

4 Learning Objectives To understand dementia-related driving risks. To appreciate limitations of research in this area. To move beyond knowledge to action, while balancing the risks.

5 Beware of Shared Delusion The one thing that unites all human beings, regardless of age, gender, religion, economic status or ethnic background, is that, deep inside, we ALL believe that we are above average drivers. Dave Barry

6 Older drivers Fastest growing segment of licensed population Vast majority continue to be safe to drive Often unfairly characterized by the media

7 THE ULTIMATE IADL Driving

8 2009 Canada Valid Driver's Licence Drove in Last Month 43.8 Driving Main Transportation Men Women Turcotte, Profile of seniors transportation habits. Statistics Canada, 2012

9 Crashes Fatal Crashes

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11 Risk of Crash Associated with Medical Warning (Ontario) Age RR 0.66 ( ) Age 75+ RR 0.34 ( ) Male RR 0.62 ( ) Female RR 0.45 ( ) Redelmeier et al, NEJM, 2012, 367

12 Older drivers high crash rate per miles driven (though not the highest) crash for different reasons than younger persons involved in different types of crashes once involved in a crash - highest mortality and morbidity of any age group

13 Why do older persons have relatively high crash rates? not age in itself the increasing prevalence of medical and functional conditions that affect driving ability

14 Driving and Medical Conditions Numerous medical conditions associated with crashes: Sensory and Motor Conditions Vision Movement (e.g. arthritis, pain) Mental Functioning Abrupt changes (e.g. seizure, cardiac, cerebro-vascular) Fluctuating (e.g. diabetes, psychiatric conditions) Progressive (e.g. dementia, respiratory) Prevalence of these conditions increases with age

15 Decision making about driving Balancing safety and quality of life

16 Driving Cessation Psychosocial consequences Depression Social isolation Loss of self esteem Many report worse than death Impact on patient/physician relationship

17 Dementia and Driving Crash rates in dementia are increased 2-8 times relative to age-matched controls. Between 22% and 64% of patients with dementia continue to drive. Many physicians do not report patients with Mild Cognitive Impairment or mild dementia because the existing guidelines are unclear and physicians are uncomfortable with them. No consensus previously on which patients to report. 17

18 Studies of crash risk in dementia Systematic review studies, 2 of highest quality(8/9 on Ottawa-Newcastle) BC: Cooper et al, 1993 Drivers with at least one collision 43 (26.1%) dementia vs 19 (11.5%) comparison. Michegan: Trobe et al, 1996; Event Rate/ Driver years 0.08 crashes/driver years in dementia AND comparison Man-Son-Hing et al, J Am Geriatr Soc 55: , 2007 Cooper et al Journal of Safety Research Vol. 24, 9-17, 1993 Trobe et al, Arch Neurol. 1996;53: , 1996

19 Absolute and Relative Risk Summary Ontario 2011 Collisions Sex Ontario 2011 Collisions Age US 2003 Fatalities M vs F (age 20-24) US 2003 Fatalities Age BC 1993 Dementia Michegan 1996 Dementia Rates 4.3% M 2.4% F 4.2%, %, /100k, M 14/100k, F 29/100k, /100k, % dem 11.5% comp 0.08 mvc/driv yr Dem and comp Absolute Difference 1.9% 57% 1.9% 59% Relative difference 0.029% 102% 0.013% 58% 14.6% 78% Ontario Road Safety Annual Report, MTO Williams et al, J Safety Research (2003); 34: Cooper et al Journal of Safety Research Vol. 24, 9-17, 1993 Trobe et al, Arch Neurol. 1996;53: , 1996

20 Proportion of Active Drivers with Mild-Moderate Dementia 28% still driving at baseline Apathy Hallucinations Herrmann, Rapoport, Sambrook et al CMAJ 2006, 175 (6) 20

21 Longitudinal Findings: Time to Receive a Rating of Unsafe on the Driving Test by CDR Group. Duchek et al., J Am Geriatr Soc 2003;51:

22 Persistance! Many patients with mild dementia continue to drive. Those that continue to drive persist for years while dementia progresses, and driving deteriorates. Behavioral factors may be more significant than cognitive ones wrt driving cessation. 22

23 MVCs among those with active licenses 9,763 (24%) And 78% of collisions occurred prior to dx of dementia N=40,508 dementia With active licenses Rapoport et al, 2008 JAGS 56(10)

24 Psychotropics and MVCs in Dementia Rapoport et al, 2008 JAGS 56(10)

25 Patient, Family, Doctor Correctly classified Selfrating Informant Rating Physician Rating Brown et al, JAGS

26 Dementia and Driving in Ontario Study Rapoport et al (2014) Am J Geriatric Psychiatry The working differential diagnosis is mild Alzheimer's disease vs. mild cognitive impairment 26

27 Crashes Caregiver concern Cognitively slow Irritable Abnormal Clock 27

28 Plan Report Road Test A No No B No Yes C Yes Yes D Yes No 28

29 Predictive Model The combination of Abnormal Clock and Caregiver Concern accounted for: 62% of the variance in report with or without a road test (C or D) Rapoport et al, AJGP,

30 Screening at the Government Level Chi-Square 10.98, df (1), p< Fatality rate per 100, Young Driver Old Driver 5.37 Before After 5.83 Young Pedestrian Old Pedestrian Siren and Meng, Accid Analysis Prev 2012; 45: 634-8

31 DEMENTIA & DRIVING The diagnosis of dementia does not automatically mean no driving (some people with mild dementia can drive albeit for a limited period of time before they must hang up the keys) The diagnosis of dementia does mean: You must ask if the person is still driving You must assess and document driving safety and follow your provincial reporting requirements If safe to drive, you must reassess fitness-to-drive every 6 months You should start to counsel regarding eventual driving retirement as early as possible to allow the patient to process, adjust and prepare

32 Byszewski, Dementia and Driving Toolkit (online resource.

33 Mandatory Reporting Location Mandatory reporting? Canada United States -All medically unfit drivers (dementia not mentioned) in all provinces and territories, except: - -Quebec and Nova Scotia (discretionary), Alberta (interpreted as discretionary), and BC (only if refuse to stop driving). - California - disorders characterized by lapses of consciousness, including Alzheimer s disease and related disorders. - Pennsylvania - neuropsychiatric conditions (e.g. Alzheimer s disease). - Delaware, Nevada, New Jersey- conditions with losses or lapses of consciousness (no specific mention of dementia). - Oregon - severe cognitive and/or functional impairments. - Indiana- handicapped persons. - Arizona, Connecticut, Idaho, Kentucky, Maine, & New Mexico Yes, not specified ; meaning unclear. - Other states - no mandatory reporting. 33

34 Recommendations for assessment of driver with dementia Canada: - diagnosis of dementia not sufficient to remove a driver s license - moderate to severe dementia is a contraindication to driving. - driving ability of persons with mild dementia should be tested on an individual basis - comprehensive off- and on-road test at a specialized driving centre. US: - diagnosis of dementia is not sufficient to withdraw driving privileges. - withdrawing of these privileges should be based on the individual s driving ability. - focused medical assessment with a formal assessment of driving skills for those in whom there are concerns about their driving ability. Australia: - should not drive if impaired significantly in memory, visuospatial skills, insight or judgment. - importance of a baseline and periodic review of driving for these individuals emphasized. - if unsure, refer to a driver assessor. New Zealand: - should not drive if impaired cognition may affect driving safety. - may be able to drive if they have early dementia with intact insight, judgment, and no disorientation or confusion. - Cognitive assessment and specialist referral suggested. - A full assessment of driving skills will often be a valuable way of determining whether an individual may continue to drive a motor vehicle. UK: - patients with symptoms of impaired memory, disorientation, lack of insight and judgment are almost 34 certainly not fit to drive - in early dementia, formal driving assessment may be necessary.

35 MMSE and driving Systematic Review (Molnar et al, JAGS 54, , 2006) Positive Association No Association N w dementia Outcome Friedland Reported MVCs No Lucas-Blaustein Reported MVCs No Gilley, Reported MVCs No Trobe Database MVC No Rebok Simulator score No Harvey Simulator score No Cox Simulator score No Fitten On-road score No Fox On-road score No Bieliauskas On-road score No 35 Cutoff?

36 Selected Other in-office tests and driving Blessed Dementia Rating Scale Trails A Digit Span; Digit Symbol Block Design Logical Memory Test; Benton Visual Retention Test Trails B; Picture Arrangement Category Fluency Boston Naming Test 36 (Molnar et al, JAGS 54, , 2006)

37 Caveat with Cog Testing as Screen Data from large prospective cohort study re-analyzed. Cognitive Predictors: UFOV, Trails B, Delayed Recall and Motor Free Visual Perception Test (Visual Closure) (MVPT-VC) Highest OR was for MVPT-VC 4.96 MVPT/VC of 5 or more correctly predicted 18 crashes, had 258 false positives, 93 false negatives and 1503 true negatives in the 1872 participants who had valid test results. PPV of 93%, NPV of 94%, 83% Sensitivity, 85% specificity. Need to screen 143 older drivers in order to prevent one crash in the following 20 months and an additional 20 drivers will fail testing Staplin (2003) and Martin, Marottoli and O Neil (2009) 37

38 The Trails B debate Roy M, Molnar F. Systematic review of the evidence for Trails B cut-off scores in assessing fitness-to-drive. Canadian Geriatrics Journal Sept articles reviewed Cut-off scores reported based on research include: 90 seconds, 133 seconds, 147 seconds, 180 seconds and 3 errors Conclusion: the best available evidence supports the 3 or 3 rule for reporting patients to the ministry of transportation as having findings that might impact on driving This is not the same as a final determination of fitness-to-drive Trails B findings should be felt to reflect true function (consistent with other tests and/ or history; not altered by language, anxiety, learning disability ) Conclusion; more and better research needed including ROC analysis of sensitivity vs. specificity for various cut-offs.

39 Rational Use of Cognitive Testing Are the test results consistent with other clinical evidence? What are we really measuring? What is the trajectory? What is my duty? Common sense Qualitative and dynamic aspects of testing. Trichotomization Molnar, F.J., Rapoport, M.J., Roy, M. (2012) CGS CME.

40 How To Document re: Driving Ask Family. Review cognition, behavior, function, hearing, motor, and sensory function. Rule out significant dangerous medical conditions (eg. Seizure disorder, sleep apnea, stroke, PD), medications (esp anticholinergic) and substances. Decide on referral for specialized testing. Give feedback. 40

41 Disclosure 1. Preparatory meeting with family. Set ground rules/educate Put family in a supportive role. Address family resistance 2. Meeting with patient and family Ground rules and educate Give patient positive role. Address patient resistance 3. Post-disclosure Letter Documentation Alternate transportation plans Dealing with difficult situations Molnar, Byszewski, Rapoport, Dalziel, Geriatrics & Aging, 2009

42 Summary Not the same as driving in the elderly. Many cognitive skills required. Dementia increases crash risk, but also decreases exposure. Not enough info. Drivers with dementia are persistent. Many patients in the early stages may be safe to drive. Cognitive testing limited predictive ability. We need better tools. Individualized assessment needed. We need to make this practical and affordable. Behavioral changes play a significant role, especially psychosis, apathy and depression. Legislation - Safety outweighs autonomy, very challenging to balance, and doctors are not reporting. 42