TO DRIVE OR NOT TO DRIVE: THAT IS THE QUESTION

Transcription

1 TO DRIVE OR NOT TO DRIVE: THAT IS THE QUESTION Gary Naglie, MD, FRCPC, FGSA Department of Medicine, Baycrest & University of Toronto Scientist, Rotman Research Institute, Baycrest & Toronto Rehabilitation Institute, University Health Network Hunt Family Chair In Geriatric Medicine, University of Toronto

2 None Conflict of Interest

3 Learning Objectives By completion of this session, you will be familiar with: 1. Driving risk associated with dementia 2. Guidelines regarding dementia and driving 3. Approaches to the assessment of fitness to drive in persons with dementia

4 Case - Peter Pan Age 80+ Medical Hx: COPD, CHF, diabetes and hearing loss Decreased mobility and falls ETOH dependence Progressive decline in cognition associated with impairment in managing meds, appointments and mail, and using phone Urinary incontinence Depression

5 Case - Peter Pan (Cont d) Driving is vital to him for mobility and independence He feels he is a very safe driver He denies ever drinking and driving He denies any crashes or tickets Wendy and Tinkerbelle never drive with him

6 Do people with dementia continue to drive?

7 COSID - Proportion with Mild-Moderate Dementia Still Driving 28% still driving at baseline Herrmann et al. CMAJ 2006;175:

8 Estimated Numbers of Drivers with Dementia in Ontario , ,909 21,803 24,083 30,642 32,373 34, Hopkins et al. Can J Psychiatry 2004;49:434-8

9 What is the Driving Risk Associated with Dementia?

10 At-Fault Crash Relative Risk Diller et al. NHTSA June, 1999

11 Driving Performance in Dementia Systematic Review of 25 case-control studies; predominately very mild-mild AD 17 studies of driver performance 11 used on-road evaluation 4 used simulator evaluation 1 used caregiver report 1 used traffic sign test All 17 found that drivers with dementia performed significantly worse than controls Man-Son-Hing et al. JAGS 2007;55:878-84

12 Crash Risk in Dementia 3 studies of caregiver-reported crashes found that drivers with dementia crashed more often than controls 2.3x, 7.9x, 10.7x 2 studies of state driving records of crashes found drivers with dementia crashed more often than controls 2x, 2.5x Man-Son-Hing et al. JAGS 2007;55:878-84

13 On-Road Driving Performance

14 On-Road Driving Performance Pooled Data Controls V. Mild AD Mild AD (n=102) (n=73) (n=61) Clear Pass 79% 49% 37% Marginal 19% 38% 31% Fail 2% 13% 32% Duchek et al. JAGS 2003;51: Ott et al. Neurology 2008;70:

15 Can Cognitive Assessments Identify Unsafe Drivers?

16 Cognitive Predictors of Driving Fitness (cont d) Systematic review of 27 studies that correlated driving performance with neuropsychological tests in drivers with very mild or mild dementia Visuospatial and executive measures had strongest correlations with driving impairment UFOV (a computer-based test of speed of processing & divided and selective attention), Porteus Maze (assesses ability to plan and problem solve), Trails B, Clock Drawing MMSE did not predict future crashes or traffic violations Silva et al. Rev Assoc Med Bras 2009;55:

17 Cognitive Predictors of Driving Fitness Systematic review of 16 studies of in-office cognitive tests that differentiate safe from unsafe drivers with diagnosis of dementia Tremendous inconsistency regarding association between cognitive test results (including MMSE) and driving outcome measures Studies did not provide cut-off scores for the relationship between cognitive tests and unsafe driving, making it impossible for them to be used clinically at an individual level Molnar et al. JAGS 2006;54:

18 What do guidelines recommend about drivers with dementia?

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20 3 rd Canadian Consensus Conference on Dementia 1. Clinicians should counsel that giving up driving inevitable strategies to ease this transition should occur early in clinical course (Grade B, Level 2) 2. Driving is contraindicated in persons unable for cognitive reasons to perform multiple IADLS or any BADLS (Grade B, Level 3) 3. Driving ability in earlier stages of dementia should be tested on an individual basis (Grade B, Level 3) Hogan et al. Alzheimer s & Dementia 2007;3:

21 3 rd Canadian Consensus Conference on Dementia Mild to Moderate 4. No single brief cognitive test (e.g. MMSE) or combination of tests has sufficient sensitivity or specificity to be used as sole determinant of driving ability. Abnormalities on tests such as MMSE, clock drawing and Trails B should result in further in-depth testing (Grade B, Level 3) 5. A health professional-based comprehensive off- and on-road driving evaluation is the fairest method of individual testing (Grade B, Level 3) 6. For those deemed safe to drive, reassessment of driving ability should take place every 6-12 months or sooner if indicated (Grade B, Level 3)

22 American Academy of Neurology The CDR scale is useful at identifying patients at increased risk for unsafe driving, but 41%-85% of patients with CDR will be found to be safe drivers by on-road driving tests (ORDT) (Level A) 2. An MMSE score < 25 is possibly useful in identifying patients at increased risk for unsafe driving, but the correlation between MMSE scores and driving performance is unclear and data are conflicting (Level C) Iverson et al. Neurology 2010;74:

23 American Academy of Neurology While neuropsychological testing itself may better define dementia severity, there is insufficient evidence to support or refute the benefit of neuropsychological testing in evaluating driving risk in patients with dementia (Level U)

24 American Academy of Neurology Reduced driving mileage or self-reported situational avoidance is possibly associated with increased risk of poor driving performance (Level C) 5. A patient s self-rating of safe driving ability (Level A) and lack of situational avoidance (Level C) is not useful for determining that the patient is a safe driver 6. A caregiver s rating of a patient s driving ability as marginal or unsafe is probably useful in identifying unsafe drivers, but caregiver s ratings correlate only modestly with ORDT (Level B)

25 American Academy of Neurology A history of a crash in the previous 1-5 years or a traffic citation in the previous 2-3 years is possibly useful in identifying patients with decreased driving ability (Level C) 8. Aggressive or impulsive personality characteristics are possibly useful to identify patients with increased driving risk (Level C)

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27 Clinical Assessment of Fitness to Drive

28 Assessing Fitness to Drive Disclaimer There are no evidence based, validated office-based screening assessments of fitness to drive

29 CDR Level B evidence Level C evidence Other Evaluate for risk factors Caregiver report of marginal or unsafe skills History of citations History of crashes Driving < 100 km/week Situational avoidance Aggression, impulsivity MMSE < 24 Alcohol, medications, sleep disorders, visual impairment, motor impairment

30 Questionnaires The questionnaires addresses historical features with Level A, Level B, or Level C evidence of relevance to driving competency, as well as selected items from the Manchester Driver Behaviour Questionnaire It is only intended to be used in the qualitative determination of driving risk in elderly patients and patients with dementia It has not been validated for use in the quantitative determination of driving risk Iverson et al. Neurology 2010;74:

31 Patient Questionnaire 1. How many times have you been stopped or ticketed for a traffic violation in the last three years? 2. How many accidents have you been in, caused, within the last three years? 3. In how many accidents were you at fault in the last three years?

32 Patient Questionnaire (cont d) 4. I have concerns about my ability to drive safely. 5. Others have concerns about my ability to drive safely. 6. I have limited the amount of driving that I do. 7. I avoid driving at night. 8. I avoid driving in the rain. 9. I avoid driving in busy traffic.

33 Patient Questionnaire (cont d) 10. I will drive faster than the speed limit if I think that I won't be caught. 11. I will run a red light if I think that I won't be caught. 12. I will drive after drinking more alcohol than I should. 13. When I get angry with other drivers, I will honk my horn, gesture, or drive up too closely to them. How many km a week do you drive?

34 CDR Risk factors CDR 2.0 None Few Several Multiple CDR 0.5 CDR 1.0 CDR 0.5 CDR 1.0 CDR 0.5 CDR 1.0 CDR 0.5 Relatively low risk Relatively high risk

35 2009

36 Driving and Dementia Toolkit 3 rd Ed. 1. Family concerns about person s driving Red flags

37 Red Flags Getting lost/needing a co-pilot Collisions/near-misses/traffic tickets Missing traffic signs/signals Inappropriate driving speeds Not observing during lane changes/merging Others irritated with the driver Confusing the gas and brake pedals Friends or relatives reluctant to drive with the older driver

38 Driving and Dementia Toolkit 3 rd Ed. 2. Drugs that can cause drowsiness, inattention and slow reaction time 3. Visual acuity and fields 4. Physical problems that can interfere with driving a car 5. Cognitive impact on BADL and IADL 6. Dementia type

39 Dementia Type and Driving - FTD 15 patients with FTD and 15 age, sex and education-matched healthy controls Performance on driving simulator FTD patients exceeded speed limits, ran stop signs and were involved in more crashes than controls Agitated behaviour/disinhibition was strongly correlated with crashes (r = 0.60, p<.05) De Simone et al. Dement Geriatr Cogn Disord 2007;23:1-7

40 Dementia Type and Driving - DLB Prominent attention and visuoperceptual deficits, occurrence of visual hallucinations and fluctuating levels of alertness may impact driving ability Carr and Ott. JAMA 2010;303:

41 Driving and Dementia Toolkit 7. Judgment and insight 8. Visuospatial skills (pentagons and clock drawing) 9. Trail-Making Test, Parts A (unsafe: > 2 min. or 2+ errors) and B (unsafe: > 3 min. or 3+ errors; unsure: 2-3 min. or 2 errors)

42 Driving and Dementia Toolkit 10. Reaction time (12 ruler drop test; caught by max. 9 between thumb and index finger)

43 Dementia Driving Assessment Patient not safe Uncertain safety Patient safe Provincial Ministry of Transport notification Discuss with patient and family Patient wishes to continue driving referral to specialist or specialized on-road driving evaluation Discuss with patient and family At some time driving cessation will be necessary Patient notification (letter), copy for chart or Patient decides to stop driving Ministry of Transport notification Suggest driving training and self-limitation Book 6-12 month follow-up to reassess driving safety

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45 Approaching the Topic of Driving

46 What Does Driving Mean to Older Adults? Convenience Independence Autonomy Competence Personhood

47 Consequences of Driving Cessation Loss of independence and lifestyle Lower activity levels Social isolation Loss of self-esteem Depression Decreased quality of life Increased stress on family and friends Institutionalization Marottoli et al. J Gerontology 2000;55:S334-S340 Freeman et al. J Public Health 2006;96: Windsor et al. Gerontologist 2007;47: Mezuk et al. J Gerontology 2008;63:S298-S303 Ackerman et al. Gerontologist 2008;48:

48 No One Likes to Talk About Driving Patients are afraid they will lose their license Families are afraid About the person s loss of quality of life, loss of will to live, depression About being subjected to anger, blame and guilt Physicians are also reluctant to talk about driving Not talking about driving is not an option

49 Assess driving risk Physician s Role Legally responsible to report to the Ministry of Transportation (MTO) any patient who is suffering from a condition that may make it dangerous for the person to operate a motor vehicle Provide support for emotional and transportation consequences of loss of license

50 Transportation Plan Activity How do you get there now? New ways of getting there or having service provided

51 Transportation Plan (Cont d) Discuss mobility alternatives Walking Public Transportation (service for disabled) Taxi Accounts/Vouchers Friends & Family Community Services Religious organizations and social clubs Community shuttle services Delivery services (drug and grocery stores) Social work referral

52 Conclusions 1. Number of older drivers with dementia are increasing rapidly and dementia is associated with increased crash risk 2. Some drivers with mild dementia remain safe to drive so individual assessment of driving safety is required Approaches to driving assessment have been developed, which can help identify those who may be at higher risk who need additional assessment Specialized driving assessments recommended as the gold standard

53 Conclusions (Cont d) 3. Clinicians must be aware not only of the risks of driving, but also of the potential consequences of driving cessation 4. Clinicians should provide emotional support to those who have to give up driving and help them develop an individualized transportation plan

54 Case Peter Pan (Cont d) Probable dementia with impairment in several IADLs Multiple comorbidities (COPD, CHF, DM, hearing loss) ETOH dependence Impaired mobility with falls

55 Case Peter Pan (Cont d) Moderate dementia - high crash risk Report to MTO Advise to stop driving Provide emotional support and help develop transportation plan

56 Acknowledgements Shawn Marshall Frank Molnar Mark Rapoport Malcolm Man-Son-Hing Nicol Korner-Bitensky Candrive Collaborators (