Tools to Evaluate Cognitive Impairment

Facilitator Assistant Chief Jason Berry, Washington State Patrol and Chair, Law Enforcement Standing Committee

Presenters Linda Hill, University of California at San Diego Debra Carney, Driver Fitness Officer, Iowa Department of Transportation Laura Krol, Manager, Bureau of Driver Licensing, Pennsylvania Department of Transportation

Recognizing Cognitive Impairment in Older Road Users

TREDS is Training, Research and Education for Driving Safety (TREDS) Based at the UC San Diego School of Medicine; comprised of health professionals, law enforcement and safety experts Funded by California Office of Traffic Safety since 2005 Nationally recognized for its research, training programs and Screening Tool for Cognitive Impairment

Health and Aging Concerns Our Aging Population By 2030, one in five drivers will be over age 65 Problems related to age can include Medical conditions and medications Reduced vision Decreased strength and mobility Cognitive impairment Cognitive Impairment prevalence rises with age 65-74 years: 2.4% 75-84 years: 11% Over 85 years: 34.5 50%

Dementia and Driving Mild Dementia Ability to safely operate a motor vehicle may or may not be impaired Moderate Dementia Incapable of operating a motor vehicle safely

Multidisciplinary Approach Community Health Professionals Licensing Agency Law Enforcement

Health Professionals National Highway Traffic Safety Administration (NHTSA) and American Geriatrics Society (AGS) Clinician s Guide to Assessing and Counseling Older Drivers Quick screening and referral tool 9

Clock Examples

Trail Making Examples 8:50 9:27

Law Enforcement Development and Validation of a Roadside Tool to Assess for Disorientation

Dementia Red Flags Inappropriate response to overhead lights/siren Poor personal hygiene; disheveled or inappropriate clothing for existing weather conditions Difficulty finding documents Difficulty communicating; stumble over words, ramble in short, unattached, meaningless sentences

Tool for evaluating drivers during a roadside stop Nine questions to assess drivers for orientation to person, place and time Developed and validated at the UC San Diego School of Medicine

Driver Orientation Screen for Cognitive Impairment - DOSCI Rule Out Screening Questions Scoring Criteria

Nine Questions 7-9. What is today s date? Prompt for month, day and year 1. 2. 3. 4. 5. 6. Without What is state city/town day Month your looking of are the date full we are week at home of in your birth? now? is address? in watch, it? now? Month, can Answer day you and estimate must year match required; what must document; Within time Prompt match reasonable is Day for now? if correct documents not, Answer prompt proximity day, if must needed for address be plus or listed minus on documents one hour of correct Year time

Scoring Criteria for Officers

DOSCI Validation 2.5 Average Number of Questions Missed N=68 p <.0001 2.36 2 1.5 1 0.5 0 0.22 Control n=27 Dementia n=41 Control Average Age: 77 years Dementia Average Age: 74 years 18

Frequently Missed Questions Year Day Month Day of the Week Time City State Home Address DOB 0 5 10 15 20 25 30 Number Incorrect

It is a screening tool to assist in the identification of cognitively impaired drivers encountered during the course of patrol duties. It is to be used as part of an officer s investigation of the totality of circumstances to determine when a driver reexamination referral to DMV should be completed.

Program Evolution 2-hour POST certified curriculum Abbreviated training options 1-hour refresher 30-minute briefing Development and validation of screening tool Video demonstration of DOSCI Electronic DOSCI tool

Online Training Videos http://treds.ucsd.edu/law-enforcement-video Driver Orientation Screen for Cognitive Impairment (10-minute video on DOSCI and smartphone app) Identifying and Referring Cognitively Impaired Drivers (30-minute video training) Recognizing Cognitive Impairment in Drivers (9-minute traffic stop video) Medical Conditions that Can Affect Driving (15-minute video on medical ) Use of DOSCI by Public Safety Dispatchers (8-minute video of 911 call)

Ability to Recognize Cognitive Impairment 0-49% Increase 50-100% Increase 25% 75% N = 2018 My ability to recognize cognitive impairment in older drivers has increased by %.

2014 Pilot with the Iowa Department of Transportation Why Iowa? Unique position to screen Only agency assessing drivers unless a collision occurs Has periodic contact with the same drivers In-person two year renewal for age 72+ DOSCI screening tool is similar to vision screening A research-based tool for staff to support decision making Iowa s shifting demographics support need for screening

Reasons for Assessment Medical and vision referrals Reexamination requests Appeals Licensing staff discretion based on customer interaction Determine hearing problem vs. confusion Family member answering all questions Unable to follow simple directions Appear to be confused Have difficulty finding documents

DOSCI IOWA DOT Form 433100 (10-14)

Nine Questions 9:46 3 9:49

RESULTS Based on 4444 individuals screened on 4694 occasions between November 2014 and October 2015 213 individuals were screened 2 to 5 times

Reasons for Assessment 1600 1400 1200 30.9% 29.6% 1000 21.1% 800 600 400 8.8% 200 0 2.5% 1.1% Re-Exam Recall Line Exam Local DT Hearing Other Reasons for Assessment = 4393

Number Missed per Scoring Criteria 4500 90.8% 4000 3500 3000 2500 2000 SCORING CRITERIA 5 or more incorrect probable cognitive impairment 3-4 incorrect possible cognitive impairment 0-2 incorrect consider all circumstances 1500 1000 500 0 6% 3.2% 0 to 2 3 or 4 5 or more Number of Questions Missed n = 4694

DOSCI Results and Licensing Status 59% of customers that missed 3-4 DOSCI questions no longer have a license to drive 88% of customers that missed 5 or more DOSCI questions no longer have a license to drive

Missed Questions Today's Year 505 (10.8%) Today's Day Today's Month 351 (7.5%) 1135 (24.2%) Day of the Week 417 (8.9%) Time 442 (9.4%) City 183 (3.9%) State 45 (1.0%) Home Address 449 (9.6%) DOB 82 (1.8%) 0 200 400 600 800 1000 1200 Iowa Drivers n=4694

Screening Administration Ease of Administration = 4.8 very difficult 1 2 3 4 5 very easy Acceptance by Client = 4.7 not receptive 1 2 3 4 5 very receptive Usefulness in Assessment = 3.8 not useful 1 2 3 4 5 very useful

Feasibility of DOSCI Easy to learn and administer Staff familiarity decreases times Quick to administer Efficient tool Very little time for most customers Well-received by customers Minimal complaints

2018: DOSCI Expansion to CHP Public Safety Dispatchers Reasons for Assessment Communications Center personnel are often first contact with persons suffering from cognitive impairment 911 Operators can provide additional information to prepare officers before encounters with road users

Public Safety Personnel

Public Safety Personnel Initial Training of Dispatch Operators Briefing Session POST-certified Mental Illness Training for Dispatchers CAD Computer Aided Dispatch program

Contact Linda Hill, MD, MPH TREDS Program Director University of California San Diego llhill@ucsd.edu treds@ucsd.edu 858-534-9330

Screening Iowa Drivers for Cognitive Impairment Deb Carney Driver Fitness Officer Iowa Department of Transportation

Iowa Driver Demographics

Iowa Driver Demographics 52 counties 25%-30%

Moving Forward with DOSCI

Electronic DOSCI Forms

Electronic DOSCI Forms DOSCI Result Stored in EMREMS

Licensing Status 2017 270 people scored 3-4 incorrect 105 (38.9%) License suspended or denied 64 (23.7%) Voluntarily surrendered license 92 (34.1%) License renewed 9 (3.3%) Deceased

Licensing Status 2017 134 people scored 5 or more incorrect 58 (43.3%) License suspended or denied 45 (33.6%) Voluntarily surrendered license 28 (20.9%) License renewed 3 (2.2%) Deceased

Licensing Status - Summary 63% of customers that missed 3-4 DOSCI questions no longer have a license to drive 77% of customers that missed 5 or more DOSCI questions no longer have a license to drive

Safe Driving Basics (SDB)

Safe Driving Basics (SDB) Implementation Fall, 2015 Referrals for reexamination Appeals Voluntary screening available

Safe Driving Basics (SDB) Laptop/tablet Portable Tent mode Touch screen Removes keyboard Finger/Stylus Headphones

Safe Driving Basics (SDB)

Safe Driving Basics (SDB) Visual Search A 90 seconds allowed Must pass all exercises

Safe Driving Basics (SDB) Visual Search B 180 seconds allowed Must pass all exercises

Safe Driving Basics (SDB) Visualizing Missing Information Can miss 4 of 11 Must pass all exercises

Safe Driving Basics (SDB) Route Planning Removed Drawing on the screen

Safe Driving Basics (SDB) Visual Processing Speed Removed

Safe Driving Basics (SDB) Visual Processing Speed/Divided Attention Removed

Safe Driving Basics (SDB) Visual Processing Speed/Divided Attention Removed Length Driver frustration

Safe Driving Basics (SDB) Removed exercises to reduce: Time - 15 minute screening Complex instructions Unsatisfactory attempts

Safe Driving Basics (SDB)

Safe Driving Basics (SDB) SDB results stored in EMREMS:

Safe Driving Basics Needs Medical Report

Safe Driving Basics (SDB)

Safe Driving Basics (SDB) Small number of drivers cannot use it Physical issues, tremors Language barrier Reading glasses

Safe Driving Basics (SDB) Increases health care professional s awareness of cognitive issues Increase in referrals to driver evaluation programs Iowa plans to continue using DOSCI and Safe Driving Basics

Thank you! Debra Carney Driver Fitness Officer Driver & Identification Services Iowa Department of Transportation 515-237-3180 debra.carney@iowadot.us

Pennsylvania Department of Transportation Cognitive Impairment and Driving Laura Krol Driver Safety Division Manager

Mature Driver Stats in PA 2,150,000 Number of Drivers 65+ in PA 2,100,000 2,115,442 2,050,000 2,000,000 1,950,000 1,900,000 1,901,546 1,934,397 1,850,000 1,865,494 1,800,000 1,816,186 1,750,000 1,700,000 1,650,000 2013 2014 2015 2016 2017

PA Initiatives in Mature Driver Safety Law Enforcement Reports Request for Driver Evaluation DOCSI Family/Friend Reports Drivers not meeting medical standards can turn their driver s license in and obtain a Free ID Card.

Law Enforcement Recommendation Form - DL-118 The Law Enforcement Recommendation Form is Pennsylvania s reporting mechanism for SUSPECTED medical concerns. This form is completed for any driver that a Law Enforcement Officer feels may not be safe behind the wheel.

DOSCI Permission Allows PennDOT understand the driver s condition at the time of the interaction. Screening Tool - Not used for Diagnostic Purposes

Data on Law Enforcement Reports About 70% of reports received from law enforcement are for drivers 65+ 30% 25% 20% 15% 10% Reports Received from Law Enforcement Where Cognitive Impairment was Suspected 19% 23% 25% 5% 0% 2015 2016 2017

Training of Law Enforcement 2016 and 2017 PA Highway Safety Conferences Partnering with the Pennsylvania State Police to Educate their officers Partnering with PA s Highway Safety Office grantee network. Train the Trainer session

PA Initiatives in Mature Driver Safety Mature Driver Re-Examination Program A proactive approach to determine a driver s medical qualifications for the safe operation of a motor vehicle. Medical Reporting Program * Medical Advisory Board * Health Care Community

What About Non-Compliance? If medical information requested is not received, the Medical Unit will Suspend an individual s full driving privilege until the driver complies with our request.

Mature Driver Initiatives Mature Driver Safety Project - Focus Groups - Revision/creation of Mature Driver Materials

PA Initiatives in Mature Driver Safety Mature Driver Improvement Program: AAA, AARP, Safe2Drive, and Seniors for Safe Driving Shared Ride Program

Keeping our Mature Drivers Safe As They Age Encourage Seniors to consider advanced vehicle safety features Resource: The National Safety Council s website - www.mycardoeswhat.org Driving - Self Regulation Encourage Doctors to talk about their patients driving habits Including what Rx s they are taking and how they may affect their driving. Resource AAA s website www.roadwiserx.com CAR FIT

Mature Driver Safety Challenges Proactive Communications Sometimes difficult and emotional Planning for transportation needs as drivers age. Allow Mature Drivers to continue driving as long as safely possible. Encouraging Mature Drivers to make the decision to Retire from driving before PennDOT has to take action.

Presentation Wrap-Up: Thank you! Laura Krol lkrol@pa.gov 717-346-1907

Up Next 5:30 pm - 6:30 pm Welcome Reception South Convention Lobby, Tower Building, 2nd Level