Occupational Therapy In Health Care, 28(1):62–76, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2013.867091
Driving with Dementia: Evaluation, Referral, and Resources Anne E. Dickerson Professor, Department of Occupational Therapy, East Carolina University, Greenville, NC. USA
ABSTRACT. Driving is a highly valued instrumental activity of daily living, especially for the older adults who consider it part of their definition of independence and mobility. This paper discusses the issues associated with driving and older adults, including the difficulty of identifying when it is time to give up the keys. With a review of the latest research and need for specialized services for those with diminished capacity, the paper highlights how general practice occupational therapists must work in conjunction with driver rehabilitations specialists to meet the need of this growing population. A framework for referral and judgment is described and resources offered to practitioners to use. KEYWORDS. Dementia, driver rehabilitation specialists, driving, driving evaluation, older adults
INTRODUCTION It is a well-established fact that the population segment of age 65 years and up is the fastest growing in most western countries. In terms of drivers, in 1999, 14% of the drivers were over 65. In 2009, that percentage increased to 16 or 40 million drivers, a 20% increase with a projection that by 2030, and 25% of the drivers will be over 65 years of age (National Highway Safety Traffic Administration [NHTSA], 2009). Although older adults are generally considered safe drivers and are involved with fewer fatal collisions than in the past, drivers older than 70 years have higher crash rates per mile traveled than middle-aged drivers, although not as high as young drivers (Insurance Institute for Highway Safety, 2013). The fatality rates of older adults are amplified due to the fact that as one ages, susceptibility to injury and medical complications increases. In fact, a report identified situations associated with increased crash risk for older drivers found that the crash risk ratio of twovehicle at-fault to not-at-fault drivers significantly increases after the age of 75 years (Stutts, et al., 2009). Further examination of crash data separated the two vehicle Address correspondence to: Professor Anne E. Dickerson, East Carolina University, Greenville, NC 27858 USA (E-mail: [email protected]). (Received 14 November 2013; accepted 14 November 2013)
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fatal crashes by type of intersection traffic control (e.g., stop sign, traffic signal, yield sign, and flashing signal). Although all intersections showed increases after the age of 70 years and particularly after 75 years, the data for a yield sign were literally off the chart. Based on 27 fatal crash-involved drivers, 26 were found at fault at a yield sign intersection. Stop signs were also associated with high risk when compared to other intersections. As practitioners working with older adults, we can consider the meaning and implications of these findings. As one ages, the speed of mental processing slows and thus, older adults have slower reaction times and may take longer to make decisions. In terms of daily living tasks, this slowing of processing affects balancing a checkbook, completing a shopping list, or finding a phone number. Although these activities then take more time, the slower processing has little consequences in terms of safety. Decisions about driving (i.e., planning where to go or how to get there) are most often done prior to getting in the vehicle and are not affected by slower processing. Driving, as an overlearned activity, relies on motor tasks that are automatically performed such as braking for a red light or stop sign. However, things are much more complex at a yield sign. The driver must assess the situation and often make a split-second decision about whether he or she should stop or if is safe to move into the intersection. The driver does not legally have to stop, but is forced to make an immediate decision, prompted by other drivers following immediately behind the driver, who intend to keep moving. The older adult with slower processing speed is at greatest risk at these types of intersections. As practitioners, we can suggest strategies to older clients to improve safety, for example avoiding intersections with yield signs, or to treat a yield sign as a stop sign and wait until there is clearly sufficient time to merge into traffic. However, experienced clinicians know this is only a stop-gap measure for some, which may only be effective for a short time before other driving limitations emerge. Driving is a highly complex instrumental activity of daily living and more sophisticated solutions are needed to meet the challenge of ensuring safe driving for older drivers and the public alike. The purpose of this paper is to review the state of knowledge on driving and older adults, and the need for specialized services for those with diminished driving capacity. The paper will focus on the process of driving evaluation and patient referral and will highlight how general practice occupational therapists must work in conjunction with driver rehabilitations specialists to meet the need of this growing population. Evaluating Driving Capacity Determining when or if an older person must “hang up the keys” is not easy. An estimated 6,000,000 adults over the age of 70 years stop driving each year and become dependent on others for their mobility (Foley et al., 2002). The decision to stop driving is difficult and often has adverse consequences for an older adult’s psychological outlook, health and quality of life (Eby et al., 2009). The decision is complicated significantly by the fact that the capacity to drive is related not only to a given individual’s physical and mentally competency, but it is also related to the individual’s self-perception of his or her competence (Dobbs & Dobbs, 2000). If the individual perceives him or herself as competent, and is physically and mentally competent, the individual usually makes an appropriate choice about driving
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(e.g., avoid rush hour traffic), with low risk of safety issues. The same can be said of an individual that has a physical impairment or cognitive limitation. If that individual understands the impact of these limitations on his or her driving performance and safety, that individual acts to appropriately restrict his or her driving (e.g., an individual with vision issues due to glaucoma, does not drive at night). The individual who is mentally and physically competent but perceives him or herself as incompetent is likely over restricting their mobility. This is not a safety issue, but practitioners may choose to intervene to assist in building confidence for increased mobility choices, including driving. The greatest challenge is the individual who is mentally incompetent but perceives himself as competent, this is the “at risk” individual, especially when making choices about driving. One method of categorizing the driving skills is Michon’s (1985) Hierarchy of Driving Behavior. Michon categorized driving into three levels of behavior: (1) strategic, (2) tactical, and (3) operational. The higher-level decision-making process is the strategic level of driving behavior. This level includes determining trip goals, mode of traveling, and navigation or mapping to where one is going. Decisions at the strategic affect all aspects of driving, including the self-appraisal for determining the ability to perform driving tasks under higher risk conditions (e.g., rainy weather, nighttime driving). The tactical level pertains to decisions made while driving including slowing to accommodate rain or snow, deciding when to pass a vehicle, or making a right-hand turn. Operational is the third level, performing the human−machine interaction necessary to control the vehicle safely such as braking or using the steering wheel. These skills consist of the visual−motor skills or coordination skills, which become automatic for the driver over time and remain largely intact in the course of normal aging. Using Michon’s model, one can consider different outcomes at each level. An individual with a significant physical impairment, for instance, may have an intact strategic level of driving and may be able to plan a route but needs to have someone with intact operational skills actually drive. The more difficult dilemma is the person with early stage dementia who still has good operational-level skills and perhaps even the technical level because he or she can follow the basic rules of the road, but demonstrates impairment in the strategiclevel skills. Driving for Individuals with Dementia The National Institutes of Health have determined that one in seven persons over the age of 71 years have some type of dementia (Plassman et al., 2007). This is of concern, as older adults with cognitive deficits do not always make the appropriate decisions with regards to driving modification or cessation because of lack of insight, poor judgment, and loss of reasoning ability (Adler & Kuskowski, 2003). Moreover, up to 25% of older adults continue to drive even after a physician makes the recommendation for an individual to cease driving (Dobbs et al., 2002). Since the motor aspects of driving are an overlearned skill, older adults with cognitive deficits do not have difficulties performing the physical task of driving and following the specific knowledge based rules (e.g., stopping at a stop sign, keeping in between the lines) and therefore do not perceive any difficulties with driving. Issues with cognitive impairments become evident when split second decisions are necessary due to unforeseen difficulties, problems with visual attention reduce the ability to
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respond to the dynamic environment of traffic, or route finding issues emerge even in familiar areas. For the Baby Boomers who grew up in the golden age of automobile manufacturing (Coughlin et al., 2012), learning to drive was viewed as a rite of passage. Considering how driving contributes to their self-definition of independence and mobility, it is hardly surprising that older adults, in particular, consider driving as a “right,” and are likely to challenge the licensing authorities about decisions that impact their licensing status (Dobbs, 2012). Since the majority of older adults will remain living in suburban and rural communities (Rosenbloom, 2012), they view driving as essential to meeting their social and occupational needs. Accordingly, driving will remain the primary choice and mode of personal transportation for older adults (Coughlin et al., 2012; Dobbs, 2012; Rosenbloom, 2012). The problem arises when the individual is no longer fit to drive. Moreover, as the population shifts from one in eight individuals being over the age of 65 years in 2010 to one in five by 2030 (Federal Interagency Forum on Aging-Related Statistics, 2008), public and health care services will need to be much better prepared to meet the needs of increasing numbers of older adults wanting to “age-in-place.” To reside in the suburbs or rural areas requires that you be able to drive, as you cannot get anywhere without a car. Thus, if policies to support aging-in-place are a high priority, driver screening and perhaps even training to ensure older individuals (who may be at the beginning of cognitive decline) and the public are not at risk. Thus, the remainder of this paper will: (1) review recent research about dementia and driving and its implications for individuals and family members, (2) examine the process of driving evaluation for individuals with dementia and its implications for personal and public safety, and (3) describe the screening and assessment process continuum for determining fitness to drive for individuals with dementia. Driving with Dementia: Recent Research Findings With the client with cognitive impairment or dementia, the two main questions are (1) when does the individual become unsafe and (2) what is the best method of screening those individuals. Twenty-five studies, spanning from 1992 to 2010, explored the issue of fitness to driver by individuals with dementia (Dickerson, 2013). The evidence is consistent that individuals with moderate or severe dementia should not be driving; which can be screened easily with an assessment like the Mini Mental Status Exam (MMSE) (e.g., below 18 on MMSE indicates moderate dementia, NHSTA & AAMVA, 2009). However, it is the individuals with early or mild dementia that pose the dilemma, as the MMSE does not correlate with on road performance when the client is at the upper range (24 or above). The evidence also shows that individuals with dementia consistently make more errors and demonstrate poorer on-road performance, but not always to the level of being “unsafe.” Even individuals with dementia at the level of “mild” dementia are able to pass an on-road driving evaluation, especially if the testing is only at the level of operational and tactical processing demands, described above. This indicates specialized assessment is necessary at the “mild” and “very mild” levels of dementia and regular re-evaluation is necessary. Studies also show that individuals with dementia consistently make more errors and demonstrate poorer performance on simulators, although the on-road driving assessment provides the most reliable functional
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TABLE 1. Outcome of Nine Medically at Risk Drivers for Questions About Their Driving
Years expected to drive How important is driving Rate ability to drive
Pre
Post
t
p
6.9 9.0 8.33
5.6 9.63 7.87
0.465 –1.55 –0.261
.658 .172 .811
assessment of driving ability (Dickerson, 2013; Dubinsky et al., 2000; Frittelli et al., 2009; Iverson et al., 2010). The usual approach of occupational therapists is to evaluate competency by having their client perform the task in question under “real life conditions”, and by doing so, assess the individual’s ability to perform more safely and/or avoid risk. Thus, one approach with medically-at-risk drivers would be to have them drive in conditions with increased risk in order to evaluate their driving performance. This was explored in a pilot study (Dickerson, 2012) using an interactive driving simulator with nine older adults who were either self-referred or were referred by a physician to the study. With the overarching question of whether a simulator can be used as a self-awareness tool for driving, the participants rated their driving ability prior to and after the simulation experience. All participants were: (1) oriented to the simulator through familiarization runs, (2) completed two standard scenarios with critical incidents (e.g., scenarios that required specific actions to avoid collisions), (3) trained on more safety drives on the simulator, and (4) competed the same two standard scenarios with an additional scenario to include a third critical incident. Table 1 illustrates the results. There was no significant change in the years expected to drive, importance of driving, or rating of the ability to drive. However, Figure 1 illustrates the individual’s assessment of their driving performance before and after the simulation experience. Although most of the medically-at-risk drivers maintained their confidence in driving after their simulation “exposure”, two individuals changed, one reporting better driving ability and one reporting poorer ability. The results of this pilot study are inconclusive in general terms because of the small sample. However, further analysis of the individual participants’ diagnosis and specific performance yielded some additional insights. Data clearly showed the variability of the older adults’ performance and the lack of objective and subjective measures for individual older drivers. This finding also reinforces experienced clinicians’ first-hand knowledge that there is tremendous variation between older adults’ abilities to reflect and truly understand what their actual driving capacity is once again underscoring the necessity for careful screening and assessment. Accordingly, in a recent systematic review (Dickerson, in press), evidence suggests that one assessment will not be adequate for use with all medically-at-risk drivers. More likely, there will be groups of tools for specific diagnoses. For example, in a study on Parkinson’s Disease (Classen et al., 2011), the Useful Field R (Ball et al., 1993) and the Rapid Pace Walk were found as potentially of View promising screening tools, as they best predicted road test outcomes for individuals with Parkinson’s disease. Similarly, Carr and colleagues (2011), compared measures of visual, motor, and cognitive functioning to the on-road assessment for 99 older adults with dementia. Their best predictive model with 85% accuracy was using an
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FIGURE 1. Self-Rating of Ability to Drive by Individuals Pre and Post Simulator Study. Note: 1 = poor and 10 = very good.
eight-point interview (e.g., AD-8 Dementia Screening Tool), a clock drawing, and the time to complete either the Trail Making Test A (Reitan, 1958) or the Snellgrove Maze (Snellgrove, 2010) test. In an earlier paper, Carr and Ott (2010), summarized best practices for physicians when addressing drivers who have been identified as having dementia. Specifically, they highlighted summary position statements from 13 consensus meetings or professional associations about driving and dementia. In regards to driving and dementia, driving cessation is necessary for persons with moderate to severe dementia and/or when the individual poses a serious risk. In addition, there is an agreement that individuals with mild dementia need specialized evaluation, as they still may be able to drive, although reassessments are needed at regular intervals. For specialized physicians (e.g., neurologists or geriatricians), these position/consensus statements are very useful. However, for the general practitioner (e.g., family practitioner, internal medicine), the questions remain: (1) by what measure is moderate dementia and/or (2) how does the practitioner know when an individual poses a serious risk? Driving Evaluation for Individuals with Dementia Who administers a driving evaluation depends on the setting, state of residency, and training of the evaluators. As we know, in each state, there is a licensing authority that has some level of driving evaluations for at least their novice drivers. The systems vary state to state with few systems being the same. However, in most cases, the licensing authority has a very structured system that typically results in a pass or fail outcome. States with medical review boards (e.g., North Carolina, Maryland) frequently refer more complex cases to driver rehabilitation specialists (DRSs) who then provide individualized clinical and on-road evaluations. It is
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important for practitioners and consumers to understand, that the service, resources, and consequences of these options are vastly distinct. Just like an eye exam, there are different outcomes from the school eye screening, the optometrist, and the ophthalmologist. As advocates for older clients, it is critical to understand the implications of each of these options as the difference is not simply the cost. DRSs are professionals with specialized training who plan, develop, coordinate, or implement driving rehabilitation services for individuals with disabilities (Dickeson & Schold Davis, 2012). There are about 600 DRSs in the United States and approximately 80% of DRSs are occupational therapists. The usual process for a comprehensive driving evaluation to be done by a DRS, which includes a clinical assessment component and the “in context” component or on-road assessment. The clinical assessment typically consists of the client’s medical and driving history with assessment of the physical, cognitive, visual, and perceptual skills. The on-road component typically starts in a quiet parking lot or neighborhood, progresses to low traffic, intersections, and then busy streets and/or highway. Typically, the DRSs shares the outcome of the evaluation, including recommendations, with the client and family member(s). Recommendations usually include: (1) continue to drive with no restrictions, (2) drive with restrictions (e.g., no nighttime driving, limit speed or distance, no highway), (3) periodic review in the cases of progressive diseases or disorders, (4) retirement from driving, and/or (5) assistance with community mobility through working with the client and family members to identify alternative modes of transportation to get them to where they need and want to go. The comprehensive driving evaluation can take from 2–5 hr depending on the client and selected assessment tools, recognizing that the on road component typically lasts at least 45–60 min and the clinical component from 1–3 hr. In the ideal situation, as an older adult becomes more medically compromised or when the client or family express concern, the physician would screen their client, recognize the need for specialized assessment, and refer the client to a driving rehabilitation specialist to determine their level of risk. However, the issue has and will become more of an issue due to capacity with the expanding number of older adults. For example, using Michigan and its population (e.g., 942,905 in 2011) as an example; based on Plassman’s study (2007), there would be approximately 134,700 individuals with dementia in the state in 2011. With 131 branch offices of Michigan’s licensing agency, that would mean about 1028 individuals with dementia per office. In Michigan, there are approximately 14 DRSs with 5 in one setting. That would equate to approximately 9,621 dementia referrals for each DRS, or 26 per day, 365 days a year. Clearly, one could argue that many of these individuals with dementia have already given up driving or reside in long-term care facilities. However, even if only 10% of this number needed specialized evaluations from a DRS, that would still require about three evaluations per day for each DRS and that does not consider all other types of referrals with other diagnostic categories. The question then is what is the solution to the issue? How can at-risk older drivers and in particular, medically-at-risk drivers get evaluated appropriately for either (1) goals and strategies of rehabilitation to return to driving, or (2) if necessary, retire from driving, but be able to find alternative means of meeting their transportation needs. It is unlikely the state licensing authorities have or will have the funding to build the manpower to meet the needs. The more compelling
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problem is the skill set needed to appropriately evaluate fitness to drive of individuals with complex medical issues. When evaluating individuals with beginning or mild dementia, the issue is how to determine when their strategic level skills are impaired so that he or she can no longer compensate by modifying or restricting their driving to avoid making a dangerous decisions at the technical or operational level. This complex level of evaluation requires a skilled professional, who understands the intricacies of a disease process. A recent research study illustrates this point. Davis et al. (2012) sought to compare a standardized road test to naturalistic driving for older adults both healthy and cognitively impaired. Naturalistic driving consisted of equipping the vehicle with technology to observe the performance of the driver in their vehicle over time. Each subject underwent a road test consisting of “a professional driving instructor (blind to diagnosis) administered . . . road test to participants . . . providing only oral instructions to complete the course” (p. 2057) which was compared to their naturalistic driving as a way to compare overall performance and rate of errors. The researchers found only “fair” agreement” between the two drives. I believe that the standardized road test was only testing the driver at the operational and tactical levels, following the instructor’s specific directions to turn right or left, it did not test the strategic level. In contrast, the naturalistic driving likely involved the driver making decisions about where to go, what roads to take, and route changes due to traffic. In fact, experienced DRSs will report that they include questions and directions that require the driver to use the strategic level behaviors when driving. This example is not to imply this study was poorly done or wrong, but it does illustrate two significant issues, the first being terminology. Was this a driving test or a driving evaluation? Perhaps the authors understood this issue clearly in defining the drive as a driving test, not an evaluation, although it was not discussed as such in the paper. The second issue is one of measurement and the standardization of driving tests, evaluations, and assessments. The main point here is the understanding that it takes skilled expert to evaluate fitness to driver for individuals with early dementia; the individual with early dementia, who still has intact operational driving behaviors and all or most of their tactical, may perform well on a “driving test” due to its structure. However, he or she may in fact, be in danger if there are limitations in their strategic abilities and, for example, they cannot figure out a way home if a regular driving route has been altered unexpectedly. Generalist and Specialist Occupational Therapy Services To address the risk factor of driving is to frame the activity within the scope of other complex instrumental tasks of daily living. Occupational therapy practitioners routinely evaluate safety risk of their clients for independent living, cooking, handling their finances, managing shopping, and others. Occupational therapists have the science-based knowledge to understand progressive conditions and life changes that can affect these complex IADLs, including driving. Because occupational therapists understand the role of IADL in a person’s life, they should understand the importance of driving and be able to help individuals make a smoother transition from driving to using other forms of transportation. In doing so, they help people maintain their autonomy, independence, and sense of self-worth. While general practitioners understand this for most activities, occupational therapists trained in driver rehabilitation understand the critical demands of driving and how our ability
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FIGURE 2. Occupational Therapy Intervention: Evidence, Clinical Judgment, and Risk.
to move about our community affects the quality of our lives. These occupational therapists have the skills to evaluate an individual’s overall ability to operate a vehicle safely, and, where appropriate, to provide rehabilitation to strengthen skills used in driving. The key is to integrate the generalists and specialists roles and skills sets to effectively address the driving continuum. Figure 2 illustrates an evaluation and intervention framework for using an occupational therapist’s clinical judgment to determine fitness to drive based on evidence and risk. It is clear from research, that normal aging per se is not the reason individuals cannot continue to drive (Dickerson et al., 2007). It is the medical issues, including and particularly cognitive impairment and dementia, that puts drivers at risk. The generalist occupational therapist routinely evaluates cognition, visual-perception, and motor skills and has the skill set to determine if the older adult has an impairment that exceeds the threshold for safe driving. This framework illustrates that only when the degree to which the impairment affects fitness to drive is unclear, is an on road evaluation or full evaluation by a specialist is justified. Additionally, generalist occupational therapists can begin to assist older adults in planning and building options for community mobility at the early stages of new health conditions or worsening of others. Even when the older adult can continue to drive, maximizing of skills, facilitating self-awareness can assist in prolonging the option to drive. Planning and developing transportation alternatives for that transition when driving is no longer an option can assist clients and their families to see this is a positive and constructive process over time, instead of what is too often the case, a sudden and highly disruptive event. There is evidence to support this framework. In a study to compare an IADL evaluation to the outcome of a driving evaluation (Dickerson et al., 2011), results suggested the IADL assessment, the Assessment of Motor and Process Skills (AMPS, Fisher, 2003) predicted who would fail or pass the driving evaluation. In this study, 47 drivers who ranged from healthy volunteers to clients (referred by
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FIGURE 3. Mean and Confidence Intervals of the AMPS Motor and Process Scale Scores Each of the Driving Recommendation Outcomes (e.g., Pass, Fail, Restricted).
physicians or the state DMV) received comprehensive driving evaluations and the AMPS. The AMPS evaluates an individual’s ability to organize and execute a complex IADL (e.g., preparing a salad, making a bed, brewing coffee with eggs and toast, preparing a tuna salad sandwich) that is familiar to the client. The evaluator scores the performance on two universal taxonomies of skills items that yield interval level data. In this case, this data was compared to the outcome of the driving evaluation, which was categorized as failed, restricted, or passed. Figure 3 illustrates the mean and confidence levels of the two outcome measures, grouped by the driving outcome. All participants who scored higher on both the motor and process scales, passed the on-road assessment. Conversely, participants who scored low on both the motor and process scales, almost all failed the on-road assessment. Interesting, although the clients who passed the test tended to be younger, a one way ANOVA demonstrated no significance between age and outcome (F(2,43) = 2.014, p = .146) supporting driving outcome is based on performance and not chronological age. In a more recent research of drivers recovering from stroke, Stapleton (2012) examined why all 48 drivers who completed a comprehensive driving examination “passed” the on-road component. In his qualitative study with occupational therapists, evaluators, and physicians, it appeared that the occupational therapists only referred to the driving evaluator when the individual was “ready” for the
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evaluation, that is, when it was most likely that the individual would pass the exam. Although more research is needed, this study supports the perspective that occupational therapists who observe clients performing other complex IADL can generalize their expert clinical observation to the activity of driving. Based on the belief that general practice occupational therapists can and should be the first line of providers for determining fitness to drive, the American Occupational Therapy Association joined in a cooperative agreement with the NHTSA called the Gaps and Pathways Project with implementation dates from July, 2011–June, 2014. This project’s overall aim is to build and expand programs to address driving as a means of community mobility. Specifically, the project objectives included (1) identifying the gaps for delivering best practice services, (2) improving direct service to older drivers through general practice occupational therapy practitioners and DRSs, and (3) equip practitioners through education, training, and understanding the best pathways of referrals. Not every driver rehabilitation program needs to have a full range of services, but each program might have a screening program and/or have the knowledge and access of pathways for referrals so that the older adult is getting the right level service by the right provider at the right time. Outcomes from the Gaps and Pathways Project In order to meet the identified objectives of this project, an expert meeting was planned to include transportation researchers and master clinicians with extensive experience in driver rehabilitation services. In preparation for the meeting, a comprehensive literature review was completed that summarized the present state of screening and assessment tools used for evaluation of driving of older adults. Each
TABLE 2. Ongoing Outcomes from the Gaps and Pathways Project (AOTA and NHTSA) • Genesis Rehab, a national company, partnered with AOTA to develop diagnostic sheets that will illustrate critical questions or pathways of referral for the occupational therapy generalist to consider when planning intervention for clients under various medical diagnoses. These pathway diagnostic sheets are being piloted in the Genesis Rehab company and will be shared with occupational therapy practitioners when finalized. • An educational module developed in 2007 will be revised and updated. This module will be available to all occupational therapy educational programs to use for meeting educational standards concerning driving and community mobility, especially for older adults. • A screening and assessment framework for occupational therapy general practitioners has been developed and will be piloted. This framework is intended to assist generalists who routinely determine safety risk in IADLs to translate their abilities to risk for independent mobility, particularly driving. • AOTA and the Association of Driver Rehabilitation Services (ADED) worked prior to the expert meeting and recently met again to develop a table that will address the issues of differentiating programs, levels of expertise, and expected outcomes. • A paper on methods of documentation for successful reimbursement by third party payers. This paper will assist occupational therapy practitioners in seeking support for services for older adults, especially those under Medicare. • The issue of terminology emerged from the preparation of the expert panel and other projects. For example, the term “driver evaluation” has a wide range of meanings for various stakeholders from the state licensing agencies, to practitioners and researchers. This issue was presented to the appropriate committee (e.g., Safe Mobility of the Older Persons) of the Transportation Research Board and was the topic a special mid-year meeting. The work will be pursued through this group to build a common taxonomy for measuring research outcomes.
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member of the expert committee contributed a written summary of either common medical diagnoses or related topics to driving rehabilitation. Based on the review of these papers, expertise and experience, and the discussion, the expert meeting met three goals: (1) agreement on over 60 consensus statements, (2) identified research needs, and (3) identified the gaps for achieving appropriate pathways. The consensus statements cover the areas of common diagnoses including dementia, models of programs, screening and assessment, use of driving simulators, and education of specialists. The consensus statements should be used as a tool for occupational therapy practitioners to assist in making decisions in relation to clients and program development and will be published in a future issue of Occupational Therapy in Health Care. Research needs were identified, delineated more clearly through electronic communication after the meeting, and delivered to the research group at NHSTA. Although the gaps and possible pathways were identified at the expert meeting, a prioritization process post meeting allowed several critical projects to move forward. Table 2 describes the ongoing projects from Gaps and Pathways Project, while the included appendix lists additional resources for practitioners, clients, and their families.
CONCLUSION The overall objective of this paper was to highlight the issues when considering driving and older adults and especially for individuals with dementia. As the most common method of transportation and an overlearned skill, it is difficult to discuss driving cessation with an individual struggling to maintain their independence while negotiating the trials of an insidious disease. This paper reviewed recent research about driving for individuals with cognitive impairment and its implications for individuals and family members. It also described the complexities of evaluating driving within a system that may be overwhelmed as the baby boomers continue aging and driving. A framework using both general practice occupational therapists and specialists is presented with evidence to supporting the ongoing work of multiple disciplines to determine fitness to drive. Finally, the Gaps and Pathways Project to expand driver rehabilitation services for the older adults is introduced, foreshadowing future research, and outcomes. Declaration of interest: The author reports no conflict of interest. The author alone is responsible for the content and writing of this paper.
ABOUT THE AUTHOR Anne E. Dickerson, PhD, OTR/L, FAOTA, Professor, East Carolina University, Greenville, NC 27858, USA.
REFERENCES Adler G, & Kuskowski M. (2003). Driving habits and cessation in older men with dementia. Alzheimer Disease and Associated Disorders, 17(2), 68–71.
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Ball K, Owsley C, Sloane ME, Roenker DL, & Bruni JR. (1993). Visual attention problems as a predictor of vehicle crashes in older drivers. Investigative Ophthalmology and Visual Science, 34(11), 3110–3123. Carr D, Barco P, Wallendorf MJ, Snellgrove CA, & Ott BR. (2011). Predicting road test performance in drivers with dementia. Journal of the American Geriatric Society, 59, 2112–2117. Carr DB, & Ott BR. (2010). The older adult driver with cognitive impairment. The Journal of the American Medical Association, 303(16), 1632–1641. Classen S, Witter DP, Lanford DN, Okun MS, Rodriguez RL, Romrell J, Fernandez HH. (2011). Usefulness of screening tools for predicting driving performance in people with Parkinson’s Disease. The American Journal of Occupational Therapy, 65, 579–588. Coughlin JF, D’Ambrosio LA, Pratt MR, & Mohyde M. (2012). The continuing and growing importance of mobility. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 11–26). New York: Springer Publishing Company. Davis JD, Papandonatos GD, Miller LA, Hewitt SD, Festa EK, Heindel WC, & Ott BR. (2012). Road test and naturalistic driving performance in healthy and cognitively impaired older adults: Does environment matter? Journal of Applied Gerontology, 60, 2056–2062. Dickerson AE. (2012). Using the simulator as a tool for self awareness? Paper presented at the Gerontological Society of America Conference, San Diego, CA. Dickerson AE. (2013). Capstone address: Addressing the IADL of driving. Why is it important for occupational therapy practitioners in all settings. Paper presented at the North Carolina Occupational Therapy Association conference, Raleigh, NC. Dickerson AE. (in press). Assessment tools predicting fitness to drive in older adults: A Systematic review. American Journal of Occupational Therapy. Dickerson AE, Reistetter T, Schold Davis E, & Monohan M. (2011). Evaluating driving as a valued instrumental activity of daily living. American Journal of Occupational Therapy, 65, 64–75. Dickerson AE, & Schold Davis E. (2012). Welcome to the team! Who are the stakeholders? In M.J. McGuire & E. Schold Davis (Eds.), Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (pp. 49–77). Bethesda, MD: American Occupational Therapy Association, Inc. Dickerson AE, Molnar LJ, Adler G, Bedard M, Berg-Weger M, Classen S, . . . Trujillo L. (2007). Transportation and aging: A research agenda for advancing safe mobility. The Gerontologist, 47, 578–590. Dobbs AR., & Dobbs BM. (2000). The role of concordance between perceived and real competence for mobility outcomes. In KW Schaie & M Pietrucha (Eds.) Mobility and Transportation in the Elderly (pp. 251–267). New York: Springer Publishing. Dobbs B, Carr DB, & Morris JC. (2002). Management and assessment of the demented driver. The Neurologist, 8, 61–70. Dobbs BM. (2012). The new older driver in the United States and Canada: Changes and challenges. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 119–136). New York: Springer Publishing Company. Dubinsky RM, Stien AC, & Lyons K. (2000). Practice parameter: risk of driving and Alzheimer’s disease (an evidence based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 54, 2205–2211. Eby DW, Molnar LJ, & Kartje PS. (2009). Maintaining Safe Mobility in an Aging Society. Boca Raton, FL: Taylor and Frances Group. Federal Interagency Forum on Aging-Related Statistics (2008). Older Americans 2008: Key indicators of well being. Washington, DC: US Government Printing Office. Fisher AG. (2003). Assessment of motor and process skills: Volume I and II (5th ed.). Fort Collins, CO: Three Star Press. Foley DJ, Heimovitz HK, Guralnik JM, & Brock DB. (2002). Driving life expectancy of persons aged 70 years and older in the United States. American Journal of Public Health, 92, 1284–1289. Frittelli C, Borgheti D, Iudice G, Bonanni E, Maestri M, Tognoni G, et al. (2009). Effects of Alzheimer’s disease and mild cognitive impairment on driving ability: A controlled clinical study by simulated driving test. International Journal of Geriatric Psychiatry, 24, 232–238.
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Insurance Institute for Highway Safety (2013). Older drivers. Retrieved November 10, 2013 from http://www.iihs.org/iihs/topics/t/older-drivers/topicoverview Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, & Rizzo M. (2010). Practice Parameter Update: Evaluation and management of driving risk in dementia. Neurology, 74, 1316–1324. National Highway Traffic Safety Administration. (2009). Traffic safety facts 2009 data (No. DOTHS-811-391). Washington, DC: Author. National Highway Traffic Safety Administration & American Association of Motor Vehicle Administrators (September, 2009). Driver Fitness Medical Guidelines. Washington, DC & Arlington, VA: Authors. Plassman BL, Langa KM, Fisher GG, Heeringa SG, Weir DR, Ofstedal MB, Wallace RB. (2007). Prevalence of dementia in the United States: The Aging, Demographics, and Memory Study. Neuroepidemiology, 29, 125–132. Reitan R. (1958). Validity of the Trail Making Test as an indicator of organic brain injury. Perceputal Motor Skills, 8, 271–276. Rosenbloom (2012). The travel and mobility needs of older people now and in the future. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 39–54). New York: Springer Publishing Company. Snellgrove, C. (2010). Cognitive screening for the safe driving competence of older people with mild cognitive impairment or early dementia. Austrailian Transoirt Safety Bureau. Grant Report: Australian Transport Safety Bureau. Stapleton T. (2012). An exploration of the process of assessing fitness to drive after stroke within an Irish context of practice. Unpublished dissertation, Trinity College, Dublin, Ireland. Stutts J, Martell C, & Staplin L. (2009). Identifying Behaviors and Situations Associated with Increased Crash Risk for Older Drivers. Department of Transportation (Report No: DOT Hs811 093). Washington, DC.
APPENDIX Suggested resources for physicians, health professionals, or consumers with brief description and the link to website (list developed by Anne Dickerson) The National Highway Traffic Safety Administration (NHTSA) is an agency in the Department of Transportation whose mission is to “Save lives, prevent injuries, reduce vehicle-related crashes.” NHTSA provides a wealth of information about driving safety and specifically on older drivers at this website: http://www.nhtsa.gov/Senior-Drivers The Physician’s Guide to Assessing and Counseling Older Driver was developed by NHSTA and the AMA and in its second edition. The guide provides an overview of physician interventions to improve the safety of older drivers, legal and ethical responsibilities, and medical conditions and medications that may impair driving. http://www.nhtsa.gov/staticfiles/nti/older drivers/pdf/811298.pdf The Driver Fitness Medical Guidelines is a publication by NHTSA and the American Association of Motor Vehicle Administrators. The purpose is to provide guidance to assist licensing agencies in making decisions about an individual fitness for driving. The guidelines are voluntary based on research and best practices by a group of experts. For physicians, these guidelines can be used as a resource to review the evidence about various medical conditions and whether the experts believe there is enough evidence to licensure decisions based on diagnosis. http:// www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated% 20Files/811210.pdf
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The Hartford and MIT Aging Lab together developed an excellent resource of publications for a variety of topics related to older drivers. These can be downloaded at this link OR guidebooks can be ordered for your office to be available for your patients. For physicians, Your Road Ahead: A Guide to Comprehensive Driving Evaluations, At the Crossroads: Family Conversations about Alzheimer’s Disease, Dementia and Driving, and We Need to Talk: Family Conversations with Older Drivers might be the most valuable. http://hartfordauto.thehartford.com/SafeDriving/Expertise-On-Getting-Older/Publications-And-Resources/#Crossroads. Occupational therapists have the science-based knowledge to understand the progressive conditions and life changes that can affect driving. Because of our commitment to assist clients and patients mobile in their community, the American Occupational Therapy Association has website with multiple resources for physicians as well as other stakeholders. http://www.aota.org/Practice/ProductiveAging/Driving.aspx Find a Driving Evaluation Program: Specifically, a physician can find an occupational therapist who specializes in driver rehabilitation for their patients in their local area at this link: http://myaota.aota.org/driver search/index.aspx. The AAA Foundation for Traffic Safety researched and gathered the Driver Licensing Policies and Practices data from all 50 states. The database also has descriptions of noteworthy initiatives as related to medically at risk drivers and older drivers. http://lpp.seniordrivers.org/lpp/index.cfm?selection=visionreqs The American Occupational Therapy Association has website information on their website designed specifically for consumers and their caregivers. It includes the role of occupational therapy, driver safety tips, evaluation and assessment, how to get help, and other topics. Website: http://www.aota.org/Practice/ProductiveAging/Driving/Clients.aspx The Hartford Insurance Company has website information that include driving safety, car maintenance, and older driver safety. Their materials can be downloaded or sent in the mail. Link: http://hartfordauto.thehartford.com/Safe-Driving/CarSafety/Older-Driver-Safety/driving-wellness.shtml AARP has the well known Driver Safety Programs for older adults as well as a wealth of resources on their website, including the CarFit program, and We Need to Talk. http://www.aarp.org/home-garden/transportation/driver safety/ The AAA Foundation for Traffic Safety maintains a website of resources for older drivers, families, researchers, and providers. It offers (1) general safe driving information, (2) free online self-assessments to measure driving skills and needs, and (3) education and training resources. http://lpp.seniordrivers.org/home/
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Driving with Dementia: Evaluation, Referral, and Resources Anne E. Dickerson Professor, Department of Occupational Therapy, East Carolina University, Greenville, NC. USA
ABSTRACT. Driving is a highly valued instrumental activity of daily living, especially for the older adults who consider it part of their definition of independence and mobility. This paper discusses the issues associated with driving and older adults, including the difficulty of identifying when it is time to give up the keys. With a review of the latest research and need for specialized services for those with diminished capacity, the paper highlights how general practice occupational therapists must work in conjunction with driver rehabilitations specialists to meet the need of this growing population. A framework for referral and judgment is described and resources offered to practitioners to use. KEYWORDS. Dementia, driver rehabilitation specialists, driving, driving evaluation, older adults
INTRODUCTION It is a well-established fact that the population segment of age 65 years and up is the fastest growing in most western countries. In terms of drivers, in 1999, 14% of the drivers were over 65. In 2009, that percentage increased to 16 or 40 million drivers, a 20% increase with a projection that by 2030, and 25% of the drivers will be over 65 years of age (National Highway Safety Traffic Administration [NHTSA], 2009). Although older adults are generally considered safe drivers and are involved with fewer fatal collisions than in the past, drivers older than 70 years have higher crash rates per mile traveled than middle-aged drivers, although not as high as young drivers (Insurance Institute for Highway Safety, 2013). The fatality rates of older adults are amplified due to the fact that as one ages, susceptibility to injury and medical complications increases. In fact, a report identified situations associated with increased crash risk for older drivers found that the crash risk ratio of twovehicle at-fault to not-at-fault drivers significantly increases after the age of 75 years (Stutts, et al., 2009). Further examination of crash data separated the two vehicle Address correspondence to: Professor Anne E. Dickerson, East Carolina University, Greenville, NC 27858 USA (E-mail: [email protected]). (Received 14 November 2013; accepted 14 November 2013)
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fatal crashes by type of intersection traffic control (e.g., stop sign, traffic signal, yield sign, and flashing signal). Although all intersections showed increases after the age of 70 years and particularly after 75 years, the data for a yield sign were literally off the chart. Based on 27 fatal crash-involved drivers, 26 were found at fault at a yield sign intersection. Stop signs were also associated with high risk when compared to other intersections. As practitioners working with older adults, we can consider the meaning and implications of these findings. As one ages, the speed of mental processing slows and thus, older adults have slower reaction times and may take longer to make decisions. In terms of daily living tasks, this slowing of processing affects balancing a checkbook, completing a shopping list, or finding a phone number. Although these activities then take more time, the slower processing has little consequences in terms of safety. Decisions about driving (i.e., planning where to go or how to get there) are most often done prior to getting in the vehicle and are not affected by slower processing. Driving, as an overlearned activity, relies on motor tasks that are automatically performed such as braking for a red light or stop sign. However, things are much more complex at a yield sign. The driver must assess the situation and often make a split-second decision about whether he or she should stop or if is safe to move into the intersection. The driver does not legally have to stop, but is forced to make an immediate decision, prompted by other drivers following immediately behind the driver, who intend to keep moving. The older adult with slower processing speed is at greatest risk at these types of intersections. As practitioners, we can suggest strategies to older clients to improve safety, for example avoiding intersections with yield signs, or to treat a yield sign as a stop sign and wait until there is clearly sufficient time to merge into traffic. However, experienced clinicians know this is only a stop-gap measure for some, which may only be effective for a short time before other driving limitations emerge. Driving is a highly complex instrumental activity of daily living and more sophisticated solutions are needed to meet the challenge of ensuring safe driving for older drivers and the public alike. The purpose of this paper is to review the state of knowledge on driving and older adults, and the need for specialized services for those with diminished driving capacity. The paper will focus on the process of driving evaluation and patient referral and will highlight how general practice occupational therapists must work in conjunction with driver rehabilitations specialists to meet the need of this growing population. Evaluating Driving Capacity Determining when or if an older person must “hang up the keys” is not easy. An estimated 6,000,000 adults over the age of 70 years stop driving each year and become dependent on others for their mobility (Foley et al., 2002). The decision to stop driving is difficult and often has adverse consequences for an older adult’s psychological outlook, health and quality of life (Eby et al., 2009). The decision is complicated significantly by the fact that the capacity to drive is related not only to a given individual’s physical and mentally competency, but it is also related to the individual’s self-perception of his or her competence (Dobbs & Dobbs, 2000). If the individual perceives him or herself as competent, and is physically and mentally competent, the individual usually makes an appropriate choice about driving
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(e.g., avoid rush hour traffic), with low risk of safety issues. The same can be said of an individual that has a physical impairment or cognitive limitation. If that individual understands the impact of these limitations on his or her driving performance and safety, that individual acts to appropriately restrict his or her driving (e.g., an individual with vision issues due to glaucoma, does not drive at night). The individual who is mentally and physically competent but perceives him or herself as incompetent is likely over restricting their mobility. This is not a safety issue, but practitioners may choose to intervene to assist in building confidence for increased mobility choices, including driving. The greatest challenge is the individual who is mentally incompetent but perceives himself as competent, this is the “at risk” individual, especially when making choices about driving. One method of categorizing the driving skills is Michon’s (1985) Hierarchy of Driving Behavior. Michon categorized driving into three levels of behavior: (1) strategic, (2) tactical, and (3) operational. The higher-level decision-making process is the strategic level of driving behavior. This level includes determining trip goals, mode of traveling, and navigation or mapping to where one is going. Decisions at the strategic affect all aspects of driving, including the self-appraisal for determining the ability to perform driving tasks under higher risk conditions (e.g., rainy weather, nighttime driving). The tactical level pertains to decisions made while driving including slowing to accommodate rain or snow, deciding when to pass a vehicle, or making a right-hand turn. Operational is the third level, performing the human−machine interaction necessary to control the vehicle safely such as braking or using the steering wheel. These skills consist of the visual−motor skills or coordination skills, which become automatic for the driver over time and remain largely intact in the course of normal aging. Using Michon’s model, one can consider different outcomes at each level. An individual with a significant physical impairment, for instance, may have an intact strategic level of driving and may be able to plan a route but needs to have someone with intact operational skills actually drive. The more difficult dilemma is the person with early stage dementia who still has good operational-level skills and perhaps even the technical level because he or she can follow the basic rules of the road, but demonstrates impairment in the strategiclevel skills. Driving for Individuals with Dementia The National Institutes of Health have determined that one in seven persons over the age of 71 years have some type of dementia (Plassman et al., 2007). This is of concern, as older adults with cognitive deficits do not always make the appropriate decisions with regards to driving modification or cessation because of lack of insight, poor judgment, and loss of reasoning ability (Adler & Kuskowski, 2003). Moreover, up to 25% of older adults continue to drive even after a physician makes the recommendation for an individual to cease driving (Dobbs et al., 2002). Since the motor aspects of driving are an overlearned skill, older adults with cognitive deficits do not have difficulties performing the physical task of driving and following the specific knowledge based rules (e.g., stopping at a stop sign, keeping in between the lines) and therefore do not perceive any difficulties with driving. Issues with cognitive impairments become evident when split second decisions are necessary due to unforeseen difficulties, problems with visual attention reduce the ability to
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respond to the dynamic environment of traffic, or route finding issues emerge even in familiar areas. For the Baby Boomers who grew up in the golden age of automobile manufacturing (Coughlin et al., 2012), learning to drive was viewed as a rite of passage. Considering how driving contributes to their self-definition of independence and mobility, it is hardly surprising that older adults, in particular, consider driving as a “right,” and are likely to challenge the licensing authorities about decisions that impact their licensing status (Dobbs, 2012). Since the majority of older adults will remain living in suburban and rural communities (Rosenbloom, 2012), they view driving as essential to meeting their social and occupational needs. Accordingly, driving will remain the primary choice and mode of personal transportation for older adults (Coughlin et al., 2012; Dobbs, 2012; Rosenbloom, 2012). The problem arises when the individual is no longer fit to drive. Moreover, as the population shifts from one in eight individuals being over the age of 65 years in 2010 to one in five by 2030 (Federal Interagency Forum on Aging-Related Statistics, 2008), public and health care services will need to be much better prepared to meet the needs of increasing numbers of older adults wanting to “age-in-place.” To reside in the suburbs or rural areas requires that you be able to drive, as you cannot get anywhere without a car. Thus, if policies to support aging-in-place are a high priority, driver screening and perhaps even training to ensure older individuals (who may be at the beginning of cognitive decline) and the public are not at risk. Thus, the remainder of this paper will: (1) review recent research about dementia and driving and its implications for individuals and family members, (2) examine the process of driving evaluation for individuals with dementia and its implications for personal and public safety, and (3) describe the screening and assessment process continuum for determining fitness to drive for individuals with dementia. Driving with Dementia: Recent Research Findings With the client with cognitive impairment or dementia, the two main questions are (1) when does the individual become unsafe and (2) what is the best method of screening those individuals. Twenty-five studies, spanning from 1992 to 2010, explored the issue of fitness to driver by individuals with dementia (Dickerson, 2013). The evidence is consistent that individuals with moderate or severe dementia should not be driving; which can be screened easily with an assessment like the Mini Mental Status Exam (MMSE) (e.g., below 18 on MMSE indicates moderate dementia, NHSTA & AAMVA, 2009). However, it is the individuals with early or mild dementia that pose the dilemma, as the MMSE does not correlate with on road performance when the client is at the upper range (24 or above). The evidence also shows that individuals with dementia consistently make more errors and demonstrate poorer on-road performance, but not always to the level of being “unsafe.” Even individuals with dementia at the level of “mild” dementia are able to pass an on-road driving evaluation, especially if the testing is only at the level of operational and tactical processing demands, described above. This indicates specialized assessment is necessary at the “mild” and “very mild” levels of dementia and regular re-evaluation is necessary. Studies also show that individuals with dementia consistently make more errors and demonstrate poorer performance on simulators, although the on-road driving assessment provides the most reliable functional
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TABLE 1. Outcome of Nine Medically at Risk Drivers for Questions About Their Driving
Years expected to drive How important is driving Rate ability to drive
Pre
Post
t
p
6.9 9.0 8.33
5.6 9.63 7.87
0.465 –1.55 –0.261
.658 .172 .811
assessment of driving ability (Dickerson, 2013; Dubinsky et al., 2000; Frittelli et al., 2009; Iverson et al., 2010). The usual approach of occupational therapists is to evaluate competency by having their client perform the task in question under “real life conditions”, and by doing so, assess the individual’s ability to perform more safely and/or avoid risk. Thus, one approach with medically-at-risk drivers would be to have them drive in conditions with increased risk in order to evaluate their driving performance. This was explored in a pilot study (Dickerson, 2012) using an interactive driving simulator with nine older adults who were either self-referred or were referred by a physician to the study. With the overarching question of whether a simulator can be used as a self-awareness tool for driving, the participants rated their driving ability prior to and after the simulation experience. All participants were: (1) oriented to the simulator through familiarization runs, (2) completed two standard scenarios with critical incidents (e.g., scenarios that required specific actions to avoid collisions), (3) trained on more safety drives on the simulator, and (4) competed the same two standard scenarios with an additional scenario to include a third critical incident. Table 1 illustrates the results. There was no significant change in the years expected to drive, importance of driving, or rating of the ability to drive. However, Figure 1 illustrates the individual’s assessment of their driving performance before and after the simulation experience. Although most of the medically-at-risk drivers maintained their confidence in driving after their simulation “exposure”, two individuals changed, one reporting better driving ability and one reporting poorer ability. The results of this pilot study are inconclusive in general terms because of the small sample. However, further analysis of the individual participants’ diagnosis and specific performance yielded some additional insights. Data clearly showed the variability of the older adults’ performance and the lack of objective and subjective measures for individual older drivers. This finding also reinforces experienced clinicians’ first-hand knowledge that there is tremendous variation between older adults’ abilities to reflect and truly understand what their actual driving capacity is once again underscoring the necessity for careful screening and assessment. Accordingly, in a recent systematic review (Dickerson, in press), evidence suggests that one assessment will not be adequate for use with all medically-at-risk drivers. More likely, there will be groups of tools for specific diagnoses. For example, in a study on Parkinson’s Disease (Classen et al., 2011), the Useful Field R (Ball et al., 1993) and the Rapid Pace Walk were found as potentially of View promising screening tools, as they best predicted road test outcomes for individuals with Parkinson’s disease. Similarly, Carr and colleagues (2011), compared measures of visual, motor, and cognitive functioning to the on-road assessment for 99 older adults with dementia. Their best predictive model with 85% accuracy was using an
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FIGURE 1. Self-Rating of Ability to Drive by Individuals Pre and Post Simulator Study. Note: 1 = poor and 10 = very good.
eight-point interview (e.g., AD-8 Dementia Screening Tool), a clock drawing, and the time to complete either the Trail Making Test A (Reitan, 1958) or the Snellgrove Maze (Snellgrove, 2010) test. In an earlier paper, Carr and Ott (2010), summarized best practices for physicians when addressing drivers who have been identified as having dementia. Specifically, they highlighted summary position statements from 13 consensus meetings or professional associations about driving and dementia. In regards to driving and dementia, driving cessation is necessary for persons with moderate to severe dementia and/or when the individual poses a serious risk. In addition, there is an agreement that individuals with mild dementia need specialized evaluation, as they still may be able to drive, although reassessments are needed at regular intervals. For specialized physicians (e.g., neurologists or geriatricians), these position/consensus statements are very useful. However, for the general practitioner (e.g., family practitioner, internal medicine), the questions remain: (1) by what measure is moderate dementia and/or (2) how does the practitioner know when an individual poses a serious risk? Driving Evaluation for Individuals with Dementia Who administers a driving evaluation depends on the setting, state of residency, and training of the evaluators. As we know, in each state, there is a licensing authority that has some level of driving evaluations for at least their novice drivers. The systems vary state to state with few systems being the same. However, in most cases, the licensing authority has a very structured system that typically results in a pass or fail outcome. States with medical review boards (e.g., North Carolina, Maryland) frequently refer more complex cases to driver rehabilitation specialists (DRSs) who then provide individualized clinical and on-road evaluations. It is
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important for practitioners and consumers to understand, that the service, resources, and consequences of these options are vastly distinct. Just like an eye exam, there are different outcomes from the school eye screening, the optometrist, and the ophthalmologist. As advocates for older clients, it is critical to understand the implications of each of these options as the difference is not simply the cost. DRSs are professionals with specialized training who plan, develop, coordinate, or implement driving rehabilitation services for individuals with disabilities (Dickeson & Schold Davis, 2012). There are about 600 DRSs in the United States and approximately 80% of DRSs are occupational therapists. The usual process for a comprehensive driving evaluation to be done by a DRS, which includes a clinical assessment component and the “in context” component or on-road assessment. The clinical assessment typically consists of the client’s medical and driving history with assessment of the physical, cognitive, visual, and perceptual skills. The on-road component typically starts in a quiet parking lot or neighborhood, progresses to low traffic, intersections, and then busy streets and/or highway. Typically, the DRSs shares the outcome of the evaluation, including recommendations, with the client and family member(s). Recommendations usually include: (1) continue to drive with no restrictions, (2) drive with restrictions (e.g., no nighttime driving, limit speed or distance, no highway), (3) periodic review in the cases of progressive diseases or disorders, (4) retirement from driving, and/or (5) assistance with community mobility through working with the client and family members to identify alternative modes of transportation to get them to where they need and want to go. The comprehensive driving evaluation can take from 2–5 hr depending on the client and selected assessment tools, recognizing that the on road component typically lasts at least 45–60 min and the clinical component from 1–3 hr. In the ideal situation, as an older adult becomes more medically compromised or when the client or family express concern, the physician would screen their client, recognize the need for specialized assessment, and refer the client to a driving rehabilitation specialist to determine their level of risk. However, the issue has and will become more of an issue due to capacity with the expanding number of older adults. For example, using Michigan and its population (e.g., 942,905 in 2011) as an example; based on Plassman’s study (2007), there would be approximately 134,700 individuals with dementia in the state in 2011. With 131 branch offices of Michigan’s licensing agency, that would mean about 1028 individuals with dementia per office. In Michigan, there are approximately 14 DRSs with 5 in one setting. That would equate to approximately 9,621 dementia referrals for each DRS, or 26 per day, 365 days a year. Clearly, one could argue that many of these individuals with dementia have already given up driving or reside in long-term care facilities. However, even if only 10% of this number needed specialized evaluations from a DRS, that would still require about three evaluations per day for each DRS and that does not consider all other types of referrals with other diagnostic categories. The question then is what is the solution to the issue? How can at-risk older drivers and in particular, medically-at-risk drivers get evaluated appropriately for either (1) goals and strategies of rehabilitation to return to driving, or (2) if necessary, retire from driving, but be able to find alternative means of meeting their transportation needs. It is unlikely the state licensing authorities have or will have the funding to build the manpower to meet the needs. The more compelling
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problem is the skill set needed to appropriately evaluate fitness to drive of individuals with complex medical issues. When evaluating individuals with beginning or mild dementia, the issue is how to determine when their strategic level skills are impaired so that he or she can no longer compensate by modifying or restricting their driving to avoid making a dangerous decisions at the technical or operational level. This complex level of evaluation requires a skilled professional, who understands the intricacies of a disease process. A recent research study illustrates this point. Davis et al. (2012) sought to compare a standardized road test to naturalistic driving for older adults both healthy and cognitively impaired. Naturalistic driving consisted of equipping the vehicle with technology to observe the performance of the driver in their vehicle over time. Each subject underwent a road test consisting of “a professional driving instructor (blind to diagnosis) administered . . . road test to participants . . . providing only oral instructions to complete the course” (p. 2057) which was compared to their naturalistic driving as a way to compare overall performance and rate of errors. The researchers found only “fair” agreement” between the two drives. I believe that the standardized road test was only testing the driver at the operational and tactical levels, following the instructor’s specific directions to turn right or left, it did not test the strategic level. In contrast, the naturalistic driving likely involved the driver making decisions about where to go, what roads to take, and route changes due to traffic. In fact, experienced DRSs will report that they include questions and directions that require the driver to use the strategic level behaviors when driving. This example is not to imply this study was poorly done or wrong, but it does illustrate two significant issues, the first being terminology. Was this a driving test or a driving evaluation? Perhaps the authors understood this issue clearly in defining the drive as a driving test, not an evaluation, although it was not discussed as such in the paper. The second issue is one of measurement and the standardization of driving tests, evaluations, and assessments. The main point here is the understanding that it takes skilled expert to evaluate fitness to driver for individuals with early dementia; the individual with early dementia, who still has intact operational driving behaviors and all or most of their tactical, may perform well on a “driving test” due to its structure. However, he or she may in fact, be in danger if there are limitations in their strategic abilities and, for example, they cannot figure out a way home if a regular driving route has been altered unexpectedly. Generalist and Specialist Occupational Therapy Services To address the risk factor of driving is to frame the activity within the scope of other complex instrumental tasks of daily living. Occupational therapy practitioners routinely evaluate safety risk of their clients for independent living, cooking, handling their finances, managing shopping, and others. Occupational therapists have the science-based knowledge to understand progressive conditions and life changes that can affect these complex IADLs, including driving. Because occupational therapists understand the role of IADL in a person’s life, they should understand the importance of driving and be able to help individuals make a smoother transition from driving to using other forms of transportation. In doing so, they help people maintain their autonomy, independence, and sense of self-worth. While general practitioners understand this for most activities, occupational therapists trained in driver rehabilitation understand the critical demands of driving and how our ability
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FIGURE 2. Occupational Therapy Intervention: Evidence, Clinical Judgment, and Risk.
to move about our community affects the quality of our lives. These occupational therapists have the skills to evaluate an individual’s overall ability to operate a vehicle safely, and, where appropriate, to provide rehabilitation to strengthen skills used in driving. The key is to integrate the generalists and specialists roles and skills sets to effectively address the driving continuum. Figure 2 illustrates an evaluation and intervention framework for using an occupational therapist’s clinical judgment to determine fitness to drive based on evidence and risk. It is clear from research, that normal aging per se is not the reason individuals cannot continue to drive (Dickerson et al., 2007). It is the medical issues, including and particularly cognitive impairment and dementia, that puts drivers at risk. The generalist occupational therapist routinely evaluates cognition, visual-perception, and motor skills and has the skill set to determine if the older adult has an impairment that exceeds the threshold for safe driving. This framework illustrates that only when the degree to which the impairment affects fitness to drive is unclear, is an on road evaluation or full evaluation by a specialist is justified. Additionally, generalist occupational therapists can begin to assist older adults in planning and building options for community mobility at the early stages of new health conditions or worsening of others. Even when the older adult can continue to drive, maximizing of skills, facilitating self-awareness can assist in prolonging the option to drive. Planning and developing transportation alternatives for that transition when driving is no longer an option can assist clients and their families to see this is a positive and constructive process over time, instead of what is too often the case, a sudden and highly disruptive event. There is evidence to support this framework. In a study to compare an IADL evaluation to the outcome of a driving evaluation (Dickerson et al., 2011), results suggested the IADL assessment, the Assessment of Motor and Process Skills (AMPS, Fisher, 2003) predicted who would fail or pass the driving evaluation. In this study, 47 drivers who ranged from healthy volunteers to clients (referred by
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FIGURE 3. Mean and Confidence Intervals of the AMPS Motor and Process Scale Scores Each of the Driving Recommendation Outcomes (e.g., Pass, Fail, Restricted).
physicians or the state DMV) received comprehensive driving evaluations and the AMPS. The AMPS evaluates an individual’s ability to organize and execute a complex IADL (e.g., preparing a salad, making a bed, brewing coffee with eggs and toast, preparing a tuna salad sandwich) that is familiar to the client. The evaluator scores the performance on two universal taxonomies of skills items that yield interval level data. In this case, this data was compared to the outcome of the driving evaluation, which was categorized as failed, restricted, or passed. Figure 3 illustrates the mean and confidence levels of the two outcome measures, grouped by the driving outcome. All participants who scored higher on both the motor and process scales, passed the on-road assessment. Conversely, participants who scored low on both the motor and process scales, almost all failed the on-road assessment. Interesting, although the clients who passed the test tended to be younger, a one way ANOVA demonstrated no significance between age and outcome (F(2,43) = 2.014, p = .146) supporting driving outcome is based on performance and not chronological age. In a more recent research of drivers recovering from stroke, Stapleton (2012) examined why all 48 drivers who completed a comprehensive driving examination “passed” the on-road component. In his qualitative study with occupational therapists, evaluators, and physicians, it appeared that the occupational therapists only referred to the driving evaluator when the individual was “ready” for the
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evaluation, that is, when it was most likely that the individual would pass the exam. Although more research is needed, this study supports the perspective that occupational therapists who observe clients performing other complex IADL can generalize their expert clinical observation to the activity of driving. Based on the belief that general practice occupational therapists can and should be the first line of providers for determining fitness to drive, the American Occupational Therapy Association joined in a cooperative agreement with the NHTSA called the Gaps and Pathways Project with implementation dates from July, 2011–June, 2014. This project’s overall aim is to build and expand programs to address driving as a means of community mobility. Specifically, the project objectives included (1) identifying the gaps for delivering best practice services, (2) improving direct service to older drivers through general practice occupational therapy practitioners and DRSs, and (3) equip practitioners through education, training, and understanding the best pathways of referrals. Not every driver rehabilitation program needs to have a full range of services, but each program might have a screening program and/or have the knowledge and access of pathways for referrals so that the older adult is getting the right level service by the right provider at the right time. Outcomes from the Gaps and Pathways Project In order to meet the identified objectives of this project, an expert meeting was planned to include transportation researchers and master clinicians with extensive experience in driver rehabilitation services. In preparation for the meeting, a comprehensive literature review was completed that summarized the present state of screening and assessment tools used for evaluation of driving of older adults. Each
TABLE 2. Ongoing Outcomes from the Gaps and Pathways Project (AOTA and NHTSA) • Genesis Rehab, a national company, partnered with AOTA to develop diagnostic sheets that will illustrate critical questions or pathways of referral for the occupational therapy generalist to consider when planning intervention for clients under various medical diagnoses. These pathway diagnostic sheets are being piloted in the Genesis Rehab company and will be shared with occupational therapy practitioners when finalized. • An educational module developed in 2007 will be revised and updated. This module will be available to all occupational therapy educational programs to use for meeting educational standards concerning driving and community mobility, especially for older adults. • A screening and assessment framework for occupational therapy general practitioners has been developed and will be piloted. This framework is intended to assist generalists who routinely determine safety risk in IADLs to translate their abilities to risk for independent mobility, particularly driving. • AOTA and the Association of Driver Rehabilitation Services (ADED) worked prior to the expert meeting and recently met again to develop a table that will address the issues of differentiating programs, levels of expertise, and expected outcomes. • A paper on methods of documentation for successful reimbursement by third party payers. This paper will assist occupational therapy practitioners in seeking support for services for older adults, especially those under Medicare. • The issue of terminology emerged from the preparation of the expert panel and other projects. For example, the term “driver evaluation” has a wide range of meanings for various stakeholders from the state licensing agencies, to practitioners and researchers. This issue was presented to the appropriate committee (e.g., Safe Mobility of the Older Persons) of the Transportation Research Board and was the topic a special mid-year meeting. The work will be pursued through this group to build a common taxonomy for measuring research outcomes.
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member of the expert committee contributed a written summary of either common medical diagnoses or related topics to driving rehabilitation. Based on the review of these papers, expertise and experience, and the discussion, the expert meeting met three goals: (1) agreement on over 60 consensus statements, (2) identified research needs, and (3) identified the gaps for achieving appropriate pathways. The consensus statements cover the areas of common diagnoses including dementia, models of programs, screening and assessment, use of driving simulators, and education of specialists. The consensus statements should be used as a tool for occupational therapy practitioners to assist in making decisions in relation to clients and program development and will be published in a future issue of Occupational Therapy in Health Care. Research needs were identified, delineated more clearly through electronic communication after the meeting, and delivered to the research group at NHSTA. Although the gaps and possible pathways were identified at the expert meeting, a prioritization process post meeting allowed several critical projects to move forward. Table 2 describes the ongoing projects from Gaps and Pathways Project, while the included appendix lists additional resources for practitioners, clients, and their families.
CONCLUSION The overall objective of this paper was to highlight the issues when considering driving and older adults and especially for individuals with dementia. As the most common method of transportation and an overlearned skill, it is difficult to discuss driving cessation with an individual struggling to maintain their independence while negotiating the trials of an insidious disease. This paper reviewed recent research about driving for individuals with cognitive impairment and its implications for individuals and family members. It also described the complexities of evaluating driving within a system that may be overwhelmed as the baby boomers continue aging and driving. A framework using both general practice occupational therapists and specialists is presented with evidence to supporting the ongoing work of multiple disciplines to determine fitness to drive. Finally, the Gaps and Pathways Project to expand driver rehabilitation services for the older adults is introduced, foreshadowing future research, and outcomes. Declaration of interest: The author reports no conflict of interest. The author alone is responsible for the content and writing of this paper.
ABOUT THE AUTHOR Anne E. Dickerson, PhD, OTR/L, FAOTA, Professor, East Carolina University, Greenville, NC 27858, USA.
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Ball K, Owsley C, Sloane ME, Roenker DL, & Bruni JR. (1993). Visual attention problems as a predictor of vehicle crashes in older drivers. Investigative Ophthalmology and Visual Science, 34(11), 3110–3123. Carr D, Barco P, Wallendorf MJ, Snellgrove CA, & Ott BR. (2011). Predicting road test performance in drivers with dementia. Journal of the American Geriatric Society, 59, 2112–2117. Carr DB, & Ott BR. (2010). The older adult driver with cognitive impairment. The Journal of the American Medical Association, 303(16), 1632–1641. Classen S, Witter DP, Lanford DN, Okun MS, Rodriguez RL, Romrell J, Fernandez HH. (2011). Usefulness of screening tools for predicting driving performance in people with Parkinson’s Disease. The American Journal of Occupational Therapy, 65, 579–588. Coughlin JF, D’Ambrosio LA, Pratt MR, & Mohyde M. (2012). The continuing and growing importance of mobility. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 11–26). New York: Springer Publishing Company. Davis JD, Papandonatos GD, Miller LA, Hewitt SD, Festa EK, Heindel WC, & Ott BR. (2012). Road test and naturalistic driving performance in healthy and cognitively impaired older adults: Does environment matter? Journal of Applied Gerontology, 60, 2056–2062. Dickerson AE. (2012). Using the simulator as a tool for self awareness? Paper presented at the Gerontological Society of America Conference, San Diego, CA. Dickerson AE. (2013). Capstone address: Addressing the IADL of driving. Why is it important for occupational therapy practitioners in all settings. Paper presented at the North Carolina Occupational Therapy Association conference, Raleigh, NC. Dickerson AE. (in press). Assessment tools predicting fitness to drive in older adults: A Systematic review. American Journal of Occupational Therapy. Dickerson AE, Reistetter T, Schold Davis E, & Monohan M. (2011). Evaluating driving as a valued instrumental activity of daily living. American Journal of Occupational Therapy, 65, 64–75. Dickerson AE, & Schold Davis E. (2012). Welcome to the team! Who are the stakeholders? In M.J. McGuire & E. Schold Davis (Eds.), Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (pp. 49–77). Bethesda, MD: American Occupational Therapy Association, Inc. Dickerson AE, Molnar LJ, Adler G, Bedard M, Berg-Weger M, Classen S, . . . Trujillo L. (2007). Transportation and aging: A research agenda for advancing safe mobility. The Gerontologist, 47, 578–590. Dobbs AR., & Dobbs BM. (2000). The role of concordance between perceived and real competence for mobility outcomes. In KW Schaie & M Pietrucha (Eds.) Mobility and Transportation in the Elderly (pp. 251–267). New York: Springer Publishing. Dobbs B, Carr DB, & Morris JC. (2002). Management and assessment of the demented driver. The Neurologist, 8, 61–70. Dobbs BM. (2012). The new older driver in the United States and Canada: Changes and challenges. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 119–136). New York: Springer Publishing Company. Dubinsky RM, Stien AC, & Lyons K. (2000). Practice parameter: risk of driving and Alzheimer’s disease (an evidence based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 54, 2205–2211. Eby DW, Molnar LJ, & Kartje PS. (2009). Maintaining Safe Mobility in an Aging Society. Boca Raton, FL: Taylor and Frances Group. Federal Interagency Forum on Aging-Related Statistics (2008). Older Americans 2008: Key indicators of well being. Washington, DC: US Government Printing Office. Fisher AG. (2003). Assessment of motor and process skills: Volume I and II (5th ed.). Fort Collins, CO: Three Star Press. Foley DJ, Heimovitz HK, Guralnik JM, & Brock DB. (2002). Driving life expectancy of persons aged 70 years and older in the United States. American Journal of Public Health, 92, 1284–1289. Frittelli C, Borgheti D, Iudice G, Bonanni E, Maestri M, Tognoni G, et al. (2009). Effects of Alzheimer’s disease and mild cognitive impairment on driving ability: A controlled clinical study by simulated driving test. International Journal of Geriatric Psychiatry, 24, 232–238.
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Insurance Institute for Highway Safety (2013). Older drivers. Retrieved November 10, 2013 from http://www.iihs.org/iihs/topics/t/older-drivers/topicoverview Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, & Rizzo M. (2010). Practice Parameter Update: Evaluation and management of driving risk in dementia. Neurology, 74, 1316–1324. National Highway Traffic Safety Administration. (2009). Traffic safety facts 2009 data (No. DOTHS-811-391). Washington, DC: Author. National Highway Traffic Safety Administration & American Association of Motor Vehicle Administrators (September, 2009). Driver Fitness Medical Guidelines. Washington, DC & Arlington, VA: Authors. Plassman BL, Langa KM, Fisher GG, Heeringa SG, Weir DR, Ofstedal MB, Wallace RB. (2007). Prevalence of dementia in the United States: The Aging, Demographics, and Memory Study. Neuroepidemiology, 29, 125–132. Reitan R. (1958). Validity of the Trail Making Test as an indicator of organic brain injury. Perceputal Motor Skills, 8, 271–276. Rosenbloom (2012). The travel and mobility needs of older people now and in the future. In Coughlin & D’Ambrosio’s (Eds.) Aging America and transportation: Personal choices and public policy (pp. 39–54). New York: Springer Publishing Company. Snellgrove, C. (2010). Cognitive screening for the safe driving competence of older people with mild cognitive impairment or early dementia. Austrailian Transoirt Safety Bureau. Grant Report: Australian Transport Safety Bureau. Stapleton T. (2012). An exploration of the process of assessing fitness to drive after stroke within an Irish context of practice. Unpublished dissertation, Trinity College, Dublin, Ireland. Stutts J, Martell C, & Staplin L. (2009). Identifying Behaviors and Situations Associated with Increased Crash Risk for Older Drivers. Department of Transportation (Report No: DOT Hs811 093). Washington, DC.
APPENDIX Suggested resources for physicians, health professionals, or consumers with brief description and the link to website (list developed by Anne Dickerson) The National Highway Traffic Safety Administration (NHTSA) is an agency in the Department of Transportation whose mission is to “Save lives, prevent injuries, reduce vehicle-related crashes.” NHTSA provides a wealth of information about driving safety and specifically on older drivers at this website: http://www.nhtsa.gov/Senior-Drivers The Physician’s Guide to Assessing and Counseling Older Driver was developed by NHSTA and the AMA and in its second edition. The guide provides an overview of physician interventions to improve the safety of older drivers, legal and ethical responsibilities, and medical conditions and medications that may impair driving. http://www.nhtsa.gov/staticfiles/nti/older drivers/pdf/811298.pdf The Driver Fitness Medical Guidelines is a publication by NHTSA and the American Association of Motor Vehicle Administrators. The purpose is to provide guidance to assist licensing agencies in making decisions about an individual fitness for driving. The guidelines are voluntary based on research and best practices by a group of experts. For physicians, these guidelines can be used as a resource to review the evidence about various medical conditions and whether the experts believe there is enough evidence to licensure decisions based on diagnosis. http:// www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated% 20Files/811210.pdf
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The Hartford and MIT Aging Lab together developed an excellent resource of publications for a variety of topics related to older drivers. These can be downloaded at this link OR guidebooks can be ordered for your office to be available for your patients. For physicians, Your Road Ahead: A Guide to Comprehensive Driving Evaluations, At the Crossroads: Family Conversations about Alzheimer’s Disease, Dementia and Driving, and We Need to Talk: Family Conversations with Older Drivers might be the most valuable. http://hartfordauto.thehartford.com/SafeDriving/Expertise-On-Getting-Older/Publications-And-Resources/#Crossroads. Occupational therapists have the science-based knowledge to understand the progressive conditions and life changes that can affect driving. Because of our commitment to assist clients and patients mobile in their community, the American Occupational Therapy Association has website with multiple resources for physicians as well as other stakeholders. http://www.aota.org/Practice/ProductiveAging/Driving.aspx Find a Driving Evaluation Program: Specifically, a physician can find an occupational therapist who specializes in driver rehabilitation for their patients in their local area at this link: http://myaota.aota.org/driver search/index.aspx. The AAA Foundation for Traffic Safety researched and gathered the Driver Licensing Policies and Practices data from all 50 states. The database also has descriptions of noteworthy initiatives as related to medically at risk drivers and older drivers. http://lpp.seniordrivers.org/lpp/index.cfm?selection=visionreqs The American Occupational Therapy Association has website information on their website designed specifically for consumers and their caregivers. It includes the role of occupational therapy, driver safety tips, evaluation and assessment, how to get help, and other topics. Website: http://www.aota.org/Practice/ProductiveAging/Driving/Clients.aspx The Hartford Insurance Company has website information that include driving safety, car maintenance, and older driver safety. Their materials can be downloaded or sent in the mail. Link: http://hartfordauto.thehartford.com/Safe-Driving/CarSafety/Older-Driver-Safety/driving-wellness.shtml AARP has the well known Driver Safety Programs for older adults as well as a wealth of resources on their website, including the CarFit program, and We Need to Talk. http://www.aarp.org/home-garden/transportation/driver safety/ The AAA Foundation for Traffic Safety maintains a website of resources for older drivers, families, researchers, and providers. It offers (1) general safe driving information, (2) free online self-assessments to measure driving skills and needs, and (3) education and training resources. http://lpp.seniordrivers.org/home/
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