FitnesstoDrive in Persons with Dementia

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Fitness-to-Drive in Persons with Dementia

• Dr. Anna Byszewski
• Dr. Bill Dalziel
• Dr. Frank Molnar
• Regional Geriatric Program of Eastern Ontario
• City Wide Rounds
• April 18, 2008

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Objectives

• To describe the scope of the problem of unfit
  drivers that will impact on the medical system
• To highlight the complexity of the assessment of
  fitness to drive
• To provide practical approaches for assessing
  fitness to drive in persons with dementia
• To discuss how to manage difficult reactions when
  people are told they are not safe to continue to
  drive.

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Projections
Source LÉcuyer et al. (2006). Transport Canada
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A Major Public Health Concern

• When involved in a crash, seniors are over 4
  times more likely to be seriously injured and
  hospitalized than are drivers 16-24 years of age.
• Treatment of injuries to seniors is more costly,
  recovery slower, less complete.
• Majority of crash-injured seniors were driving
  the vehicle.
• Most (3 of 4) crashes involving older drivers are
  multiple vehicle crashes.

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It is Not Age

• Medical conditions and medications are the
  primary cause of declines in driver competence.
• Can make even the best of drivers unsafe to
  drive.
• Can affect drivers of any age Increasingly
  likely as we age.
• Not presence but severity and/or instability of
  conditions /- high doses and/or changing doses
  of medications
• Medical community best placed to first recognize
  possibly impairing medical conditions.

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Increased Risk of an At-Fault Crash
7.6
5.0
5.0
Risk of an At-Fault Crash
2.8
3.0
2.5
2.1
2.2
1.8
Epilepsy
Psychiatric
Pulmonary
Diabetes
Visual Acuity
BAC .08
Cognitive
Neuological
Cardiovascular
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Assessment of Fitness-to-Drive

• DEMENTIA DRIVING
• The Facts

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The Scope of the Problem

• Hopkins

2.5 of the elderly are DDs (demented drivers)
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Take Home Message

• The diagnosis of dementia does not automatically
  mean no driving
• The diagnosis of dementia does mean
• You must ask if the person is still driving
• You must assess and document driving safety and
  follow your provincial reporting requirements

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Dementia and Driving

• Consensus statements
• Swedish (1997)
• Australian Geriatrics Society (2001)
• American Academy of Neurologists (2000)
• AMA and Canadian Medical Association guidelines

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Dementia and Driving

• Conclusions of Consensus statements (cont)
• Recognize limitations of data
• those with moderate to severe dementia should not
  drive (CMA Moderate 1 ADL or 2 iADLs impaired
  due to cognition)
• individual assessment for those with mild
  dementia
• periodic follow-up is required (every 6 - 9
  months)
• gold standard is comprehensive on-road
  assessment

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Expert / Consensus Guidelines

• Limitations of Guidelines
• Based on expert opinion recommend tests such as
  MMSE, Clock Drawing, Trails B
• Do not provide guidance regarding HOW physicians
  are to apply such tests (e.g. how to respond to
  different scores, what cut-offs to use )

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2 Practical Approaches

• Dr. Dalziel
• The 15 Minute Driving Evaluation
• Dr. Byszewski
• Driving and Dementia Toolkit

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Dr. Bill Dalziel

• The 15 Minute Driving Evaluation
• (not evidence based)

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Case Study

• An 80 year old male with BP 165/85 and no
• family history of dementia
• Still driving
• No obvious cognitive problems
• Do you screen this type of patient ALREADY?
• Question 2 IS HIS RISK OF DEMENTIA
• 5
• 10
• 15
• 25
• Over 25

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The Doubling Rule (Think 2) For Dementia Risk

• Risk Doubles every 5 years of age.

• But each additional risk factor approximately
  doubles the risk

• ve family history
• doubles the risk.

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Dementia Quick Screen 2 Minutes

• 3 item recall (0-1 correct OR 3.1)
• Animals in 1 minute (lt15 OR 20.2)
• Clock drawing (abnormal OR 24)

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The Decide Study

• National screening study for cognitive impairment
  (CI) over 1500 65 patients of family
  physicians (FP)
• Entry criteria
• Age 65 and over
• 2 or more vascular risk factors
• FP felt patient had NO CI
• Screening tests Animal fluency/MOCA
• Results
• Animal fluency score lt15 52
• MOCA score lt 26 56
• At end FP felt ve CI 43

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• The 10 Item Quick Dementia and Driving Checklist
  (10-15 minutes)
• not evidence based

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Case History

• Mrs Brown is a married 78-year-old woman, healthy
  except for mild arthritis and hypertension
  controlled with HCTZ 25 mg qd. Her husband
  reports that he has seen some forgetfulness in
  his wife, slowly worsening over the last year
  with some irritability, apathy and disinhibition.
  
• She has had trouble with shopping and remembering
  to take her HCTZ. She continues to drive
  occasionally, and has no recent accidents or
  tickets. Her mother had memory troubles in her
  70s.

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Case History
MMSE 24/30 MOCA 19/30 Dx Mixed AD/VAD
Driving ? ? Safe _______ ? ? Unsafe______ ??
Unsure ________
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The MMSE and Driving Capacity

• There is questionable correlation between driving
  safety and the MMSE.
• Functional abilities (IADLs) are better
  correlated.

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The MMSE and Driving Capacity

• It is critical to emphasize that driving capacity
  depends on a GLOBAL CLINICAL PICTURE
• including cognition, function, physical
  abilities, medical conditions, behaviour, and
  driving record and circumstances.
• The MMSE (when adjusted for age and education)
  can provide a rough framework for assessing
  driving safety. Patients scoring under 20 are
  likely unsafe to drive.

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10 Item Quick Dementia and Driving Checklist

• Type of Dementia
• FTD unsafe (disinhibition/judgement)
• LBD unsafe (hallucinations/fluctuations)
• AV, VAD, Mixed AD/VAD are safer types of
  dementia

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10 Item Quick Dementia and Driving Checklist

• Severity
• Generally, functional losses stratify severity
  better than MMSE (very mild is likely safe, mild
  is likely unsafe)
• Very mild generally involves only mild losses,
  e.g., problems with 1 (not more) instrumental
  activities of daily living (IADLs) (i.e., SHAFT)
  or MMSE 24 (education gtgrade eight)
• S Shopping
• H Housework
• A Accounting finances
• F Food preparation
• T Transportation (some patients with mild
  dementia may still be safe to drive)

Also laundry, small machinery and use of
telephone
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10 Item Quick Dementia and Driving Checklist

• Family Concerns (? In car lately?)
• Collisions and/or damage to the car
• Getting lost
• Needing a co-pilot
• Near-misses with vehicles, pedestrians
• Confusing the gas and brake
• Traffic tickets
• Missing stop signs/lights stopping for green
  light
• Right of way problems
• Not observing during lane changes/ merging
• Others honking/irritated with the driver

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10 Item Quick Dementia and Driving Checklist

• Driving PEARL

The Granddaughter Question
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10 Item Quick Dementia and Driving Checklist

• Significant visuospatial problems poorly done
  intersecting pentagons/number placement on clock
  drawing, etc.
• Reaction time (dropping a 12 ruler between
  thumb and index finger usually caught by
  maximum of 9 or so)

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RED FLAGS - Behavioural Issues

• Delusions
• Disinhibition
• Hallucinations
• Impulsiveness

• Agitation
• Anxiety
• Apathy
• Depression

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10 Item Quick Dementia and Driving Checklist

• Poor judgment/insight e.g., what would you do
  if fire in neighbours kitchen, approaching
  yellow light, understanding driving with dementia
  is a risk

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10 Item Quick Dementia and Driving Checklist

• Trails A and B tests of visuospatial, executive
  function, attention and speed of processing
  (generally failed by failing to understand
  concept of test or by making errors, not by
  exceeding time limit)

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Trails A
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Trails B
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Trails A B
Trails A and B are tests of memory, visuospatial,
attention and executive function. Any errors or
scoring below the 10th percentile in the time
taken raises concerns about driving safety.
Norms for Trails A and B by age (in seconds) and
education
Trails A performance decreases with age but is
NOT affected by education
Trails B performance decreases with age AND
with education
Although this test does help determine who should
not be driving, passing Trails AB does not
necessarily mean that the patient is safe to drive
TN Tombaugh Arch clin neuropsychol 200419.pg
203-14
(Failure error(s) or time lt10th percentile)
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10 Item Quick Dementia and Driving Checklist

• Medications that may affect driving (especially
  high doses or changing doses)

• alcohol
• benzodiazepines
• antipsychotics
• muscle relaxants
• sedating antidepressants and antihistamines
• anticonvulsants

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Reference List of Drugs with Anticholinergic
Effects

• Miscellaneous
• Flexeril
• Lomotil
• Rythmodan
• Tagamet
• Digoxin
• Lasix

• Antidepressants
• Antipsychotics
• Antihistamines/
• Antipruritics
• Antiparkinsonian
• Antispasmotics
• Antiemetics

The medications in the miscellaneous category
have been shown to have anticholinergic
properties by radioimmunoassay but are
less anticholinergic than the other medications
listed. However, they may add to total
anticholinergic load.
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10 Item Quick Dementia and Driving Checklist

• Vision/hearing
• Other medical/physical

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VaD vascular dementiaMoCa Montreal Cognitive
Assessment
Nasreddine ZS et al. J Am Geriatr Soc, 2005.
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Canadian Consensus Guidelines 2006 - Driving

• No single brief cog test that is sufficient as a
  sole determinant of driving ability (Grade B,
  level 3)
• Driving is contraindicated in persons with an
  inability to perform multiple instrumental ADLs
  or any basic ADL (Grade B, level 3)
• Driving ability should be tested on an individual
  basis a comprehensive off and on road driving
  test is the fairest method (Grade B, level 3)
• If deemed safe, reassessment every 6-12 months
  (Grade B, level 3)

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Mrs Brown Is Unsafe

• She has mild dementianot very mild dementia
• Her dementia is mixed AD/VAD
• Poor s/hands on clock/poor pentagons
• Her Trails A was slow Trails B was obviously
  impaired
• Her reaction time was very slow
• Poor neck ROM

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After Driving Assessment
Patient not safe
Uncertain safety
Patient safe
Discuss with patient and family
Discuss with patient and family
At some time driving cessation will be necessary
Provincial Ministry of Transport notification
Patient wishes to continue driving ? referral to
specialist or specialized on-road driving
evaluation
Suggest driving training and self-limitation
Patient notification (letter), copy for chart
or
Patient decides to stop driving Ministry of
Transport notification
Book six- tonine-month follow-upto reassess
driving safety
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Dr. Anna Byszewski

• The Driving and Dementia Toolkit
• Driving and Dementia Tool Kit for Family
  Physicians (Dementia Network of Ottawa-Carleton)
  at www.rgpeo.com .
• www.CanDRIVE.ca

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The Driving and Dementia Toolkit Development

• Driving Assessment has been identified as a major
  gap in dementia care by Family Physicians (FP)
  and other service providers
• Providers expressed frustration in dealing with
  this issue
• Caregivers of persons with dementia have
  identified this area as a concern

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The Driving and Dementia Toolkit

• Several Physician Focus Groups held
• Mini-task force was struck (geriatric medicine,
  neuropsychology, neurology, psychiatry,
  occupational therapy, family practice)
• Focus groups held with FPs with input from key
  older person organizations involved ( ie. AS,
  CCAC etc.)

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Toolkit Contents

• Local Resources Algorithm for Family Physicians
• General Information on Alzheimers Disease and
  Driving
• Office Assessment Strategies
• Safe Drive Checklist
• Listing of Local Resources for assessment of
  cognitive capacity
• Forms MMSE, Specialized on the road assessment
  referral forms, MOT Medical Condition Form,
  Sample Patient Letter etc.
• Filing of a Medical Report to the Ministry of
  Transportation

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www.mto.gov.on.caBill Fee Code K035
Medical Condition Report
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Case 1

• Mrs. D, an 82 year old retired schoolteacher, has
  a history of breast cancer and congestive heart
  failure (stable). She has mild cognitive
  impairment (Folstein MMSE 28/30). She enjoys one
  glass of wine daily.
• She drives to church and the local grocery store.
  She has lost her keys on occasion and has gotten
  lost in a less familiar area a couple of times.
  No history of any accidents.
• What do you do? (page 1, algorithm)
• General assessment medical history, physical
  exam, cognition (MMSE-F2,MOCA, Trails B)
• Medications and alcohol
• Ask has the family driven with her? (page 5, 6)
• If safe to drive, consider 55 Alive course
• Needs follow up (6-12 month review by FP)

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Case 2

• Mr. T has early Alzheimer disease (MMSE is
  25/30). He has had one fender bender in the last
  year. Daughter is worried. Wife thinks he is OK.
• What do you do?
• Comprehensive evaluation (page1, F2)
• History and physical exam
• Appropriate investigations
• ?Further paper based tests
• OT/neuropsychological evaluation (page 9,10)
• Specialized on the road test (F3, F4)

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Case 2 continued

• Possible scenarios
• Mr.T is deemed safe to drive
• prepare for the future, discuss alternatives,
  emphasize the MD legal responsibility (page 7)

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Case continued

• Mr. T is deemed unsafe to drive and insists on
  driving
• Notify MOT (F5)
• Write a letter for the patient stating the
  recommendations and reasons copy to patient and
  caregiver (F8)
• If Mr. T refuses to stop driving despite losing
  license
• - need to hide keys
• - disable the car
• - call police.

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The End

• Are there any other scenarios that you would like
  to discuss?
• Any other questions?
• Any other comments?