Assessment Group: Discussion and Unresolved Issues

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Assessment Group Discussion and Unresolved
Issues
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An assessment flow
Why? Identify drivers with functional changes
that may compromise personal or public health or
safety
Why? Identify individuals who may benefit from
prevention, education, remediation
Who? Many different sources of screening and
referral (self, family, law enforcement, DMV,
other agencies, health care professionals, driver
rehabilitation specialists, driver educators,
community-based agencies and groups, etc, etc)
What? Tier One Brief screening of cognitive,
motor, sensory and health/medication functions.
The form of Tier 1, and its next steps, are
contingent on who does the assessment.
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An assessment flow
What? Tier One Brief screening of cognitive,
motor, sensory and health/medication functions.
The form of Tier 1, and its next steps, are
contingent on who does the assessment.
At each tier, there should be appropriate
referrals
What? Tier Two In-depth assessment of
cognitive, motor, sensory and health/medication
functions, personality/motivation/awareness. The
next steps, are contingent on who does the
assessment. Often done with Tier 3.
What? Tier Three Behind the wheel assessment
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Candidate measures

• The domains that follow in red come from the
  NHTSA/AAMVA recommendations
• A goal is that a battery should be evidence-based
  (with regard to its predictiveness of driving
  performance, which could include crashes,
  on-the-road driving errors, or other performance
  measures).
• There are alternative pathways.
• One approach focuses less on specific domains,
  but tries to include a battery whichin
  combinationmaximizes predictive salience.
• A second approach tries to represent multiple
  domains. This will be more useful for making
  rehabilitation recommendations and identifying
  the sources of problems.
• The two approaches are not mutually exclusive.

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Tier 2 Candidates Cognition
Domain Candidate measures Notes
Mental Status Mini-Mental Status Examination Telephone Interview for Cognitive Status Does it make sense to separately predict driving for demented and non-demented elders? Where does MCI fit in? TICS has wonderful advantages, including phone plus better memory than MMSE.
Divided Attention Trails A B Useful Field of View Trails is widely used, and AMA recommended UFOV is predictive and trainable, but equipment intensive.
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Tier 2 Candidates Cognition
Domain Candidate measures Notes
Perceptual Speed/Visual Search Letter Cancellation Task Digit Symbol Substitution Task Trails Does this add anything beyond the speeded Divided Attention Tasks?
Reaction Time Complex Reaction Time (e.g., Doron There is no shortage of CRT tasks. Again, these generally require a computer Doron is driving stimulus-specific. Is a simulator (not portable) a better choice?
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Tier 2 Candidates Cognition
Domain Candidate measures Notes
Judgment/ Decision Making RoadSmart Judgment Test Driver risk inventory We have not seen this measure, but it is referenced, and raises the intriguing prospect of domain-specific reasoning. Is there room for basic reasoning measures here, like Inductive Reasoning?
Episodic Memory Hopkins Verbal Learning Test Telephone Interview for Cognitive Status TICS phone-admin., but picks up memory well is this really a screen for impairment?
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Tier 2 Candidates Cognition
Domain Candidate measures Notes
Working Memory Digit Span Task (consider also Delayed Memory) Again, does this add anything meaningful beyond divided attention tasks? Are better working memory tasks to be used?
Driving Knowledge Rules of the Road Test Traffic Signs Test Cognitive science tells us that in expert domains, the best predictor of performance is domain-specific knowledge this is also an assumption of state-level licensing programs
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Tier 2 Candidates Cognition
Domain Candidate measures Notes
Spatial ability Block Design MVPT (horizontal) Is this too domain-general? Is a specific map-reading task more meaningful?
Visualization of missing information Visual closure subtest of MVPT Taps into ability to generate expectancies about impending visual threats?
Complexity/situa-tion awareness (not a domain. . belongs in the flow elsewhere) DriveABLE CA/ MD(GrimpsUFOV2) Model Are these the Tier 1 measures?
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Tier 2 Candidates Sensory
Domain Candidate measures Notes
Proprioception Foot tap time Simulator? Brake reaction time Face validity with moving foot from gas to break pedal
Cutaneous sensation (pressure on sole of foot) Semmes Weinstein? Pressure and localization sensation test? Evidence?
Pain Jette McGill VAS Association with back pain and vehicle crashes Disability specific pain (Arthritis)
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Tier 2 Candidates Sensory Vision
Domain Candidate measures Notes
Oculomotor Control Manual assessment Subjective Typically an issue in neurologically involved drivers, not older adults
Visual Fields Perimetry testing with Humphrey or Goldmann Confrontational field testing may be sufficient Identifies blind spots and other visual field disturbances but does not indicate an impact on driving or if driver compensates
Visual Acuity Wall charts Automated testing machines Identifies ability to visually decipher the environment Determines if driver meets state vision guidelines Predictability of crashes? Dynamic visual acuity not measured
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Tier 2 Candidates Sensory Vision
Domain Candidate measures Notes
Depth / Stereopsis (For the newly monocular) Optec Keystone Porto Clinic Stereo Fly Stereopsis is a binocular skill cant measure monocular drivers In most vision testing machines Connection to crashes?
Color Recognition Optec Keystone Porto Clinic Included in most vision testing machines Connection to crashes?
Contrast Sensitivity F.A.C.T. Pelli Robson Chart Regan Low Contrast Letter Acuity Chart Vision batteries Linked to driving performance and crashes
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Tier 2 Candidates Sensory Visual Motor
Domain Candidate measures Notes
Visual Motor Test of Visual Motor Skills (TVMS-R) Bender Visual-MotorGestalt Test Rey-Osterrieth Complex Figure Test Evidence linking assessment performance to driving performance?
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Tier 2 Candidates Motor
Domain Candidate measures Notes
Range of motion Knee flexion Cervical rotation, flexion, extension, lateral bend (head-neck flexibility) Trunk rotation dorsiflexion Upper extremity Limited L knee flexion associated with adverse events. Limited evidence of correlation with driving performance for cervical, UE and trunk ROM. Older impaired drivers gt risk at T-intersections
Strength (Leg strength especially) Grip Pinch? Manual muscle testing Functional grasp association with crash involvement. Which muscle groups?
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Tier 2 Candidates Motor
Domain Candidate measures Notes
Gross Mobility Rapid Pace Walk Get up and go test Number of blocks walked Foot abnormalities Fall history Association with falls and vehicles crashes Adverse driving events and distance walked Redundancy with balance and proprioception assessment?
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Tier 2 Candidates Sensorimotor
Domain Candidate measures Notes
Balance (dizziness) Romberg Berg Balance Scale Tandem Stand Side-to-side stand Single leg stand Smart Equitest Sitting balance Complete Romberg or segments? Association with weighted error score for tandem stand. History of falls associated with vehicle crashes Neurocom Equitest assessment (Quantify/train or cost prohibitive)?
Reaction Time Foot reaction time (brake) - Doron? Association with increase vehicle crashes among women
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• Behavior, Personality, Beliefs Driver Risk
  Assessment (risk taking), impulsivity, empathy,
  aggression, cautiousness
• Depression
• Mania

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Unresolved issue The Criterion Problem

• By which criteria should we evaluate the
  predictive salience of our battery?
• Accidents?
• Simulator?
• Field driving tests?
• Standardized driving courses?
• Subjective driving evaluations?
• Is the more sensible goal the multidimensional
  assessment of different aspects of driving?

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Unresolved issue Measurement selection

• There is a wide variety of studies
• Few multidimensional studies in which measures
  evaluated simultaneously
• Great variation in dependent variables used
  across studies
• It seems important to first identify demented
  individuals different prediction equations
  likely for non-demented elders more likely to
  predict subtle driving errors

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Unresolved issues Cognition

• Should we do a gross check for dementia, and
  triage such individuals out of further
  assessment? Or do we need tests like Clock
  Drawing (special Freud scoring),
  Cognitive-Linguistic Quick Test, Boston Naming,
  Wechsler Memory Scale, WAIS Picture Completion
• Some commonly used tests seem redundant with what
  we have shown (Stroop, Minnesota Rate of
  Manipulation, AARP Reaction Time)
• Interesting dimensions not commonly studied,
  including Motor-Free Visual Perception Test,
  Unilateral Neglect

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Unresolved issues Sensory

• Is there a better proprioception test for the
  lower extremity?
• What amount of pressure is needed for breaking?
• Should pain assessment be used and if so, which
  pain assessment is the most appropriate?

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Unresolved issues Motor

• Should all ROM measurements be functional rather
  than exact?
• Should upper extremity ROM be tested?
• Should MMT be done on lower extremity muscle
  groups (such as knee extension) and if so, should
  it be quantified with hand-held dynamometry?
• If we were to choose one gross mobility test
  only, which is the best?

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Unresolved issues Sensorimotor

• Should a balance (dizziness) test be used?

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Unresolved issues

• Who is screened? (everyone? just at risk
  drivers? just older drivers?)
• Who screens? (what kind of training is needed?)
• Who pays? (what is the estimated cost, and what
  are some possible sources of funding?)
• What are the legal implications? (what supportive
  policy/legislation is needed?)