Driving+Safety+and+the+Elderly+Diagnosis

- Anonymous
  In 2005, 11% of fatal crashes involved drivers at least 65 years old. Road safety analysts predict that by 2030, all baby boomers will be at least 65 and they will be responsible for 25% of all fatal crashes. (6) “According to a study by Carnegie Mellon University and the AAA Foundation for Traffic Safety, from ages 75 to 84 the rate of about three deaths per 100 million miles driven is equal to the death rate of teenage drivers. For drivers 85 and older, the fatality rate is nearly four times higher than that for teens.” (6) The U.S. Census Bureau projects there will be 9.6 million people 85 and older by 2030, which is a 73% increase from 2007. (6) Elderly drivers in car crashes are more likely to suffer more serious injuries. Drivers aged 70-74 years of age are twice as likely to die in car accidents compared to drivers aged 30-59 years of age. (5) Even more so, drivers over the age of 80 are five times as likely to die due to injuries sustained in car accidents.

In Kansas, individuals over the age of 65 are required to renew their license every 4 years. A visual screening test is performed as well as an open book examination. Based on the results of these two components, drivers are either granted or denied a renewal. Certain restrictions can be placed on individuals such as only driving from sunrise to sunset or prohibiting from driving during rush hour. (9) Many adults continue to drive despite impaired ADLs, decreased strength, and advancing age. (3) Ideally, older citizens would be screened more extensively than what the DMV requires. Assessment of safe driving in the elderly should include visual, cognitive, and motor testing done by either a physical therapist or a physician. (1)

It should be the responsibility of primary care physicians to evaluate older drivers. The following study addressed physician-perceived barriers to assessing older drivers in their practice. Two major themes that emerged from this study were that physicians do not want to be held liable for the results of driving-related screening, and they are concerned about patients reacting unfavorably to the results of a driving assessment and cognitive tests. Most importantly, “physicians uniformly agreed that a protocol to guide driving assessment would be useful.” Establishing a single protocol as a standardized objective measure would keep physicians from having to make a decision about the road safety of their patients. This would prevent physicians from being held liable for their screening and help avoid upsetting patients over the subjectivity of their decision. ([]) (7)

Safe Driving Factors affected by age (5)
 * * = can be assessed by PT
 * Cognitive Abilities
 * Visual Acuity
 * Reaction time/Motor Speed*
 * Physical Strength/Endurance*
 * Medical Conditions
 * Flexibility*

As physical therapists, we can play a role by conducting the motor components. Motor portion of testing should include (1) 1. Joint Motion/Function 2. Muscle Strength 3. Coordination

>> {Found to be a relative risk for crashes (5)} >>
 * 1. ROM Joint Testing: = Must be WFL (2)**
 * Neck rotation
 * For looking side to side
 * {Found to be a relative risk for crashes (5)}
 * Finger Curl
 * Steering
 * Shoulder Flex
 * Reaching the steering wheel
 * Elbow Flex
 * Steering
 * Ankle Dorsiflexion
 * Need ROM for acceleration/deceleration
 * Ankle Plantarflexion
 * Need ROM for acceleration/deceleration

//**Example of ROM testing for Ankle:**// media type="youtube" key="prcK_1oh0-U" height="390" width="640" http://www.youtube.com/watch?v=prcK_1oh0-U


 * 2. Muscle Testing: = Must Score 4/5 (2)**
 * Shoulder
 * Adduction
 * Steering
 * Abduction
 * {No significant correlation w/ crashes (5)}
 * Steering
 * Flexion
 * Steering
 * Wrist
 * Flexion
 * Steering
 * Extension
 * Steering
 * Hip
 * Flexion
 * Using pedals
 * Extension
 * Using pedals
 * Ankle
 * Plantarflexion
 * For acceleration/deceleration
 * Dorsiflexion
 * For acceleration/decleration
 * Hand Grip Strength
 * For grip of steering wheel
 * {No significant correlation w/ crashes (5)}

//**Example of Strength testing for Lower Extremity**// media type="youtube" key="ECG2URRVSQ8" height="390" width="640" http://www.youtube.com/watch?v=ECG2URRVSQ8


 * 3. Coordination-Bruininks Motor Ability Test (BOTMP for adults)**

BMAT components include:
 * Fine motor integration
 * Manual dexterity
 * Coordination
 * Balance and Mobility
 * Strength and Flexibility

media type="youtube" key="OoLVGbFlMnk" width="425" height="350"

http://www.youtube.com/watch?v=OoLVGbFlMnk&feature=player_embedded

After the assessment is done, the patient is given a fine motor, gross motor and total motor score. (8)

>>>
 * Functional Measures relating to risk of motor vehicle accidents:**
 * Falls
 * Found to be correlated with a high risk of crashes (5)
 * This was found using quantitative gait markers in a study by Verghese et al. that assessed fall risk. The study showed that in the fully adjusted model, slower gait speed was associated with a higher fall risk. Other indicators for fall risk were worse performance on swing, longer periods in double support, swing time variability, and stride length variability. (10)
 * These associations remained significant even after accounting for cognitive impairment and disability, which would both independently affect one’s driving ability.
 * Self-reported impairment of ADL's


 * Other Screenings that should be considered for elderly populations:**


 * 1. Multitasking & Driving Ability: impact of visual and auditory secondary tasks**
 * According to Friedman et al., a study of drivers 70 years of age and older reported that assessing higher order visual processing skills (combination of 3 different paper and pencil tests) was significantly associated with motor vehicle involvement (11).


 * Wood et al. conducted a study which simulated multitasking and visual impairment and measured driving performance based on road sign recognition, detection and avoidance of low-contrast hazards, gap judgment, and time to complete the course.
 * Driving with two levels of visual impairment was compared against a baseline condition:
 * Goggles designed to replicate the effects of cataracts or blur
 * Goggles were used to reduce binocular visual acuity to a mean level of 20/40.
 * Secondary tasks required participants to add orally pairs of numbers presented through a computer speaker (auditorily) or via a dashboard-mounted monitor (visually).
 * Results indicated that multitasking impairs driving performance and the effects are exacerbated for older and younger drivers with visual impairments (i.e. cataract conditions) (12).


 * Cataracts - Curious Cat! (13)






 * 2. Executive Function and Effect on Driving Performance**

Aging is associated with a decline in many cognitive abilities that are relevant to performing complex tasks such as driving. This includes:

1) Decline in selective attention, divided attention, sustained attention and switching attention
 * ===== Driving in traffic requires the ability to pay attention to necessary information, but also to ignore irrelevant information in complex visual situations. For this reason, speed at which visual information is processed is an important factor for driving safety. =====
 * ===== Adequate reaction times are also crucial for avoiding collisions. =====

2) Decline in Executive Function (shown by neuroimaging studies showing age-related changes in the prefrontal cortex)
 * ====== Executive function is necessary for integrating information and planning a response. ======
 * ====== Crashes in which older adults are involved in generally happen in complex traffic situations (intersections), possibly due to this decline in executive function. ======

3) Physical frailty and medical conditions may also put older adults at risk of unsafe driving

Driving and Dementia : with the increasing age of the American population, the proportion of older drivers on the road is also rising. Given that age is the most significant risk factor for developing dementia, it is apparent that large numbers of licensed drivers in North America are demented or are likely to become demented. Studies have shown that the driver with dementia is at increased risk to cause traffic accidents. In a literature review by Brown, they took a look at individuals with dementia’s ability to drive an automobile. They identified several factors that might be useful in differentiating people with dementia who are able to safely operate an automobile from those who are not. - These factors include:
 * =====Duration and Severity=====

Risk rates of causing an accident while driving increase dramatically after year 3 of disease progression.

 * =====Sex=====

Male sex and associated arthritis were found to increase risk of driving accidents or violations◦

 * =====Patient self assessment=====

Patients with dementia are generally not good predictors of their own driving ability due to having little insight into their skills.

 * =====Family assessment=====

Brashear and colleagues developed a 12 question survey related to family caregivers regarding diving impairments in patient

 * =====Neuropsychological measures=====

=
45 minute road test using a closed course and in traffic components. Using an on-road evaluation it is able to correlate performance in traffic to cognitive test scores on MMSE, visual memory, and traffic sign recognition tests; however, no correlations are found with simple reaction time.=====
 * =====Driving simulator testing=====

=
Using a driving simulator to assess driving skills while maintaining the safety of the patient, testers, and the community. Even though they are often fairly expensive to purchase, once obtained they become a more cost effective way to assess abilities than on-road evaluations.=====

=

 * There is currently no “gold standard” for assessment of risk in patients with dementia and the on-road and driving simulator testing may cause more anxiety and may not reflect a person’s true ability. There is also research that states the elderly population is less comfortable with the electronic driving simulator and would perform better with their own car that they are comfortable with (14).=====

4) Reductions in grip and muscle strength and endurance, flexibility and motor speed (5).

 * W****hen creating diagnostic tool for determining if an elderly individual is safe to drive or not, t****he following 5 criteria: ROM, strength, coordination, multitasking ability, and executive function should be considered. Due to differences among individuals, the 5 criteria should be synthesized into an overall score, which could then be utilized across the population. At this time, the weight of each of the 5 criteria is unknown. Additionally,** **it is important to consider the psychosocial aspects of driving; an individual could be become severely depressed or isolated after a license is revoked.**
 * Inter-professional collaboration would also be required for the diagnostic tool to be effective.**

Active Links

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10.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709543/

11.http://www.ncbi.nlm.nih.gov/pubmed/23307969

12. []

13.http://www.nei.nih.gov/eyedata/cataract.asp

14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292210/

Citations

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2. Linda Hill, Jill Rybar, Sara Baird, Susanna Concha-Garcia, Raul Coimbra, Kevin Patrick, Road safe seniors: Screening for age-related driving disorders in inpatient and outpatient settings, Journal of Safety Research, Volume 42, Issue 3, June 2011, Pages 165-169, ISSN 0022-4375, 10.1016/j.jsr.2011.05.005. Retrieved from []

3. J. L. Mathias and L. K. Lucas (2009). Cognitive predictors of unsafe driving in older drivers: a meta-analysis. International Psychogeriatrics, 21, pp 637-653. doi:10.1017/S1041610209009119. Retrieved from []

4. Carr, D. B., Flood, K. L., Steger-May, K., Schechtman, K. B. and Binder, E. F. (2006), Characteristics of Frail Older Adult Drivers. Journal of the American Geriatrics Society, 54: 1125–1129. doi: 10.1111/j.1532-5415.2006.00790.x Retrieved from []

5. Kaarin J. Anstey, Joanne Wood, Stephen Lord, Janine G. Walker, Cognitive, sensory and physical factors enabling driving safety in older adults, Clinical Psychology Review, Volume 25, Issue 1, January 2005, Pages 45-65, ISSN 0272-7358, 10.1016/j.cpr.2004.07.008. Retrieved from []

6. Davis, R. (2007, 05 02). Older, dangerous drivers a growing problem. USA Today. Retrieved from http://usatoday30.usatoday.com/news/nation/2007-05-02-older-drivers-usat1a_N.htm. Retrieved from []

7. Bogner, H. R. (2004). The role of physicians in assessing older drivers: barriers, opportunities, and strategies. J Am Board Fam Med, Volume 17(Number 1), 38-43. doi: 10.3122/jabfm.17.1.38 Retrieved from []

10. Verghese, J. (2009). Quantitative gait markers and incident fall risk in older adults. //J Gerontol A Biol Sci Med Sci//, //Volume 64A//(Issue 8), 896-901. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709543/

11. Friedman, C. (2013). Association between higher order visual processing abilities and a history of motor vehicle collision involvement by drivers ages 70 and over. // Invest Ophthalmol Vis Sci. //, // Volume 54 // (Number 1), 778-82. doi: 10.1167/iovs.12-11249. http://www.ncbi.nlm.nih.gov/pubmed/23307969

12. Transportation Research Board of the National Academies (2007). how multitasking interacts with visual impairment and age on measures of driving performance. // Transportation Research Record: Journal of the Transportation Research Board //, // Volume 1980 // , 65-69. doi: 10.3141/1980-11 []

13. National Eye Institue. (2012). // Cataracts //. Retrieved from http://www.nei.nih.gov/eyedata/cataract.asp http://www.nei.nih.gov/eyedata/cataract.asp

14. Brown, L. (2004). Driving and dementia: A review of the literature. // J Geriatr Psychiatry Neurol. //, // Volume 17 // (Issue 4), 232-240. doi: 10.1177/0891988704269825 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292210/