DriveWise®: Lessons learned
from a hospital based driving
clinic
Margaret O’Connor PhD/ABPP
Beth Israel Deaconess Medical Center
Harvard Medical School
Driving: A Right or Privilege?
• Most pervasive marker of self esteem
• American culture “in love” with the
automobile; the car is celebrated in song,
art, movies, music
• Well defined entry but no system to exit
Mandatory Vs. Voluntary Reporting
• Most states - voluntary
• Oregon, CA, Utah, and PA mandatory
reporting dementia
• 30 states -immunity to physicians
MASS RMV
• Reporting Procedures
– Self reporting state: driver’s responsibility
– MDs not mandated but encouraged
• No Immunity or Legal Protection
• RMV Follow Up
– If general public, medical clearance requested
– If MD or law enforcement- imminent threat
voluntary surrender in 10 days
• Anonymity not guaranteed
– Person must file written request for identification of reporter
THE OVER 90 CROWD
Hollis, Lee, Kapust, Phillips, Wolkin & O’Connor (2013)
• 88 patients 27 (90-97); 61 (80-87)
• Drivers age 90+ at no greater driving risk
than those 10 years younger
• Made similar types and frequency of on
road errors
• Age, in and of itself, does not predict poor
driving!
Which Lobes are Key For Driving?
Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352:
692-9
Does Age Or A Diagnosis Of Dementia
Preclude Safe Driving?
• Procedural memory ages well
• Heterogeneity in dementia
• Let’s be fair: balance autonomy and safety
• Does the driving risk for mild dementia
exceed the crash rate of 16-19 year old
males?
• Need for evidence based solutions…gives
the patient their “day in court”
American Academy of Neurology
Practice Parameter
(Dubinsky et al., 2000)
• One Class I and several Class II studies:
increased crash risk in AD
• CDR 0.5 risk ~ 16-19 yo or BAC <.08%
• CDR 1 - greater than society tolerates
• CDR of 1 - discontinue driving (Standard)
• CDR of 0.5 – driving exam (Guideline)
• Reassessment every six months (Standard)
STEP 4: Rating Dementia Severity
Predictive Screening Tests
MMSE <24 - unsafe (Odenheimer, 1994; O’Connor et al, 2010)
>24 - not signficant (DeRaedt 2001; Grace et al. 2005)
MoCA <18 - unsafe driving (Hollis et al, 2014)
TMTB - 3 X 3 rule versus 180”
TMTA > 50”; TMTB > 126” (Duncanson et al., 2015)
Errors - TMTA - NS; TMTB = 3 (Duncanson et al., 2015)
Clinical Dementia Rating Scale (CDR)
Brown et al., 2005: 46% CDR 0.5,41% CDR 1 passed
Limitations: Outcome Measures
• Crash rate: low frequency event, under
reporting (memory loss, less citations)
• Simulator studies: expensive,
cumbersome, motion sickness
• Road tests: subjective, limited driving
(no hazardous situations, etc)
DRIVEWISE
Beth Israel Deaconess
Medical Center
Division of Cognitive Neurology
Beth Israel Deaconess Medical Center
617- 667- 4074
Driving Assessment Process
Referral
Social Work
Evaluation
Occupational
Therapy
Evaluation
Road
Evaluation
Team
Meeting
Feedback
Session w/
Social Work
Who are the clients?
• Over 700 individuals tested over 15 years
• Patients with underlying medical, cognitive
or psychiatric problems that may impair
driving safety
• A range of diagnoses: Alzheimer’s disease,
MS, Parkinsons, ALS, Stroke, post ECT,
bipolar, orthopedic problems, brain tumors
• Ages: 17-97
Demographics
Breakdown by Age
95-99 yrs
1%
85-89 yrs
14%
17-25 yrs 30-39 yrs 40-49 yrs
1%
2%
4%
90-94 yrs
6%
50-54 yrs
3% 55-59 yrs
3%
60-64 yrs
7%
65-69 yrs
9%
80-84 yrs
19%
70-74 yrs
12%
75-79 yrs
19%
The Social Work Assessment
• Sign consent form
• Take psychosocial/driving history
• Begin to anticipate negative consequences
• Administer MoCA; complete 4C’s
• Set up feedback session at which time
good/bad news delivered in detailed letter
Montreal Cognitive Assessment
(MoCA)
• Visuospatial/executive,
naming, memory,
attention, language,
abstraction &
orientation
(Nazzredine et al, 2005)
THE 4 C’S
Crash/
Citation
(family)
Concern
(family)
Clinical
Status
Cognition
(family)
1
No Crashes None
Good health
Intact
2
1+ fender
bender
Mild
concern
Mild
medical
Mild
decline
3
Major
Citation
Moderate
concern
Moderate
medical
Moderate
decline
4
Crash(es)
Extreme
concern
Severe
medical
Severe
decline
Occupational Therapy Evaluation
• Three key domains of driving are assessed
• Vision
• Cognition
• Physical Function
•
Standardized On Road Evaluation
Vision Testing
• Visual acuity- 20/40 or better,
– Daytime only restrictions available
• Visual Field- 120 degrees of lateral field at
eye level
• Tracking
• Depth perception
• Contrast Sensitivity
Mini-Mental State Examination
(MMSE)
• Orientation,
recognition,
calculation, recall,
and language
Folstein MF, Folstein SE,
McHugh PR., 1975
MMSE
MoCA vs MMSE
in the prediction of driving test
outcome
• 92 adult drivers
• Neither test predictive for cognitively intact
• For dementia MoCA was a better predictor
• As MoCA score decreased by 1 point,
person was 1.36 times more likely to fail
• MoCA ‘cut score” of 18 or less
Useful Field of View Test
• Measures the size of the visual field in
which one can process rapidly presented,
increasingly complex information with a
single glance
• Relies on cognitive function as well as
visual function
Useful Field of View
Test (Ball et al, 1988)
Test 1 Measures speed
identifying
a single object.
UFOV Test 2
Measures speed dividing attention between two
objects.
Trail Making Tests
• Sensitive to divided
attention
• Divided attention is
known to be important
for safe driving
Reitan, 1955
Trail Making Test Part B
Physical Assessment
• Strength and range of motion
• Coordination
• Sensation
• Functional control
• Mobility
• Brake reaction time
On Road Evaluation
• The ‘gold standard’ for assessing driver safety
• Standardized assessment based on the
Washington University Road Test - presents a
variety of driving challenges (Hunt et al, 1997)
• OT and CDI both separately score driving
performance
• Evaluation is only a ‘snapshot’ of driving
On Road Evaluation
• Starting and securing the car
• Following instructions and road signs
• Visual awareness
• Positioning & lane control
• Maneuvers
• Responding to obstacles & situations
• Speed control
• Problem solving
Outcomes of the Evaluations
• Individuals can either pass, fail, or be
referred for remediation.
• The decision was not made for a handful of cases.
By Gender
Overall Results
120
Pass
Fail
Remediation
Unclear
1%
16%
39%
Female
80
44%
Male
108
100
94
71
63
60
40
32
33
20
1
4
0
Pass
Fail
Remediation
Unclear
Breaking Bad News Techniques
• Enlist family support
• Take time and allow for silences
• Focus on history of resilience
• Define independence broadly
• Focus on actual driving errors
• Discuss safety for self and others
• Medicalize the problem
• Monitor for mood changes
Driving Cessation
• Older adults who have relinquished their license
make fewer trips and engage in fewer activities
• They experience greater health problems, including
a higher incidences of depression
• Although rides may be available, ‘discretionary
travel’ for social and recreational needs is often
reduced
• Family members struggle to ‘pick up the slack’
(Sutts & Wilkins, 2003; Perkison et al, 2005).
Transportation Alternatives
• 73 % of U.S. adults age 65+ live in areas with
little or no access to public transportation; 30%
live alone
• In urban areas adults over 65 make only 6% of
trips by mass transit and less than 1% by taxi
• Public transportation is often inaccessible to
those older adults with mobility or memory
impairments.
(Taylor, & Tripodes, 2001).