Evaluating Fitness To Drive:

The Current IssuesMedicalConditions-500


Drivers with medical conditions have a significantly increased crash risk:


The greatest increase in risk occurs when cognition is affected. However, there are a wide variety of medical conditions can affect mental abilities important for safe driving. (McCracken, Caprio Triscott et al. 2001)

Conservatively, cognitive impairment is associated with a 2 to 8 fold increase in the risk of at fault crash (Diller, Cook et al. 1998)(Carr, 1997). Other studies have shown even higher crash risk. These drivers are impaired 24 hours a day 7 days a week. To put this in perspective, a driver with a BAC of 0.08 has only a 5 fold Increase in crash risk (Kruger 2000)

In Australia, 42% of men with probable dementia and 63% with possible cognitive impairment were classified as current drivers. For women, 11% with probable dementia and 19% with possible cognitive impairment were classified as current drivers (Ross, 2009)

“57% of seniors with some medical impairment are drivers. One out of every four elderly people with serious cognitive problems has a valid driver's license, 72% of those with serious cognitive problems drive at least 3 times a week” (Bess, 1999)

“The literature shows that individuals with dementia continue to drive for approximately 4 years after the onset of symptoms. Because the average duration of dementia is about 8 to 10 years after the onset of symptoms, it appears that persons with dementia continue driving well into the disease.” (Hopkins, 2004)




An ageing population will only compound this problem


One in four people over the age of 65 currently has significant cognitive impairment: 8 % due to dementia & another 17% due to other illnesses. (C.S.H&A.W.G 1994)

This translates to 77,000 people over 65 in Western Australia alone with significant cognitive impairment and this number will only escalate as the baby boomers enter their senior years (ABS 2008).

Older driver fatal crashes are projected to increase by 155% by 2030 (Lyman et al. 2002). The health and safety of other road users are at risk because most older driver crashes involve multiple vehicles.

 


Evaluation & recommendation about medical fitness to drive is currently the responsibility of medical practitioners. However, they have not been provided with effective tools to make accurate judgements about driving abilities.


“Increasingly, the responsibility for identifying drivers with dementia has fallen on the health care system, a role for which it was never designed nor equipped to handle. The risks associated with the dramatically increasing number of drivers with dementia demand a psychometrically sensitive and efficient screening procedure.” (Hopkins et al. 2004)

“When assessing older drivers for medical fitness-to-drive, physicians are working in an ‘evidence-based vacuum’ and have to rely on subjective impressions rather than on objective measures” (Molnar et al., 2005).

Dementia is missed in 67% of cases in the primary care setting & mild cognitive impairment is missed in most (90%) of cases (Valcour, Masaki et al. 2000). If medical professionals are not identifying the problem how can they be expected to make a judgement on the degree to which it affects a persons driving?

“There are several problems inherent to relying exclusively on the favourable recommendation from a driver’s physician. First, to protect their doctor/patient relationship, physicians may feel compelled to render favourable recommendations. An unfavourable recommendation could lead to a loss of continued medical oversight by a previously trusted clinician as the client either “doctor shops” or stops seeing the physician. Second, the vast majority of physicians do not have any formal training in assessing the cognitive and physical skills that are needed to be a safe driver. (Soderstrom & Joyce, 2008)

“Physicians & neurologists lack sufficient tools to make evidence-based decisions about driving competence in the case of cognitive impairment” (Dobbs, Caprio Triscott et al. 2004)

“The standard, age-related medical examination is ineffective in identifying drivers who may be medically at risk” (Hakamies-Blomqvist and Siren 2003) (Johansson, Bronge et al. 1996).

Less than half of physicians often / always obtain a patient history of driving crashes and infractions or perform cognitive testing as part of their assessments (Jang, 2007)

The majority of medical practitioners feel that they have insufficient training to make recommendations about fitness to drive. (Jang, 2007)(Hakamies-Blomqvist, 2002) Physicians often have poor knowledge of the medical restrictions on fitness to drive & remain unclear as to which tests they are supposed to perform to determine eligibility for a licence. (Steier et al., 2003)

Austroads has developed guidelines for “Assessing Fitness to Drive”. However, there are significant limitations to these guidelines. These limitations are serious for large subsets of the driving population in need of medical fitness-to-drive assessments. Seniors provide a common example. Most seniors have not one, but several medical conditions. To compound things, seniors also typically take several prescription medications as well as several over-the-counter medications. The problem becomes apparent when you consider that the effects of any single medical condition on the person’s competence to drive may be altered dramatically by co-existing illnesses and treatments. The effects of chronic conditions combine, often in largely unknown ways, and those interactive effects are further modulated by age, medications, and other factors, to substantially alter the functional outcome for individuals beyond what it would be from an isolated illness. For seniors, this medical complexity is the rule, not the exception.

AFTD-512



Treating medical professionals often don’t want the perceived responsibility for making judgements of fitness to drive.


The Australian Medical Association's Position Statement on "The Role of the Medical Practitioner in Determining Fitness to Drive Motor Vehicles" states: "Medical assessment for fitness to drive needs to be available independently of the patient's normal practitioner to avoid the conflict situation of the caring practitioner also having to adjudicate on fitness to drive" (AMA 2008)

Health care professionals report that they do not wish to make these decisions, which have such potential to impact negatively on the general well being and mobility of their patients. Moreover, general practitioners have indicated that they need more objective tools to assess potentially at-risk drivers for referral to licensing authorities (Andrea 2001) (Charlton 2002)

75% of doctors feel that assessing patients as an unsafe driver places them in a conflict of interest and negatively impacts on the patient and the physician-patient relationship (Jang, 2007)

Alternative forms of testing available to date have been found to lack validity & can unfairly disadvantage drivers that remain competent.

“Current driving tests administered by licensing authorities have a limited ability to identify older drivers who may be a higher crash risk.”(MUARC 2000). In addition, nearly 30% of healthy, competent experienced drivers fail the standard on road tests (Dobbs, Caprio & Triscott et al. 2004). Road tests that go beyond those developed for the novice driver are more effective for the medically at-risk / older driver population (Grabowski, Campbell et al. 2004)

“Physicians commonly assume that sending patients with cognitive impairment and dementia for conventional licensing road tests is sufficient to determine fitness to drive. Unfortunately, these road tests have not been effective in revealing the driving problems of those with cognitive impairment. Undoubtedly, this is because the road tests focus on assessing basic skills which, for the experienced driver, already are highly learned. Over-learnt skills tend to be preserved when mental competence declines (McCracken, Caprio Triscott et al. 2001)

Recent Austroads studies in WA showed no statistical significance between Health Screen For Drivers, Occupational Therapist Health Rating, CALTEST & On-Road Ratings by Occupational Therapy Driver Assessor with crash risk (MUARC 2009)

Unsafe driving behaviour in Alzheimer’s Disease patients has been repeatedly shown not predictive by MMSE scores (eg. Fritelli, 2009) yet this continues to be regularly used by Australian health professionals when making fitness to drive decisions.





References

ABS (2008). Population by Age and Sex, Australian States & Territories. A. B. o. Statistics. 3201.0.

AMA (2008). The Role of the Medical Practitioner in Determining Fitness to Drive Motor Vehicles - 2008, Australian Medical Association

Andrea, D., Charlton, J.L. & Fildes, B. (2001). "Assessing Older and Disabled Drivers: Evaluation of Referral Assessment Tools and a Modified Hazard Perception."

Bedard, M., Molloy, D., Lever, J. (1998) Factors associated with motor vehicle crashes in cognitively impaired older adults. Alzheimer Disease & Associated Disorders 12:135–9.

Bess, I. (1999). Seniors behind the wheel. Canadian Social Trends (Statistics Canada Catalogue No. 11-008), 54(2), 2-7.

Bureau of Transport Economics (2000). Road Crash Costs in Australia. Report 102. Canberra, Bureau of Transport Economics.

Carr, D.B. (1997). Motor vehicle crashes and drivers with DAT. Alzheimer Disease and Associated Disorders, 11(Suppl 1), 38-41.

Canadian Study of Health and Aging Working Group (1994). "The Canadian Study of Health and Aging: study methods and prevalence of dementia." Canadian Medical Association Journal 150: 899-913.

Cairney, R. (1997) Work by Alberta researchers may free MDs from awkward fitness-to-drive decisions.Canadian Medical Association Journal. 157(11).

Charlton, J. L., Fildes, B., Koppel, S., Andrea, D., Newstead, P.E., Pronk, N. (2002). Evaluation of a GP Referral Assessment Tool for Assessing Older and Functionally Impaired Drivers. Research and development report GR/2002. VicRoads.

Diller, E., L. Cook, et al. (1998). Evaluating drivers licensed with medical conditions in Utah 1992-1996. NHTSA Technical Report HS 809023. Washington.

Dobbs, A. (2005). The DriveABLE Assessment Technical Manual Version 3.0. Edmonton, Alberta, Canada.

Dobbs, A., J. Caprio Triscott, et al. (2004). "Considerations for assessment of medical competence to drive in older patients." Geriatrics and aging 7(1): 42 - 46.

Dobbs, B. (2008). The SIMARD: A reliable and valid in office screening tool for the identification of medically at risk drivers. The Gerontologist, 2008. 48(Oct): p. 505.

Dobbs, B., Zirk, H., Daly, S. (2009). Tackling a tough issue: Strategies for identifying, assessing & supporting drivers with dementia in the primary care setting. The Canadian Review of Alzheimer's Disease & Other Dementias.12(1):13-22

Friedland, R.P,. Koss, E., Kumar, A., et al. (1988). Motor vehicle crashes in dementia of the Alzheimer type. Annals of Neurology, 24, 782-786.

Frittelli, C., 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: p. 232-238.

Grabowski, D., C. Campbell, et al. (2004). "Elderly licensure laws and motor vehicle fatalities." Journal of the American medical association 291(23): 2840 - 2846.

Hakamies-Blomqvist, L., et al., (2002) Attitudes of primary care physicians toward older drivers: a Finnish-Swedish comparison. Journal of Applied Gerontology, 2002. 21: p. 58-69.

Hakamies-Blomqvist, L. and A. Siren (2003). "Deconstructing a gender difference: Driving cessation and personal driving history of older women." Journal of safety research 34(4): 383-388.

Hopkins, R., Kilik, L., Day, D., Rose, C., Tseng, H. (2004) Driving and Dementia in Ontario: A Quantitative Assessment of the Problem. Canadian Journal of Psychiatry 49:434–438)

Jang, R., et al., (2007) Family Physicians' Attitudes and Practices Regarding Assessments of Medical Fitness to Drive in Older Persons. Society of General Internal Medicine. 22: p. 531-543.

Johansson, K., L. Bronge, et al. (1996). "Can a physician recognize an older driver with increased crash risk potential?" Journal of the american geriatrics society 44(10): 1198 - 1204.

Kruger, H.-P., Kazenwadel, J. and Vollrath, M. (2000). Grand Rapids Effects Revisited: Accidents, Alcohol & Risk. Röntgenring, Germany, Centre for Traffic Sciences, University of Wuerzburg,.

Langford, J. (2006). Older drivers and mandatory assessment of fitness to drive. Report to Victoria Roads, Monash University Accident Research Centre.

Langford, J. (2008). "Usefulness of off-road screening tests to licensing authorities when assessing older driver fitness to drive." Traffic injury prevention 9(4): 328-335.

Lloyd, S., et al. (2001), Driving and dementia: a review of the literature. Canadian Journal of OccupationalTherapy. 68(3): p. 149-56.

Lyman, S., Ferguson, S.A., Braver, E.R., & Williams, A.F. (2002). Older driver involvement in police reported crashes and fatal crashes: trends and projections. Injury Prevention, 8, 116-120.

McCracken, P., J. Caprio Triscott, et al. (2001). "Driving with Dementia." The Canadian Review of Alzheimer's Disease & Other Dementias (Dec): 14 - 20.

Miller, D., Morley, J. (1993) Attitudes of physicians towards elderly drivers and driving policy. Journal of the American Geriatrics Society 40: 722

Molnar, F., et al., Acceptability and concurrent validity of measures to predict older driver involvement in motor vehicle crashes: an Emergency Department pilot case–control study. Accident Analysis and Prevention, 2007. 39: p. 1056 -1063

Molnar, F.J., et al., In-office evaluation of medical fitness to drive: practical approaches for assessing older people. Canadian Family Physician, 2005. 51: p. 372-379.

MUARC (2000). Model Licence Re-Assessment Procedure for Older and Disable Drivers, Austroads.

MUARC (2004). Model Licence Re-Assessment Procedure for Older Drivers: Stage 2 Research. Canberra, Austroads: 129.

MUARC (2008). Trial of a Model Licence Re-Assessment Procedure for Older Drivers: Stage 3 Research Canberra, Austroads.

MUARC (2009). Older Driver Model Assessment Program: Stage 4 - Validation of Screening Tests to Assess At-Risk Older Drivers. M. U. A. R. Centre, Austroads.

OSMV (2009). Revisions to the BC Guide for Physicians in Determining Fitness to Drive a Motor Vehicle

Ross, L., et al. (2009) Older Drivers in Australia: Trends in Driving Status and Cognitive and Visual Impairment. Journal of the American Geriatricians Society,57: p. 1868 - 1873.

Shanahan, E., Sladek, R., & Phillips, P. (2007) Medical aspects of fitness to drive. What do public hospital doctors know and think? Internal Medicine Journal, 37: p. 372-376.

Soderstrom, C. (2008) Applying Research to Licensing Agency Screening of Seniors for Fitness to Drive. Gerontology & Geriatrics Education. 29(4): p. 310-325.

Soderstrom, C. & Joyce, J. (2008), 'Medical Review of Fitness to Drive in Older Drivers: The Maryland Experience',. Traffic Injury Prevention. 9(4): p. 342-349.

Steier, T.S., et al.,(2003) Are medical reports on fitness to drive trustworthy? Postgraduate Medical Journal 79: p. 52-54.

Valcour, V., K. Masaki, et al. (2000). "The Detection of Dementia in the Primary Care Setting." Archives of Internal Medicine 160(Oct): 2964 - 2968.