1 Innovation in Driving Rehabilitation: Setting a Course for SuccessDavid B. Carr, M.D Alan A and Edith L Wolff Professor of Geriatric Medicine Department of Medicine and Neurology Washington University at St. Louis Medical Director, The Rehabilitation Institute of St. Louis

2 DISCLOSURES (2015-Present)Funding Support National Institute on Aging (NIA) Missouri Department of Transportation State Farm Consulting Relationships TIRF Medscape AAAFTS American Geriatric Society University of Toronto Medical Director TRISL/Parc Provence Drug Industry Sponsored Trials/Investment-Stock-Equity None

3 PRESENTATION OBJECTIVESReview aging demographics, crash stats and medical conditions that impact driving Review current approaches and tools that are available to identify those in need of driving rehab

4 DRIVER STATISTICS Aging Demographics Acute/Chronic Disease 2013 205046 Million Older Adults 36 Million Licensed Drivers 2050 86 Million Older Adults 66 Million Licensed Drivers Acute/Chronic Disease General Population 25 million 1/10 citizens Older adults 50% affected over age 65 37% report disease is severe 16% require assistance

5 MOTOR VEHICLE CRASH RISK BY AGEScript: Older adults have increased fragility and are more likely to die from crashes that expose them to injury (1). Similar to the statistics that indicate high mortality with hip fractures, injury in a motor vehicle crash may begin the spiral downward for an older adult. (1)Insurance Institute for Highway Safety, Fatality Facts: Older People as of November Arlington (VA): IIHS 2003. Notes: You may want to add the following additional information: In the year 2000, persons aged 65 years and older made up 13% of the U.S. population (1) yet suffered 18% of all traffic fatalities (2). When adjusted for number of vehicle miles traveled, older adults have the highest rate of fatal crashes (3). Population projections of the total resident population by 5-year age groups, and sex with special age categories: middle series, 1999 to Washington DC: Population Projections Programs, Population Division, U.S. Census Bureau 2000. Traffic Safety Facts 2000: A compilation of motor vehicle crash data from the Fatality Analysis Reporting System. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2001. (3) IIHS Fatality Facts, Elderly. Arlington (VA): IIHS

6 The Importance of the AutomobileThe Transportation Method of Choice Autonomy Identity Social Connectedness Psychological and Physical Health Correlates Private cars account for over 90% of trips made by seniors Losing a license can have major consequences in a variety of areas. Clinicians should be aware of the ramifications and double their efforts at improving physical abilities when possible.

7 FITNES-TO-DRIVE STAKEHOLDERSPatient Family and Friends Health Professionals Organizations Patrol Officers State DMV Insurance Community Federal/NHTSA

8 Case-Based Approach An 83 year old female s/p stroke and mild R sided weakness. Daughter raises concerns about driving given mother’s visual impairments, medications, and other medical conditions PMH: HTN, Diabetes, Anxiety Disorder (GAD) Medications: Atenolol 50mg BID, Metformin 500g BID Alprazolam .25 TID Sertraline 25mg QD Mild (mean deviation no worse than -6 dB), moderate (mean deviation between -6 and -12 dB) or advanced (mean deviation between -12 and -22 dB).

9 Fitness to Drive Steps Step 1: Driving History and Med Review Step 2:Examine Co-Morbidities Step 3: Physical Examination Step 4: Rate Primary Disease Severity Step 5: Referral, Rehab, and/or Counseling

10 Step 1a: Driving HistoryDriving Behaviors (lostx1) Informant Rating (fair) Exposure (low) Personality (no change) Violations (none) Crashes (none) Cognitive Impairment Functional Impairment Others?

11 Step 1b: MEDICATION REVIEWNarcotics Barbituates Benzo’s (present)* Antihistamines Antidepressants Antipsychotics Hypnotics Alcohol Muscle Relaxants Antiemetics Antiepileptic Hetland A, Carr DB. Medications and Impaired Driving. Annals of Pharmacology 2014; 48(4):

12 Step 2:Co-Morbid ConditionsDobbs BM. Medical conditions and driving: a review of the scientific literature (1960–2000). Technical report for the National Highway and Traffic Safety Administration and the Association for the Advancement of Automotive Medicine Project. Washington (DC); 2005. Charlton JL, Koppel S, O’Hare M, Andrea D, Smith G, Khodr B, et al. Influence of chronic illness on crash involvement of motor vehicle drivers, Report No Clayton, Australia: Monash University Accident Research Centre; 2009. Canadian Medical Association and Austroads Medical Fitness Guidelines AMA Older Driver Curriculum Table courtesy of Dr. Thomas Meuser

13 Step 3a: Physical ExaminationVisual Acuity Visual Fields Contrast Sensitivity Motor Examination Muscle Strength Range of Motion Cognitive/Functional Testing Clock Drawing Task Trail Making Tests A Functional Exam AD-8

14 Step 3b: Cognitive/Functional Screens Trails A AD-8 Clock Drawing

15 Probability Calculator of Failing Road Test: DementiaOur Case: Trail Making Test A (TrlA) of 57 secs AD-8 Total (AD8TOT) score of 3 Clock Drawing Task-Freund (CDTf) of 4 Probability of Road Test Failure: 51% Carr DB, et al. JAGS, 2011

16 STEP 4: Rate Stroke Severity Demonstrated-Safe-Approach-Rationale- Intravenous-rtPA-Used-Acute-Stroke- Patients-NIHSS Our Case: MMSE 24, Short Blessed Test 6, NIHSS=4 Mild Stroke Severity

17 What Are The Next Steps? Green Light No red flags Monitor at intervalsFull speed ahead! Yellow Light Red flags/co-morbid illnesses Decline in traffic skills Deficits on office screening Consider referral and caution! Red Light Driving Retirement/Counseling Stop! After pursuing steps 1-3 of the POEMS algorithm, a clinician should have some sense of safety risk in regards to operating an automobile. Individuals may be on either side of the spectrum and not require further referral since they are deemed low/minimal risk or actually require immediate driving cessation. In those individuals where the risk appears elevated, a referral for a performance based road test may further assist in directing driving recommendations.

18 Which Lobes are Key For Driving?Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352: 692-9

19 Step 5: REFERRAL SOURCESPrimary Care Physician Subspecialist Neuropsychologist Occupational Therapists Physical Therapists Speech Therapists Case Managers Others Driving ability after a stroke: evaluation and recovery. [Review] Murie-Fernandez M; Iturralde S; Cenoz M; Casado M; Teasell R. Neurologia. 29(3):161-7, 2014 Apr.

20 Case Resolution No history of prior poor driving performanceAlprazolam was tapered off and sertraline ∧ Visual acuity was 20/40 corrected with no visual field cuts Physical therapy inpatient and outpatient improved strength to 4/5 in UE Speech therapy improved attention and episodic memory (Trailmaking Test B reduced from 200 secs to 150 secs) Occupational therapy DRS performed road test and educated patient on vehicle modifications Mild (mean deviation no worse than -6 dB), moderate (mean deviation between -6 and -12 dB) or advanced (mean deviation between -12 and -22 dB).

21 Conclusions Many Adults Need Driving Rehab ServicesFew Receive Services Since; Cost Access Evidence Future Innovative Reimbursement Mechanisms Recruit Others Into the Field Support Research