Fitness to drive
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Fitness To Drive. Nellemarie Hyde, OT Reg. (Ont.); CDRS Beth Crystal, OT Reg. (Ont.). The Participants. Who has previously referred a client for a driving assessment? What types of diagnoses do your clients have? (stroke? ABI? amputation? SCI? MS? dementia?)

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Fitness to drive

Fitness To Drive

Nellemarie Hyde, OT Reg. (Ont.); CDRS

Beth Crystal, OT Reg. (Ont.)


The participants

The Participants

  • Who has previously referred a client for a driving assessment?

  • What types of diagnoses do your clients have? (stroke? ABI? amputation? SCI? MS? dementia?)

  • Has anyone in whole or in part, conducted a driving assessment?

  • Prescreening for a driving assessment?


Objectives

Objectives

  • Determining who is at risk for medically impaired driving

  • Mandatory reporting and MTO process

  • Comprehensive Driving Assessment: What to expect

  • Case Studies


Road back to driving

Road back to Driving

  • Who is at risk for medically impaired driving?


Who is at risk

Who is at risk?

It is not age alone!!

  • It is medical conditions

  • Medical conditions and medications are the primary cause of declines in driver competence.

  • Can make even the best of drivers unsafe to drive.

  • Can affect drivers of any age: Increasingly likely as we age.

  • Medical community best positioned to first recognize possibly impairing medical conditions.


Medical conditions

Medical Conditions

Any medical condition that results in a change of physical, sensory, mental or emotional abilities has the potential to compromise driving performance.

  • Physical (weakness; limited movement etc)

  • Sensory (vision loss; limited feeling in limbs etc)

  • Cognitive/Perceptual (slowed thinking; attention etc)

  • Emotional (anxiety etc)


Increased risk of an at fault crash

Increased Risk of an At-Fault Crash

7.6

5.0

5.0

Risk of an At-Fault Crash

2.8

3.0

2.5

2.1

2.2

1.8

Visual Acuity

Pulmonary

Psychiatric

Diabetes

Epilepsy

BAC .08

Cardiovascular

Cognitive

Neurological


Prevalence of cognitive impairment

0%

10%

20%

30%

40%

50%

60%

70%

65-74

75-84

85+

Alzheimer’s Disease and Other Dementia

Cognitive Impairment that is not Dementia

Prevalence of Cognitive Impairment*

AGE

*(CSHA, 1991)


Highway traffic act 1990 c h 8

Highway Traffic Act 1990c. H. 8

Doctor reports to the MTO

Section 203, (1) Mandatory Reporting for:

“Every person 16 yrs. of age or over, attending upon the medical practitioner for medical services who, in the opinion of the medical practitioner, is suffering from a condition that may make it dangerous for the person to operate a motor vehicle.”


The doctor s dilemma

The Doctor’s Dilemma

  • Doctors are asked to report if a patient’s medical condition may affect their ability to drive

  • If this was carried out to the word, the MTO would likely be inundated with reports from doctors

  • Instead, doctors are left to determine, from their office, who should be reported to the MTO

  • OT’s offer valuable input to doctors


When mto is informed

When MTO is Informed

  • The license may not be suspended.

    • A file is opened with the Medical Review Section.

    • The case is reviewed by an analyst.

    • MTO will determine the next course of action.

    • Once report is made it can take 4-6 weeks for response.


Mto course of action

MTO course of action

  • may request medical information

  • go through the standard licensing procedure

  • may request a driving assessment from an approved rehabilitation facility

  • may suspend license on a medical basis

    (temporary licenses can be obtained for assessment and/or training)


Who should be assessed

Who should be assessed?

  • Collisions and/or damage to the car

  • Getting lost

  • Near-misses with vehicles, pedestrians

  • Confusing the gas and brake

  • Traffic tickets

  • Missing stop signs/lights; stopping for green light

  • Deferring right of way

  • Not observing when making lane changes, merging

  • Others honking/irritated with the driver

  • Needing a co-pilot


Who should be assessed1

Who should be assessed?

Physical Impairment:

  • Difficulty moving their body through the motions of driving (poor coordination, strength, range of motion)

  • Impaired reaction time


Who should be assessed2

Who should be assessed?

Cognitive/Perceptual Impairment

  • Impaired processing speed (>150 seconds on Trails B – may indicate increased crash risk)

  • Impaired visual perception (<30/40 on MVPT-R)

  • A history of left inattention or neglect

  • Impaired judgement, problem solving

  • Difficulty with IADLs or ADLs


Who should be assessed3

Who should be assessed?

Psychological / Emotional Impairment

  • Driving anxiety

  • Psychomotor slowing

  • Cognitive deficits

  • Side effects from medications

  • Impaired judgement


Who should be assessed4

Who should be assessed?

Vision Deficits

  • Visual Acuity: minimum 20/50 with both eyes open

  • Visual Field: 120° continuous vision with 15° above and 15° below the visual field (60° to right and left)

  • MTO Vision Waiver Program for class G license for visual field impairment


Specialized assessment

Specialized Assessment

The role of a Rehabilitation Driving Assessment:

  • Determine the impact of a medical condition on driving.

  • Recommend training and adaptive equipment if appropriate.

  • Support driving independence.

  • Monitor performance over time.


Specialized assessment1

Specialized Assessment

  • In Ontario, an Occupational Therapist is required to conduct the assessment in order to be a Ministry Approved Facility.

  • The cost of assessment is not covered by the health care or licensing system – the client covers the cost.

  • Fees are approximately $500 - $600.


Driving assessment

Driving Assessment

In the Clinic (1.5-2 hours with OT):

  • Medical and Driving History

  • Vision Screen

  • Cognitive/Perceptual Assessment

  • Physical Assessment


Driving assessment1

Driving Assessment

Cognitive/Perceptual Assessments

  • Cognistat or MMSE (as a screen)

  • MVPT-R or MVPT-3

  • Useful Field of View (UFOV)

  • Trail Making A & B

    Or

  • DriveABLE Assessment


Driving assessment2

Driving Assessment

In the Vehicle (Driver Rehab):

  • Given in dual-brake vehicle

  • Occupational Therapist and Certified Driving Instructor

  • In-clinic determines course of on-road assessment

  • Will abort drive if major errors arise


Driveable

DriveABLE™

  • DriveABLE™ -- developed through research.

  • Research won national award of excellence.

  • Alberta Heritage Foundation for Medical Research encouraged championing move from research to practice through the establishment of a University spin-off company -- DriveABLE™.


Driveable1

DriveABLE™

Cognitive/Perceptual Assessment

  • Completed on a computer

  • Touch Screen and push button response

  • Assesses areas of:

    • motor control- attention shifting

    • judgment - attentional field

    • executive function

  • On-road Assessment


Driveable2

DriveABLE™

In the Vehicle:

  • Given in dual-brake vehicle

  • Score only the competence defining errors

  • Road Course design reliably reveals the competence defining errors

  • Bad habit errors not scored

    • Protects the competent driver

  • Fail criterion is “Out of the range of normal”


Driving assessment3

Driving Assessment

Recommendations are given and may include:

  • Continue Driving

  • Future Reassessment

  • Training

  • Discontinue Driving


Functional vision assessment

Functional Vision Assessment

  • Began May 2005

  • Only five MTO approved centres in Ontario (pilot)

  • Goal: to determine if the client can compensate for vision loss


Functional vision assessment1

Functional Vision Assessment

If approved by MTO:

  • 2 hour clinical assessment (OT)

    • UFOV, CTMT, MVPT-3, Scan Course, Insight, physical assessment

      1.5 hour on road assessment (OT and DI)

  • Two road tests: residential, main road, freeway, break in between to review


Functional vision assessment2

Functional Vision Assessment

  • Expectation on road is quite high

    • Blind spot checks on turns and lane changes

    • Anticipatory scanning

    • Speed of maneuvers

    • Use of mirrors

  • Client cannot miss more than two in any category on any particular maneuver


Functional vision assessment3

Functional Vision Assessment

Recommendations include:

  • Able to compensate, recommend driving

  • Able to compensate, training in community

  • Did not compensate, training with MTO approved rehab facility

  • Unable to compensate due to inability and/or lack of insight, driving cessation recommended


Determining medical fitness to operate motor vehicles

Determining Medical Fitness to Operate Motor Vehicles

  • Published by the Canadian Medical Association

  • Addresses:

    • Functional Driving Assessment

    • Medical Reporting

    • Driving Cessation

    • Alcohol, Drugs

    • Aging

    • Sleep Disorders

    • Psychiatric Illness


Determining medical fitness to operate motor vehicles1

Determining Medical Fitness to Operate Motor Vehicles

  • Addresses (continued):

    • Nervous System Impairments

    • Vision Deficits

    • Auditory-Vestibular Disorders

    • TBI and stroke

    • Vascular, cardiovascular and cerebrovascular diseases

    • Respiratory diseases, endocrine and metabolic disorders

    • Sections on general debility, anesthesia, surgery, seat belts and air bags


Determining medical fitness to operate motor vehicles2

Determining Medical Fitness to Operate Motor Vehicles

  • Alert box

  • Overview

  • Detailed breakdown within each Section

  • Identifies where a functional driving assessment should be considered


Who should be assessed5

Who should be assessed?

  • Case Studies


Case study

Case Study

Amputation

  • 65 year old man with 16 year history of diabetes

  • Developed PVD in the (R) lower extremity 2 years ago

  • Right below knee amputation 3 months ago


Amputation

Amputation

  • What are this gentleman’s options for driving?

  • What are the potential concerns regarding his driving options?

  • At what point in his rehab should he be referred for a driving assessment?

  • Who should inform the MTO and when?


Case study1

Case Study

Vision Deficit / CVA

  • 56 year old female sustained an occipital CVA one year ago

  • Visual field testing indicates a (L) homonymous hemianopia

  • Doctor notified MTO and her License was suspended while she was in the hospital

  • Client has asked if / when she will be able to resume driving


Vision deficit

Vision Deficit

  • Can someone with HH be considered for driving?

  • What information/documentation will the MTO require?

  • Who can conduct this type of assessment?

  • What does the driving assessment entail?


Case study2

Case Study

Traumatic Brain Injury

  • 18 year old male sustained a severe TBI as a passenger in a MVA

  • At the time of the injury, he held a G1 license

  • Recent neuropsych testing shows deficits in attention, concentration, judgement

  • Family reports changes in his behaviour

  • He has expressed a desire to resume driving with his dad.


Traumatic brain injury

Traumatic Brain Injury

  • What red flags might the OT look for when considering the assessment?

  • Does he require a driving assessment or can he simply proceed through MTO testing?

  • At what point in his rehab should driving be considered?

  • Is it okay for him to practice driving with his dad?


Case study3

Case Study

Spinal Cord Injury

  • 38 year old male sustained a C5/6 spinal cord injury during an ATV roll over 6 months ago

  • Reports dizziness upon rising in the morning

  • Has expressed frustration with having to rely on Wheel Trans

  • Wishes to pursue driving


Spinal cord injury

Spinal Cord Injury

  • Is this an appropriate referral?

  • At what point in his rehab should he be referred for a driving assessment?

  • What types of assessments might be appropriate at this time?

  • When should the MTO be advised of the medical condition?


Resources

Resources

  • Determining Medical Fitness to Operate Motor Vehicles; Canadian Medical Association Driver’s Guide 7th edition. (available online)

  • www.saintelizabeth.com (select “services”; “driver”)

  • www.driveable.com (for cognitive impairment)

  • Medical Review Section 416-235-1773 (client inquiries; for a list of assessment centres)


Thank you

Thank you!

Nellemarie Hyde, OT Reg. (Ont.); CDRS


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