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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
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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