10 June 2010

Claire McRae Project Manager National Transport Commission Level 15, 628 Bourke Street Melbourne VIC 3000 Dear Claire & NTC Project Team,

Re: Assessing Fitness to Drive – Comment on Draft ( April 2010)

Thank you for the opportunity to provide feedback on the draft of the revised Assessing Fitness to Drive (AFTD) publication. I would like to give comment specifically on the topic cognitive impairment, screening and evaluation.

Cognitive Impairment

When considering the relationship between medical conditions and fitness to drive, impaired cognition has been identified as causing the greatest impact on driving ability [1, 2]. Dementia is the most common cause of cognitive impairment, currently affecting more than 1% of the Australian population [3]. However, in addition to dementia, many other common medical conditions can affect the mental abilities necessary for safe driving [2]. An extensive study showed that 25% of the population over the age of 65 has significant cognitive impairment approximately 8% attributed to dementia and 17% due to other causes [4].

However, at present the draft guidelines do not emphasize either the incidence or significance of cognitive impairment, especially impairment that is not dementia. The recent release of the “Driving & Dementia Discussion Paper” by Alzheimer’s Australia NSW, highlights the urgent need for more effective testing regimes for drivers with cognitive impairment [5]. This identified need should be addressed and reflected in the AFTD Guidelines.

Identification & Screening

Cognitive impairment is often difficult to detect clinically. For example, a study by Valcour et al. found that 63% of all dementia cases and 90% of mild cases are not detected in the primary care setting [6]. This was supported by Johansson et al. who found that clinical

examination was ineffective in differentiating drivers who were at risk from those who remained competent [7]. Studies such as these suggest that clinicians are not effective in identifying medically at-risk drivers in the majority of cases without suitable tools. Consequently, there exists a great need for a valid screening tool to be made available to clinicians to assist them in identifying such patients. Jang et al. found that 93% of physicians reported access to a clinical screening instrument that assisted them in identifying drivers who are medically at-risk would be useful in their practice [8].

Currently the draft guidelines lack guidance regarding the evaluation of a patient’s driving related cognitive functioning. The only reference is a note on the clinical examination proforma, mentioning that the Mini Mental State (MMSE) may be used for evaluation. However the MMSE has been recognised as inappropriate for making driving recommendations as it is not predictive of driving behaviour [9, 10].

Specific testing methods and tools are provided for other conditions such as substance misuse (9.2.3) and vision (10.2.1). However, no equivalent is provided for screening cognitive impairment. In the same way, a valid, evidence based screen such as the SIMARD [11] should be provided to assist medical practitioners in identifying those patients who require more specific assessment to determine their fitness to drive.

Assessment

Once a driver has been identified through screening as being at risk, the decision about whether or not they remain fit to drive should ideally be made through a specialised driving assessment consisting of comprehensive off- road and on-road testing [12]. With chronic conditions such as those causing cognitive impairment, the individual’s abilities are “directly measurable”[13] and therefore should be evaluated using an evidence based evaluation of driving ability rather than relying upon subjective clinical judgement. Medical professionals should therefore be encouraged to refer for such

Practical Driver Assessments: 4.9 (pg 22)

At present the guidelines require little standardisation or evidence base to practical driving assessments. However, research has demonstrated that standard driving assessments are inappropriate for assessing competency in experienced drivers [13, 14]. Preferably, a scientifically validated on-road test specifically designed for evaluating experienced drivers and identifying competence related errors should be used when assessing fitness to drive [13]. Such tests are available, for example, the D.O.R.E (DriveABLE On Road Evaluation) [15, 16]. Ideally, fitness to drive guidelines should move towards utilising scientifically validated, standardised tools as an evidence based alternative to the on-road testing that is currently undertaken.

Clinical Examination Proforma: Appendix 2.3 (pg 124)

The draft clinical examination proforma identifies cardiovascular, neurological, vision and hearing as the key areas to be evaluated. However it fails to recognise cognition as a primary area of concern. This is a serious omission considering the high incidence and impact severity of cognitive impairment on driving competence. Furthermore, the Patient Questionnaire (Appendix 2.2) also fails to address the issue of cognitive decline.

On page 27 of the draft it states “The model Clinical Examination Proforma provides a useful guide and template for a general assessment of fitness to drive”. If this is the purpose of the proforma, the need to assess cognition needs to be highlighted to the medical professional using this form.

Recommendations:

1) The draft “Clinical Examination Proforma” be modified to highlight the need for cognitive screening to be included in routine assessments of fitness to drive.

2) An evidence based screening tool be provided in the AFTD guidelines to assist medical professionals in the detection of at-risk drivers. The SIMARD© (Screen for the Identification of the Medically At Risk Driver) is an example of a validated tool that is freely available & quick to administer [11, 12, 17]. Please see Appendix1 for details

3) Evidence based practice in the evaluation of fitness to drive using scientifically validated tools must be encouraged rather than relying upon subjective clinical judgement.

Sincerely,

Renée McLennan Drive ABLE Australia Suite 22 / 123A Colin St West Perth, WA 6005 T: (08) 6103 8535 F: (08) 6103 8598 E: RMcLennan@driveable.com W: www.driveable.com.au

1. Diller, D., L. Cook, and J. Leonard, Evaluating drivers licensed with medical conditions in Utah

1992-96. 1998, NHTSA Technical Report: Washington.

2. McCracken, P., J. Caprio Triscott, and A. Dobbs, Driving with dementia. The Candian Review

of Alzheimer's Disease and Other Dementias, 2001(December): p. 14-20.

3. Access Economics, Keeping dementia front of mind: incidence and prevalence 2009-2050.

2009, Alzheimer's Australia.

4. Canadian Study of Health and Aging Working Group, Canadian Study of Health and Aging:

study methods and prevalence of dementia. The Canadian Medical Journal, 1994. 150: p.

899-913.

5. Alzheimer's Australia NSW, Driving and dementia in NSW - Discussion Paper 1. 2010.

6. Valcour, V., et al., The Detection of Dementia in the Primary Care Setting. Archives of Internal

Medicine, 2000(160): p. 2964-2968.

7. Johansson, K., et al., Can a Physician Recognize an Older Driver with Increased Crash Risk

Potential? Journal of the American Geriatrics Society, 1996. 44(10).

8. Jang, R., et al., Family physician's attitudes and practices regarding assessments of medical

fitness to drive in older persons. Journal of General Internal Medicine, 2007. 22(4): p. 531-

543.

9. Fritelli, C., et al., 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, 2009. 24: p. 232-238.

10. Canadian Medical Association, Determining medical fitness to operate motor vehicles. CMA

Drivers Guide. 7th Edition. 2006: Ottawa, Ontario.

11. Dobbs, B. and D. Schopflocher, The introduction of a new screening tool for the identification

of cognitively impaired medically at-risk drivers: The SIMARD A Modification of the DemTect.

Journal of Primary Care and Community Health, 2010. In press.

12. Dobbs, B., H. Zirk, and S. Daly, Tackling a tough issue: Strategies for identifying, assessing &

supporting drivers with dementia in the primary care setting. The Canadian Review of

Alzheimer's Disease and Other Dementias, 2009. 12(1): p. 13-22.

13. Dobbs, A., J. Caprio Triscott, and P. McCracken, Considerations for Assessment of Medical

Competence to Drive in Older Patients. Griatrics and Aging, 2004. 7(1): p. 42-46.

14. Dobbs, A., The Development of a Scientifically Based Driving Assessment and Standardization

Procedures for Evaluating Medically At-Risk Drivers, in Canadian Multidisciplinary Road

Safety Conference. 2005.

15. McCracken, P., The DriveABLE Assessment: A Review. The Canadian Review of Alzheimer's

Disease and Other Dementias, 2007(May): p. 4-8.

16. Dobbs, A., A Comparative approach to identify unsafe older drivers. Accident Analysis and

Prevention, 1998. 30(3): p. 363-370.

17. Dobbs, B., The SIMARD: A reliable and valid in office screening tool for the identification of

medically at risk drivers. The Gerontologist, 2008. 48(Oct (Special Issue III)): p. 505.

Based in the Department of Family

Medicine at the University of

Alberta, the Medically At-Risk

Driver (MARD) Centre is a re-

search-based centre committed to

two primary goals:

Info

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Driver Centre Driver Centre Driver Centre Driver Centre

Medically At-Risk Driver Centre

1704 College Plaza

Edmonton, AB T6G 2C8

SIMARD MD

Phone: 780-492-6273

Fax: 780-492-8191

E-mail: mard@ualberta.ca

For additional

information:

• Improving the safety, mobility,

and quality of life of medically

at-risk drivers and all road users;

and

• Reducing the social and health

impacts and economic costs as-

sociated with medically impaired

driving.

Our work to achieve these goals takes a three-

fold approach:

• Development of innovative tools and proce-

dures to help in the identification of medi-

cally at-risk drivers.

• Development of research-based policy, prac-

tice, and services related to medically at-risk

and medically impaired drivers.

• Evaluation of tools, corrective measures

where appropriate, and support for medically

impaired drivers.

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.

1 Do

bb

s, B

. M

. &

Sch

op

flo

cher

, D

. (2

01

0).

Th

e in

tro

du

ctio

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f a

new

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the

iden

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at-

risk

d

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ers:

Th

e S

IMA

RD

A M

od

ific

atio

n o

f th

e D

emT

ect.

Journal of Primary

Care and Community Health,

in

pre

ss.

2 Kal

be,

E.,

Kes

sler

, J.

, C

alab

rese

, P

., S

mit

h,

R.,

Pas

smo

re,

A.

P.,

Bra

nd

, M

., &

B

ull

ock

, R

. (2

00

4).

Dem

tect

: A

new

, se

nsi

tiv

e co

gnit

ive

scre

enin

g te

st t

o

sup

po

rt t

he

dia

gno

sis

of

mild

co

gnit

ive

imp

airm

ent

and

ear

ly d

emen

tia.

International Journal of Geriatric Psychiatry,

19

(2),

13

6–

14

3.