+ Driving after Stroke Art Science Assessment

Catherine Ballyk, MD, Physiatrist Elke Hilgendag, OT, Stroke Navigator

+ Conflict of Interest

We have no Conflict of Interest in relation to this presentation

+ Acknowledgements

We would like to thank the following experts for their guidance, support and resource use for this presentation;

Brenda Vrkljan –PhD (OT) –McMaster University

Hillel Finestone, MD CD, FRCP(C) – University of Ottawa

Wendy Niewland – OT/Certified Driver Rehab Specialist/Driver Instructor (Skill Builders)

+ Learning Objectives:

Understand how stroke survivors’ impairments can affect driving ability and safety

What medical screening measures & functional assessments can assist the healthcare team in predicting a patient’s readiness to resume driving

What our legal reporting responsibilities are related to change in medical condition (MTO)

How to support and educate our patients about driving retirement and alternatives

+ A little about home….

Brantford – District Stroke Centre for Brant-Haldimand Norfolk (Central South Region)

2013 – Integrated Stroke Unit

21 Bed Unit – Acute, Rehab, Slow Stream Rehab, Out-patient Neuro, Community Stroke Rehab

+ Our Mobility Lifespan

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Passenger

Young driver

Adult driver

Driving Retirement

+ Driving represents….

Freedom, Control, Independence

Finestone et al., (2010) Vrkljan et al.,(2007)

+ We know that….

Driving is a Complex Skill

Driving is a privilege….not a right! (Highway Traffic Act; Ontario)

Mobility is a right

Drivers are required to take responsibility for their change in medical status

Redelmeier et al., (2012)

+ We know that….

Physicians/Healthcare professionals do not want to talk to patients about driving

Healthcare professionals should discuss driving with their patients as they would the same as any other functional skill

Jang, et al., (2007)

+ Stats…

50,000 Canadians suffer a stroke each year

In developing countries, 50% of stroke survivors wish to continue driving

30-50% of stroke survivors will resume driving

Less than 35% of stroke survivors discuss driving with their doctor before discharge from hospital

87% of stroke survivors who resume driving do not receive a formal driving assessment

Devos et al, ( 2011) Petzold et al, (2010)

+ Why is there hesitation to report?

Physicians’ confidence and competence

Driving safety not addressed during physician office visit

Variance between patient groups

Vrkljan et al., (2010)

+ Why is there hesitation to report?

Medical/legal concerns

Protecting the physician/patient relationship

No standardized protocol

CMPA (2011)

+ The “easy” screen

Maggie, 69 years old

Dx – Stroke CT –moderate right temporal-parietal infarct Inpatient – 3 weeks Moderate left UE & LE weakness Walks - 2 wheeled walker – assist x 1 therapist Wheelchair – reminders to avoid linen carts on left MoCA 23/30 Clock 2/5 Driving History – 2 MVAs in last year

+ The “grey zone” screen

Abbey, 69 years old

Dx –Stroke

CT- negative

Emergency Room (not admitted)

Mild left UE & LE weakness

Symptoms resolving

Walking, talking, oriented, no visual deficits

Discharged home from ER

+ The “more difficult” screen

Ben, 67 years old

retired truck driver CT - Left subcortical (posterior limb of the internal capsule),

diffuse white matter changes Medical history - HTN, post stroke no seizures Inpatient - 5 weeks Indep ADL/IADLs, straight cane Supports – wife (does not drive) He was told not to drive. MTO notified by inpatient MRP Presents at my office two weeks later, wants to drive

Finestone et al., (2011)

+ Questions to consider

Why me?

How do I start the conversation?

How can we medically and functionally screen risk of driving without seeing them drive?

Is our screening results sufficiently conclusive?

When do we refer for a Comprehensive Driving Evaluation?

What are our legal responsibilities in reporting?

How do we support patient’s transition from driver to non-driver?

+ Evidence Matrix

PATIENT HEALTHCARE PROF.

Personal Beliefs & Convictions

Professional Values

Personal Experts

Clinical Experts

Personal Reasoning

Clinical Experience

Publicized Science Research Literature

Vrkljan, Hyde (2015) Scott et al (2009)

+ Stakeholders in Driving

Driver/Family

Public

Healthcare Professionals

MTO

Police

Research

+

+

+ Medical Conditions & Risk of Crash

+ Conceptual Model of Driving (Marshall et al., 2007)

Sensory

Visual Positioning

Hearing

Attention

Concentration

Deduction

Interpretation

General Driving

Program

Previous Driving

Experience

Insight Judgement Behaviour

Driving Ability

Tactical Level Strategic Level

Operational Level

Driving Behaviour and Functional Abilities

Motor Abilities

ROM Co-ordi

Endurance

+ Question?

What is the law in Ontario regarding the reporting of potentially medically impaired drivers?

A) There is no mandatory reporting in Ontario. It’s up the MD.

B) You can report to MTO but only with patient consent.

C) You are obligated to report any patient who may be unsafe to drive (with or without consent).

D) You have to take your patient on a road test before making a decision to report to MTO.

+ Answer is….

Ontario Highway Traffic Act [R.S.O. 1990, c. H.8, s. 203 (1)]:

“Every legally qualified medical practitioner shall report to the Registrar the name, address and clinical condition of every person sixteen years of age or over 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.”

+ Canada

CMA Guide (2012)

+ Medical Fitness to Drive

Physicians are NOT being asked to DETERMINE a patient’s fitness to drive, but to DESCRIBE!

CMA (2012)

+ MTO reporting

While the patient is awaiting response/further direction from MTO, patient should be warned to “stop driving” immediately (response from MTO will take time).

Document in the medical record and provide patient with copy of your recommendation.

Legislation requires each physician involved in the patients’ care to report to MTO.

Physician doubt? Contact colleagues or CMPA for assistance.

+ Notification About Driving Safety

Name__________________

Date___________________

You have a medical condition that may affect your ability to safely operate a motor vehicle.

As your doctor, I have a legal responsibility to report potentially unsafe drivers to the Ministry of Transportation. Even with a previous safe driving record, your risk of a car accident is too great to continue driving. Your safety and the safety of others are too important.

Stop driving immediately.

Dr._________________ Witness____________________

+ Canada: Physician Protection

In most provinces/territories, physicians’ legal responsibility to report patients with certain medical conditions override their ethical responsibilities to keep patients’ medical histories confidential.

Public safety outweighs individual confidentiality.

There are no difficulties with privacy of information or needing to gain consent. It is preferred, but not mandatory to tell patient.

Physicians may be sued by patients/victims of motor vehicle accidents/insurance companies if the courts decide that the physician could have foreseen the dangers of patient continuing to drive (Coopersmith et al 1989, CMPA)

+ Legal Considerations

67 CMPA cases reviewed, 3 themes… 1) Legal actions that a physician failed to report a patient

medically unfit to drive

2)Complaints that a report had been made to a provincial or territorial licensing authority (confidentiality breech)

3)Complaints related to the refusal to support an application of driving privileges

In the majority of cases, the College have been supportive of the physician’s decision to report.

+

+ And more details….

“not fit due to…and he is not medically fit to drive right now”

“question ability to drive…recommend driving evaluation”

“question medical status….request neurologist input”

“suffered mild stroke….no deficits noted by treatment team”

“noticing decreased cognition; MMSE 22/30, family concerned”

“I will be following this patient’s care….patient aware not to drive currently….will screen and send follow up report in 4 weeks”

Nieuwland, (2015)

+ MTO Recommends

Immediate suspension

Request for additional medical information –specific form will be sent to driver

Request for an evaluation from a specialist (neurologist/physiatrist)

Request for Comprehensive Driving Evaluation (CDE)

Request for a three part test

+

+

+

+ Question ?

Do certain strokes require different types of reporting or attention?

a) Yes, an ischemic stroke must be reported

b) Yes, a hemorrhagic stroke must be reported

c) No, there are no known types of stroke that require a report

+ Answer…..

There is no known specific type of stroke that merits absolute report to licensing authority

It is not diagnosis…….it is FUNCTION!

+ Aneurysms?

Untreated cerebral aneurysms are absolute barrier to driving any class of vehicle

Following treatment, symptom-free period of 3 months (private) and 6 months (commercial)

CMA (2012)

+ CMA/Stroke Best Practice Guidelines

Should not drive for one month after stroke

May resume driving if: No clinically significant motor, physical, cognitive or perceptual

deficit

No obvious risk of sudden recurrence

Underlying cause treated appropriately

Has not had seizure in the interim

CMA, (2012)

Canadian Best Practice Recommendations for Stroke Care (2013)

+ What do we do?

Medically screen?

Refer for a CDE/Functional Assessment?

MTO Road test?

Report?

Do nothing?

+ Driver screening in my clinic? History (medical condition, medication, sleep disorder,

alcohol)

Driving history/Family concerns

Functional Status (Mobility/transfers/ADL/IADL/Communication/Cognition/Mood)

MSK/Neurological Exam (vision/visual field, hearing, sensation/extinction, motor/reflexes, ROM, gait/balance/co-ord

Cognition (Clock drawing/Trails B/ MoCA)

Diagnostics (MRI/CT –infarct location; ? microvascular disease), Lab work

+ Question?

BP 165/85

Drives

No obvious cognitive problems

No family history of dementia

Is her risk for dementia 5%, 15%, >25%?

Amy, 80 years old

+ Risk for Dementia

Age % increase

<65 1%

65 2%

70 4%

75 8%

80 16%

85 32%

Dalziel, W. B. , (2013)

Overall Risk = age risk_____% x family hx risk multiplier______ x vascular risk multiplier ______=______%

+

+ Case Study

Ben, 67 years old

retired truck driver

CT - Left subcortical (posterior limb of the internal capsule), diffuse white matter changes

Medical history - HTN, no seizures

Inpatient - 5 weeks

Indep ADL/IADLs, straight cane

Supports – wife (does not drive)

He was told not to drive. MTO notified by inpatient MRP

+ Ben Screen results Self reports currently driving (despite knowing recommendations

from inpatient MRP) Wife states that her husband is “still an excellent driver” (she does not

drive….needs him for grocery and church); memory slightly decreased

No local children CT scan - infarct (left subcortical - posterior limb of the internal

capsule) , diffuse white matter changes Medical/Medication review Right UE – slight weakness hand, co-ord (CMSA stage 5) Rapid Walk Test - WNL (straight cane) MMSE – 29/30 MOCA – 25/30 Clock drawing 4/5 (Hand placement) Trails B – no mistakes, 3 min. to complete

+ What should we do?

After screening there are three possibilities:

A) Patient is fit to drive B) Patient is fit not to drive C) Patient may be unfit to drive; (further assessment required)

+ Results

Ben

didn’t stop/ yield

difficult following instructions

unsafe!

Unsuccessful Comprehensive Driving Evaluation

+ Key points to “drive” home!

Ask

Identify

Screen (medically/functionally)

Report

Document

Alternatives

+

“Why can’t you people get organized?” One day you take my license away and the next

day you ask to see it.”

+ What’s “driving” our brain?

+ How does Stroke affect Driving

Language

Vision

Motor

Sensory Cognition

Visuospatial perception

Executive Function

Knox, Gregoire (2015)

+ What makes OTs the “functional” experts?

+ OTs take a holistic approach

ADL/IADLs

Medication management

Multi-tasking in function

Community

Leisure

Driving

+ OT – 3 - Tiers of Expertise

Generalist – screening, identifying at risk drivers

Advanced – assess impairments

Advanced-specialized – assess, train/retrain, vehicle modifications, assistive technology

Korner-Biensky et al., 2007 CAOT

+ The BAD News!

There is no “one” perfect office based tool !

CMA, (2012)

+

Attention & Memory Tests

Perceptual Tests

Executive & Thinking Functions

Verbal Functions

•Trails A & B •Rey-Osterreith Complex Figure

UFOV

Marshall et al. (2007)

WAIS Picture Comp. Test Cancellation Test Cube copy Copy a Cross WAIS Block Design Color Vision Spatial Relationship…..

FIM Cognitive

Auditory Comprehension Reading Verbal Expression

WAIS- R Digit Sym Test Serial Digit Modal Test

Raven’s Progressive Matrices

+ Trails B

Divided attention

Visuomotor tracking

executive function

>3 min or 3 errors

+ Rey-Osterreith Complex Figure Design

•Visuospatial •Memory, attention

•Planning •Executive function

+ Useful Field of View Test

Visual & Divided Attention

Visual Memory

Static visual field & acuity

Computer based

15 min. to administer

+

+ MoCA

Short term memory

Visuospatial

Executive Functions, Abstraction

Verbal Fluency, Language

Orientation

30 point screen

+ Clock Drawing

Visuospatial, praxis

Attention

Executive Function

+ Motor- Free Visual Perceptual Test

Visual Search

Visual Discrimination

Figure Ground

Visual Closure

Visual Memory

+ SIMARD-MD

Cognitive based

Score: <30 Failure likely 31-70 Uncertain > 70 Pass likely

Lack of precision - too many errors

Bedard, et al. (2013)

+ Screening considerations

Consider all factors of influence

Results consistent with other evidence

Consider qualitative information

CMA, (2012)

+ The GOOD News!

Research continues….

+ Research continues….

Candrive Cohort Study of Older Drivers

+1000 participants (7 Canadian cities) x 5 years (+ Michigan, Australia)

Objective: Developing a screening tool for physicians to use to determine who amongst their older patients is safe or not safe to drive

+ Comprehensive Driving Evaluation

MTO Approved Driving Centre

Ontario - 73 centres (23 vision)

Assessment completed by OT & Driving Instructor Specialize in driver assessment and rehabilitation

Goal of the assessment Determine impact of a medical condition on driving On-road test with OT & Driving Instructor Recommend training & adaptive equipment Re-testing post training option

MTO

+ CDE vs MTO Driving Test

CDE Ministry Driving Test

OT & Driving Instructor (3hrs)

Ministry Staff (20-30 min.)

Dual-brake vehicle Driver’s own vehicle

Evaluation inc. standardized tools Vision Test Cognitive Screen

Assess and Treat Assess

Vrkljan (2015)

+ Vision Waiver Program

Ontario – 23 centres

MTO will “waive” a part of the vision standards for Class G

Allows stroke survivors with a visual field impairment (Homonymous Hemianopsia) to have an independent certified driving evaluation (post 3 months)

Part A – Vision Report and Medical Report

Part B – Functional Assessment (CDE)

+ Visual Acuity

Snellen chart

Not less than 20/50 both eyes open and examined together

+ Visual Field

+

In-Clinic

1.5-2 hrs Occupational Therapist Medical, Driving & Licensing History Physical Assessment Visual Screen Cognitive/Perceptual Assessment Equipment review

Comprehensive Driving Evaluation

+ Interview

Community mobility

Driving history

Functional Status

Insight

+ Comprehensive Driving Evaluation

On the Road

45 min.

OT & Driving Instructor

Driving performance

Ability to respond to feedback

+ Gold Standard

On-Road driving evaluation by a qualified examiner (OT)

+ Results of CDE

Provide immediate feedback to stroke survivor and family regarding performance

Provide recommendations….training (vehicle, rehab), adaptive equipment, re-testing

Initiate counselling on driving cessation

Report to MTO

Report to referral source

+

In Vehicle Training Adaptive Equipment training Anxiety/fear Cognitive

Rehab Training Physical function Vision training Cognitive Mental Health Counselling

Driving Rehabilitation

+ Adaptive Equipment

Hand controls

Steering Aides

Left foot gas pedal

Low-effort and zero-effort steering

Signal light extension

Large side mirrors

ccmta (2013)

+ Left Foot Accelerator

+ Steering Aides

+ Secondary Controls

+ Mirror Extensions

+ “Why can’t poor people drive?”

Testing

Therapy

Training

Equipment

+ If I can’t drive…..

Social isolation

Depression

Anger

Autonomy

Quality of Life

Self Esteem

Scott et al., (2008); Carr, D et al. (2010)

+ Not Fit to Drive!

Legal obligation

Provide evidence PRN

Reinforce safety to patient and others

Stay firm!

Avoid “taking license away”

Document

+ Preparing our patients for driving retirement

What happens after discharge from hospital Home location (urban/rural)

Therapy

Community activities (Leisure)

Appointments

What supports are available Family/Friends

Finances

Transportation options

? Benefit

+ Provide Resources

+ More key points to “drive” home…

Driving after stroke is possible!

Screening tools

Functional status is key!

On-Road is gold

Comprehensive Driving Evaluations

Support the transition

+ Questions?

Thank you

balca@bchsys.org ehilgendag@bchsys.org

+ Resources

American Medical Association, Physician’s Guide to Assessing and Counseling Older Drivers, 2nd ed.

Canadian Best Practice Recommendations for Stroke Care: Table 5.11 Stroke Rehabilitation Assessment Tools for Pre-Driving Screening (2013)

Canadian Medical Association. Determining Medical Fitness to Operate Motor Vehicles: CMA Driver’s Guide. 8th ed. 2012

Canadian Medical Protective Association (Reporting Fitness to Drive -April 2015)

Canadian Council of Motor Transport Administrators (ccmta) (Vers.13)(2013).

Canadian Association of Occupational Therapists Driving and Dementia Toolkit (Dementia Network of

Ottawa Carleton and Regional Geriatric Assessment Program)

Ministry of Transportation – Medical Review

+ References

Bedard, M., Weaver, B., Man-Son-Hing, M., Classen, S., Porter, M., The SIMARD Screening Tool to Identify Unfit Drivers: Are We There Yet? Journal of Primary Care & Community Health, 2011, 2(2) 133-135.

Carr, D., Barco, P., Wallendorf, M., Snellgrove, C., Ott, B. Predicting Road Test Performance in Drivers with Dementia. Journal of the American Geriatrics Society. 2011, (59) 2112-2117.

Carr, D., Ott, B. The Older Adult Driver with Cognitive Impairment: “It’s a very frustrating life.” Journal of American Medical Association. 2010, 303 (16) 1632-1641.

Cumming, T.B., Bernhardt, J., Linden, T. The Montreal Cognitive Assessment – Short Cognitive Evaluation in a Large Stroke Trial. Stroke. 2011, 4(24), 2642-2644.

Devos, H, Akinwuntan, A.E., Nieuwboer, A., Truijen, S., Tant, M., De Weerdt, W. Screening for fitness to drive after stroke. Neurology 2011, (76) 747-756.

Dobbs, A. Accuracy of the DriveABLE cognitive assessment to determine cognitive fitness to drive. Canadian Family Physician, 2013 (59) 156-161.

+ References

Dow, J., Jacques, A. Educating Doctors on Evaluation of Fitness to Drive: Impact of a Case-Based Workshop. Journal of Continuing Education in the Health Professions, 2012, 32(1), 68-73.

Finestone, HM., Gershkoff, A. Driving After Stroke: What Are the Appropriate Criteria? American Academy of Physical Medicine and Rehabilitation, 2011, (3), 873-878.

Finestone, HM., Guo, M., O’Hara, P., Greene-Finestone, L., Marshall, S., Hunt, L., Biggs, J., Jessup, A. Driving and Reintegration into the community in patients after stroke. American Academy of Physical Medicine and Rehabilitation, 2010, (2), 497-503.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P. & Letts, L. The person-environment-occupation model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 1996, 63, 9-23.

+ References

Korner-Bitensky NA, Mazer BL, Sofer S, et al. Visual testing for readiness to drive after stroke: a multicenter study. Am J Phys Med Rehabil. 2000, (79), 253-259.

Mazer, B.L.,, Korner-Bitensky N.A., Sofer, S.,Predicting ability to drive after stroke. Arch Phys Med Rehabil 1998;79:743-50

Michon, J.A., A critical view of driver behavior models: What do we know, what should we do? In: Evans L, Schwing R, eds. Human Behavior and Traffic Safety. New York: Plenum Press, 1985; 485-520.

Petzold, A., Korner-Bitensky, N., Rochette, A., Teasell, R., Marshall, S., Perrier, M.J. Driving Poststroke: Problem Indentification, Assessment Use, and Interventions Offered by Canadian Occupational Therapists. Stroke Rehabilitation. 2010, 17 (5), 371-379.

Poole, D., Chaundry, F., Jay, W. Stroke and Driving. Stroke Rehabilitation, 2008, 15(1), 37-41.

+ References Redelmeier, D.A., Yarnell, C.G., Thiruchelvam, D., et al. Physicians’

warning for unfit drivers and the risk of trauma from road crashes. N Engl J Med 2012, (367),1228-1236.

Scott, C., Rapport, L., Coleman-Bryer, R., Griffen, J., Hanks, R., McKay, C. Self-assessment of driving ability and the decision to resume driving following stroke. Journal of Clinical and Experimental Neuropsychology, 2009, 31(3), 353-362.

Vrkljan, B., McGrath, C., Letts, L., Assessment tools for evaluating fitness to drive: A critical appraisal of evidence. Canadian Journal of Occupational Therapy, 2011 (78), 80-96.

Vrkljan, B., Myers, A., Blanchard, R., Crizzle, M., Marshall, S. Practices used by Occupational Therapists and others in driving assessment centers for determining fitness to drive: A case-based approach. Occupational Therapy in Geriatrics 2015, 33(2), 163-174.

Wiseman E., Souder E. The older driver: a handy tool to assess competence behind the wheel. Geriatrics. 1996, (51), 36-45.

+ Presentations on this topic Stroke + Driving – N. Korner-Bitensky, Phd (McGill University)

The Assessment of Fitness-To-Drive In Persons with Dementia – Dr. Frank Molnar (University of Ottawa)

Driving After Stroke: How to Integrate Science, Law and the Art of Reporting – Dr. Hillel Finestone (University of Ottawa)

Stroke & Driving; Using evidence to inform practice – Brenda Vrkljan, PhD, Jocelyn Harris, Associate Professor (McMaster University)

Driving & Cognitive Impairment; When to Suspect, How to Test, What to do? Dr. William Dalziel (University of Ottawa)

Driving and Stroke; Hilary Knox, OT, Christine Gregoire, OT (Alberta Health Services)

Determining Medical Fitness to Drive – Wendy Nieuwland, OT (Skill Builders Physiotherapy & Rehabiliation Centre – Barrie)