~DRIVER EVALUATION: Maintaining Independence and Safety

Driving is the Ultimate IADL

Requires:

• Physical Skills

• Visual Skills

• Cognitive Skills

• Emotional/Behavioral Appropriateness

Driving is the Ultimate IADL

Environment:

• Constantly changing

• Requires quick interaction and good timing

• Visual information 360 degrees around you

• Unpredictable – other drivers’ errors

Why are driver evaluations needed?

• Medical changes

  • Stroke, Traumatic brain injury, Neurological impairments, SCI

• Normal Aging changes

  • Vision changes/impairments, hearing, and processing speed

• Physical changes (lots of aging changes!)

  • Amputation, Arthritis (in hands), joint problems, postural changes (kyphotic)

• Diabetic conditions

  • Peripheral neuropathy (i.e., feet don’t feel sensations in the same way), diabetic retinopathy

• Dementia/Alzheimer’s

• Mental Illness/Attention Deficit/Learning Impairment

Occupational Therapy Driving Evaluation: 2 parts

Part 1: In-clinic Evaluation

• Conducted by an OT

• Evaluation of the component skills needed for driving

• Followed by an in-vehicle assessment if appropriate

• Requires an MD prescription/referral (not covered by Medicare, but some commercial insurances do cover)

  • usually clients have to self-pay (Medicare does not care if you want to leave your house/enter the community)

• Reaction time tester, *OPTEC, and various paper-and-pencil tests (no high-tech virtual; all low-tech and practical)

  • nothing too immersive, as there will be an in-vehicle evaluation anyway

• Length of test- up to 60 minutes

  • time is also an indicator of performance

Part 2: In-vehicle Evaluation: Gold Standard

• On the road test with a trained individual

• May include an adapted van/car evaluation

*= right image

• patient puts their forehead onto a little screen to test their…with road signs of different colors, sizes, depths, etc.; patient also has their foot on a gas/brake pedal to test their reaction times when a green/red light comes on

  • …vision/visual acuity

  • …depth perception

  • …peripheral vision

Benefits of Clinical Test

• Under the supervision of a physician

  • gets you the medical clearance to drive (safety!!!- especially for someone who may, e.g., have a history of strokes)

• Becomes part of the medical record

• Possible future litigation and insurance concerns

  • i.e., if someone were to get into an accident

• Let us be the “bad guys”; assist families

  • image: helps facilitate the difficult conversation of having a patient stop driving 

• Assists physicians in making informed decisions

Areas evaluated by OT

• Vision

• Perception 

• Cognition

• Reaction time

• Motor skills and strength

• Coordination

• ROM

• Knowledge of traffic situations

• Need for adaptive equipment

  • e.g., hand controls, spinner knob, L foot accelerator, etc…

Visual Components

• ***Acuity 20/40 minimum

  • NYS requires 20/40 in 1 eye

• Convergence/Fusion Deficits

• Scanning

• Saccades

• Pursuits/ROM/Fixation

• Depth Perception

• Peripheral Fields

Common Visual Deficits Neuro Pts:

Ocular-motor deficits (pursuits and saccades)

• from, e.g., concussion, cerebellar stroke, or some other type of brain injury that impacts the visual center

• Decreased ability to scan for hazards

• Nerve palsy —> decreased eye ROM

• Nystagmus —> abnormal oscillations of the eye(s)

Convergence/Fusion Deficits

• Not using both eyes together as a team

• Loss of depth perception

Eye Alignment deficits (diplopia/shadows)

• Active double vision SHOULD NOT DRIVE!

• Phoria/Tropia —> eye muscle deviations

Peripheral Field Deficits

• Visual Field Cuts (more common in CVA) 

  • One eye only

  • Homonymous- Both eyes affected

    • *requirements vary state to state* NY: 140 degrees binocular

  • Normal binocular field of vision is 180 degrees on the horizontal meridian

Visual Deficits in Older Adults

• Presence of diseases of the eyes

• Cataracts

  • more easily fixed

  • clouding of the eye's natural, clear lens, caused by protein clumps that block light, leading to blurry, hazy, or dim vision, faded colors, and glare

• Macular Degeneration (AMD)

  • degenerative condition affecting the central part of the retina

  • loss of vision in the central field

• Glaucoma

  • a group of eye diseases that damage the optic nerve, which connects the eye to the brain, often due to increased fluid pressure inside the eye, leading to gradual, irreversible vision loss, typically starting with peripheral vision

    • ”tunnel vision”

• Diabetic Retinopathy

  • diabetes complication damaging the retina's blood vessels, leading to blurry vision, floaters, or vision loss, and is a leading cause of blindness

*Considerations: contrast sensitivity and glare recovery

• contrast sensitivity

  • ability to perceive subtle differences in luminance between objects and their backgrounds, allowing a person to distinguish shades of gray or objects with low contrast

• glare recovery

  • time it takes for your eyes to regain clear vision after being exposed to a bright light, like headlights or sunlight

  • by e.g., a large truck with blinding lights in backroads with no other supporting lights (i.e., how long does it take for someone to stop seeing spots), is particularly important when driving at night

Visual Attention Deficits (BI/CVA)

• Inattention/Neglect (more in CVA)

  • Field is either normal or decreased (it’s an attentional/neglect deficit!)

  • Unfit for driving (as the person is unaware of their deficit)

  • Compensation is difficult

• Decreased divided visual attention

  • Field can be either normal or decreased

  • Common in neurological dx, but also prevalent in the well elderly

Visual Processing; simple vs complex

• Simple

  • Recognizing objects, colors, and shapes

  • Ability to make gross discriminations of size, position, and direction

• Complex

  • Ability to perceive detailed visual scenes

  • Ability to make subtle discriminations

  • Inter-twined relationships among multiple visual stimuli

  • Requires concentration, effort, and analysis

  • e.g., seeing a school bus in your peripheral vision

  • e.g., hearing an ambulance coming your way

Visual Processing Deficits

• Combines visual and cognitive systems 

• Slow processing commonly found in dx, such as

  • Neurological diagnosis: CVA, Parkinson’s, Multiple Sclerosis, TBI

  • General aging population

• Compounded by (important for knowing ways of how you can reduce risk):

  • Low illumination

    • e.g., don’t drive at night

  • Stress

  • Fatigue

  • Sensory Overload

Perceptual Components

• Spatial Relations

  • block design- 3D and copy

  • Copy lines 2D

• Figure Ground (Ayres Figure Ground Test)

  • 3 pictures overlapping

• L/R discrimination (Directionality)

• Motor Planning Skills (Non-routine response)

  • may do a formal assessment, but also want to see some of their spontaneous planning too (e.g., tested when doing the timed gas/break test when the green/red light comes on)!

Perceptual/Spatial Skills Deficits: 

• Figure ground

  • Differentiating foreground from background

  • e.g., understanding a stop sign amongst a bunch of trees

• Form Constancy

  • Perceiving the whole object when you see only a piece

• Position in Space

  • Up/down; front/back; left/right

• Topographical Disorientation

  • Finding your way in space

  • e.g., knowing the directions from the grocery store to your home

• Spatial Relations

  • what your eyes see + how your brain processes and makes sense of it

  • Position of objects in relation to each other

  • Interpreting speeds of movement

    • e.g., understanding how fast/slow the car infront of you is going

Perceptual/Spatial Skills Deficits Con’t:

Implications for Driving

• Time and space management (stopping too late/early)

• Not seeing signs, confusing arrows

• Difficulties with parking (especially backing up)

• Lane integrity- position on the road

  • could be based on their attention, endurance, and awareness of where they are in the lane

• Interpretation of the unexpected (construction, accidents, breakdowns)

• Getting lost in familiar surroundings

• Lane selection

Cognitive Components

• Visual Vigilance (Abreau)/Dual Attention

  • single (visual processing with 1 thing) and dual (visual processing with multiple things happening) stimuli

    • most people do fine with single stimuli (e.g., knock once when you see a circle), but some start to break down with dual stimuli (e.g., knock once when you see a circle + knock twice when you see a triangle)

  • trail making* if time allows and there are difficulties, i.e., doing a more standardized assessment

    • e.g., MoCA

• Auditory Attention

  • e.g., OT reads 50 letters out loud; when you hear the letter “A”, knock on the table

• Sequencing

• Memory

  • relevant to driving safety if…

    • you’re forgetting where you’re going (navigational sense)

    • you’re losing track of time (e.g., still not back home by many hours after your dentist’s appointment)

    • you’re losing procedural memory (e.g., forgetting what each of your gear shift letters means)

  • test 20-minute recall of 3 items

• Safety/Judgment/Problem Solving/Mental Flexibility

• Sign Symbol Identification

• Direction Following

• Insight

Cognitive Deficits

lots of measuring through general observations + interviewing the client hypothetical questions (e.g., what would you do when your car has a flat tire? —> to an 80-year-old man)

• Attention/Concentration

  • Sustained, divided, shifting

• Initiation

• Planning/Organizing

• Mental flexibility/abstract thinking

• Self-monitoring/self-correction

• Problem-Solving

• Judgment

• Anticipatory awareness

• Memory

  • Semantic

    • store and recall general information we have learned throughout our lives (e.g., stop at red lights)

  • Procedural

    • below the level of consciousness; automatic

  • Working

    • temporarily holding information

  • Prospective

    • future intentions- difficulty with unfamiliar situations

Reaction time

• SIMPLE

  • Respond to a red light in the presence of distraction

    • converse with them during this task to see if they can handle this distraction

  • Looking for < ~1 sec

• COMPLEX

  • Same as above, but filter out/ignore the yellow light (i.e., not slowing down at the yellow light)

    • are they keeping track of this new task as they continue to drive + are they able to still converse with you

  • Looking for .5-.8 seconds; will accept more based on performance on other tests; normal range for 66 years+ is .5-.6 second

Motor Components

• Cervical

• UE & LE ROM

• Muscle Strength

• Sensation

• Tone & Coordination

• Posture

• Reaction Time: Reaction Time Tester to determine Simple and Complex Reaction Time

• Motor Response and Planning

In-Clinic Evaluation Results

• Recommendations

  • Refer to the in-vehicle evaluation

    • may need visual clearance

  • No referral to in-vehicle evaluation

    • Driving is no longer a safe option, or it may be an option in the future

• Factors that go into recommendations

  • Overall performance

  • Combination of deficits

  • Quality of performance

In-Vehicle Driving Evaluation

• On-the-road test from a local driving school with a trained individual for up to 60 minutes

• Back road, highway, traffic

• May include evaluation for adaptive devices

  • Spinner knob

  • Hand controls

  • Left foot gas pedal

  • Panoramic mirror

  • Adapted van/car

In-Vehicle Evaluation Results

• In-Vehicle results are reviewed by the Occupational Therapist before being given to the client/MD

  • Pass with or without vehicle modifications

    • Recommend annual re-testing?

  • Pass, but due to safety concerns, driving is not recommended

    • especially in certain conditions (e.g., night, during bad weather, etc.)

  • Did not pass and will need additional driver training

  • Did not pass, and further training is not recommended

Recommendation to no longer drive

• A letter is sent to physician to inform them of the results, as well as a physician’s statement for medical review (DS-6)

• A letter is sent to the patient along with resources for transportation

  • e.g., ubers, taxis, lyfts, senior-specific transportation options

Patient and Family Education

• Provide family and patient with transportation options

• Clearly state whether there ss a chance for retesting or driving is not a future option (6 months minimum)

  • yes or no!

• Family support and acknowledgment are key to the success of the intervention

• Explain potential liability to the patient and family if recommendations are ignored

  • e.g., client continues to drive, and harms someone else on the road