DISCLOSURES (2014-Present) Epidemiologyc.ymcdn.com/sites/ · • Insidious onset and gradual progression ... • Prosopagnosia • Prolonged color after-images Crutch et al Alzheimer’s

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Dementia and Driving: Current Evidence and Clinical Relevance

Peggy P. Barco, OTD, OTR/L, SCDCM, CDRSDavid B. Carr, MD

Washington University School of Medicine

Carol Wheatley, MS, OTR/LMedStar Good Samaritan Hospital

Annual Conference for Association for Driver Rehabilitation Specialists. August 2016

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DisclosuresPeggy P. BarcoGrant Funding• National Institute of Age

(NIA)• National Institute of Health

(NIH) • National Institute of Mental

Health (NIMH/OBSSR)• Missouri Department of

TransportationConsulting Merck ManualTransportation Injury Research Foundation(TIRF)

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DISCLOSURES (2014-Present)

• Funding Support (last two years)• National Institute of Health (NIA, NEI)• Missouri Department of Transportation• State Farm

• Consulting Relationships• American Geriatric Society• TIRF• Medscape

• Medical Director• Parc Provence• The Rehabilitation Institute of St. Louis

• Investment/Stock/Equity• None

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Objectives

1. To develop an understanding of the types of dementia and the unique impacts on driving performance.

2. To develop a broader perspective and knowledge base related to cognition and driving

3. To gain a better understanding of evidence based assessment approaches in driving rehabilitation

4. To understand the various considerations, evidence, and discussions regarding restricted driving recommendations for individuals with dementia.

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Objective

1. To develop an understanding of the types of dementia and the unique impacts on driving performance

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Affects > 5 million people in the U.S. (20 million world-wide)

Results in > 100,000 deaths per year/Costs > $100 billion annually

Epidemiology

16

14

12

0

2

4

6

8

10

2000 2010 2020 2030 2040 2050

45.8

6.88.7

11.3

14.3

5 Million AD Cases Today—Over 14 Million Projected Within a Generation

Year

2

Department of NeurologyKnight ADRC

Forecast of Prevalence in U.S.

65-74 Years 75-84 Years 85+ Years

2030 2050

7.7 Million (est) 13.2 Million (est)

2000

4.5 Million (est)

Source: Hebert LE, et al. Arch Neurol. 2003;60:1119-1122.


Brain Aging

Mild Cognitive Impairment

Stable or Reversible Impairment

Otherdementias

Alzheimer’sdisease

VascularDementia

Mixed Mixed

NormalCognition

ProdromalDementia

Dementia

From Golomb, Kluger, Ferris NeuroScience News, 2000

The Changing Definitions of Cognitive Impairment and Dementia


In vivo Amyloid ImagingPittsburgh Compound B (PIB) (Klunk et al, Ann Neurol 2004)

N

SNH11CH3

HO

PET Imaging -[11C]6-OH-BTA-1 (PIB)

N

SN

CH3

CH3

H3C

CH+

6 1

Histology - Thioflavin TAmyloid Plaques

Courtesy of William Jagust


Experience revealed that multiple cognitive domains frequently were impaired in MCI (Grundman M et al, Arch Neurol 2004;61:59-66)

MCI criteria thus were broadened in 2004 to include multiple domain MCI, leaving only “essentially normal functional activities” to distinguish from dementia

2004 MCI Classification Process

Petersen RC, J Int Med 2004; 256:183-194; Winblad B et al., J Int Med 2004; 256:240-246Slide Courtesy of Dr. John Morris

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Health Professionals/Organizations

• Primary Care Physician/NP’s• Neurologist• Geriatrician• Psychiatrist• Pharmacist• Neuropsychologist• Alzheimer’s Association• Case managers/social workers

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The Clinical Dementia Rating

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Rating Dementia Severity by Tests

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Reversible Causes of Cognitive Decline

• D: Drugs

• E: Emotional disorders

• M: Metabolic disorders

• E: Eye/ear impairment

• N: Nutritional deficiencies

• T: Tumor, trauma

• I: Infection

• A: Atherosclerotic complications

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Review of Brain Functions

Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science

CLUES TO SPECIFIC NEURODEGENERATIVE DISEASES

Alzheimer’sDisease

Rapidlyevolving

dementias

Frontotemporaldementias

Lewy bodydementia

Vascular dementia

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• Progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function

• Core features (2probable DLB; 1possible DLB)• Fluctuating cognition• Recurrent visual hallucinations• Parkinsonism

• Supportive features• Repeated falls• Syncope and transient loss of consciousness• Neuroleptic sensitivity• Systematized delusions• Hallucinations in other modalities• REM sleep disorder

Dementia Lewy Body:Consensus Criteria

DLB = dementia with Lewy bodies; REM = rapid eye movement.Source: McKeith IG, et al. Neurology. 1996;47:1113-1124.

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• Core features• Insidious onset and gradual progression

• Early decline in social interpersonal skills or language skills

• Early emotional blunting or early loss of insight

• Supportive features• Behavioral disorders

• Speech/language disorders: aspontaneity, pressure speech, stereotypical speech, echolalia, perseveration, and mutism

• Physical signs: primitive reflexes, incontinence, parkinsonism, and low/labile blood pressure

• Neuropsychology testing: significant frontal lobe impairment

• Neuroimaging: frontal and/or anterior temporal lobe abnormalities

Frontotemporal Dementia: Clinical Diagnostic Criteria

Source: Neary D, et al. Neurology. 1998;51:1546-1554.

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• Core Features• Insidious onset and gradual progression

• Prominent visuoperceptual and visuospatial impairments but no significant impairment in vision itself

• Relative preservation of memory and insight

• Evidence of complex visual disorders (e.g. elements of Balint’s syndrome/Gerstmann’s syndrome, visual field defects, visual agnosia, environmental disorientation

• Absence of stroke or tumor

• Core Features• Presenile onset

• Alexia

• Ideomotor or dressing apraxia

• Prosopagnosia

• Prolonged color after-images Crutch et al Alzheimer’s Dementia 2013

Posterior Cortical Dysfunction

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• Core features• Evolves hyperacutely (over days or weeks)

• Evolves subacutely (months to 1-2 years)

• More rapidly than expected

• Myriad of Causes• Neurodegenerative: Prion disease (CJD)

• Antibody mediated brain diseases

• Sarcoid

• MS

• Lupus

• Vasculitis

• Other

Rapidly Progressive Dementia: Clinical Criteria

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Behavioral and Psychological Symptoms of Dementia (BPSD)• Common: >90% of patients have at least 1 symptom

• Occur early in the disease—present in MCI

• Multiple simultaneous symptoms

• Symptoms emerge as disease progresses

• Once present, highly recurrent

• Decrease patient and caregiver quality of life

• Precipitate institutionalizationSources: Srikanth S, et al. J Neurol Sci. 2005;236:43-48.

Shin IS, et al. Am J Geriatr Psychiatry. 2005;13:469-474.Phillips VL, et al. J Am Geriatr Soc. 2003;51:188-193.

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Differential Presentation of BSPD• Alzheimer’s disease:

• Irritability

• Self-centeredness

• Delusions

• Hallucinations

• Apathy

• Depression

• Insomnia

• Agitation and aggression

• Vascular dementia:• Emotional liability

• Severe depression

• Apathy

• Disinhibition

• Frontotemporal dementia:• Decline in interpersonal skills

• Apathy

• Decline in personal hygiene

• Mental rigidity/inflexibility

• Distractibility

• Hyperorality

• Stereotyped behavior

• Dementia with Lewy bodies:• Psychosis

• Anxiety and/or depression

• Apathy/amotivational states

• Aggressivity/violent behavior

• Nocturnal confusion/insomnia

• REM behavior disorderSources: Bakker TJEM, et al. Dement Geriatr Cogn Disord. 2005;20:215-224; Neary D, et al. Neurology. 1998;51:1546-1554; Roman GC. J Am Geriatr

Soc. 2003;51(5 Suppl Dementia):S296-S304; McKeith IG, et al. Neurology. 1996;47:1113-1124; McKeith IG, et al. Neurology. 1999;53:902-905.

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Mechanism of Impaired Driving based on Dementia Subtypes

• AD

• Amnestic, executive function: way finding, multitasking

• FTD

• Language and behavior: road rage, reading signs

• DLB

• Visuospatial: lane changing, gap acceptance

• PCA

• Cortical blindness: disorientation, lane maintenance

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The Long QT Syndrome• Disorder of myocardial repolarization

• Increased risk of life-threatening arrhythmia: torsade de pointes (TdP)

• Symptoms: palpitations, syncope, seizures, and sudden cardiac death

• Causes: Metabolic (low states), CNS, CTD, Cardiac, HIV, Meds

• Meds• Antiarrhythmics: (Amiodarone, disopyramide, procainamide, sotalol)

• Antidepressants: (TCA’s, SSRI’s)

• Antibiotics: (Quinolones, Macrolides)

• Antipsychotics: (Haloperidol, respiridone, clozapine, thioridazine, ziprasidone)

• Others: (Cisapride, ondansetron, sumatriptan, zolmitriptan, HIV drugs

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Rudolph, J. L. et al. Arch Intern Med 2008;168:508-513.

Sedation and Anticholinergic Side Effects

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The Serotonin Syndrome• Definition: potentially life-threatening adverse drug reaction that

results from therapeutic drug use, intentional self-poisoning, or inadvertent drug interactions

• Classic triad: mental status-changes, autonomic hyperactivity, and neuromuscular abnormalities

Boyer EW, Shannon M. The Serotonin Syndrome. NEJM 2005;352:1112-20

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Response N (%)No / does not take PDI medications routinely 70 (31.1)Yes / does take PDI medications routinely 155 (68.9)

Selective serotonin reuptake inhibitors 69 (30.7)Proton pump inhibitors 40 (17.8)Hypoglycemic agents 38 (16.9)Antiepileptic agents 26 (11.5)Antiparkinsonian agents 22 (9.8)Second generation / related antidepressants 18 (8.0)Benzodiazepines 15 (6.6)Opioid analgesics 10 (4.5)Non-benzodiazepine hypnotics 9 (4.0)Tricyclic antidepressants 9 (4.0)

Most prevalent* PDI medications by original(literature informed) drug class list

Hetland et al. Annals of Pharmacol 2014

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ESS

PDI medication use: Epworth Sleepiness Scale

Sample mean(N = 218)

7.25

‘Yes’ on PDI mean (N = 152)

7.80

‘No’ on PDI mean (N = 66)

5.98

P value 0.007

Association with PDI meds/sleepiness

Hetland et al. Annals of Pharmacol 2014

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Medications/Driving

• Narcotics• Barbituates• Benzo’s• Antihistamines• Antidepressants• Antipsychotics• Hypnotics• Alcohol• Muscle Relaxants• Antiemetics• Antiepileptic

Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC

Pharmacist/Client Resources

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How to detect and manage drug side effects for non-clinicians…• Be aware of reports from patient or family that note

associations with drugs

• Sedation, confusion, slowed response time, impaired attention, dizziness could be due to medications

• Drinking alcohol with any psychotropic medication may cause problems

• If you suspect side effects from medications, recommend your client discuss their drugs with their PCP/Pharmacits/RoadWiseRXSources: Srikanth S, et al. J Neurol Sci. 2005;236:43-48.

Shin IS, et al. Am J Geriatr Psychiatry. 2005;13:469-474.Phillips VL, et al. J Am Geriatr Soc. 2003;51:188-193.

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Objective

2. To develop a broader perspective and knowledge base related to cognition and driving

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Cognition and Dementia

Impairments:Episodic memory (e.g., forgetting conversations, repetition, missing appointments, forgetting recent events or details)

Executive function (e.g., impaired function, attention, organizing, planning)

Language (e.g., naming deficits/word finding deficits, aphasia)

Visuospatial /perceptual skills (e.g., not perceiving shapes or distance accurately)

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Dementia and Driving

• 88% of drivers with very mild dementia and 69% of drivers with mild dementia were still able to pass a formal on-road evaluation.

• The median time to cessation of driving in very mild dementia was 2 years from the time of the evaluation and in mild dementia it was 1 year

(Duchek et al., 2003; Ott et al., 2008).

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• Recent studies have indicated that tests of executive function and visual attention predict driving abilities in adults with early cognitive decline

(Dawson, Anderson, Uc, Dastrup, & Rizzo, 2009; Ott, et al., 2008; Whelihan, DiCarlo, & Paul, 2005)

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Attention

• Attention is an essential part of memory and information processing. Attention is related to many other cognitive functions.

• Consistently, researchers found that low scores on measures of attention were correlated with crash risk (Anstey, Wood, Lord, &

Walker, 2005).

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Type of Attention Difficulty

Example of Affected Driving Behaviors

Selective attention Visual: Difficulty selectively attending to a road sign while ignoring other distracters in the environment

Auditory: Difficulty selectively attending to a siren coming from behind due to attending to the music on the radio

Sustained attention

Difficulty sustaining attention for a prolonged period of time while driving on the highway

Alternating attention

Difficulty preparing for a lane change when alternating attention from glancing back and forth while looking in the side mirror and back to monitoring traffic conditions in the front of the car

Divided attention Difficulty maintaining safe control of the car while holding a conversation with a passenger at the same timeDifficulty maintaining safe control of the car while simultaneously attending to weather, road, and traffic conditions

Neglect Inaccurate lane positioning by not attending to the (affected) side of the road completelyLack of attending to a vehicle or pedestrian on the affected side while driving

Barco, P.P., Stav, W. B., Arnold, R., & Carr, D. (2012). Cognition and Community Mobility. In M. J. McGuire & E. Schold Davis (Eds.). AOTA Self-paced clinical course: Driving and community mobility. Bethesda, MD: AOTA.

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Video Clip #1

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Memory Loss in Dementia

Memory Loss in Dementia is known as a main symptomCommon statements:• ”I can’t remember where I was going”• “ I can’t remember what I did earlier in the day”• “ I can’t remember how to get home from the grocery

store”

Memory Loss – In advancing dementia• “I can’t remember do I put my foot on the gas or brake

when I shift into reverse”• “What does the sign mean with the people on it?”

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Type of Memory Difficulty


Short-term memory

Difficulty immediately remembering instructions on the driving assessment regarding which way to turn.

Working memory Difficulty if they miss a turn (turning around and going back). To do this, the individual must hold the original directions in their memory while “working” on the alteration.

Episodic memory Difficulty remembering where he or she parked the car after going grocery shopping

Difficulty remembering how to go to a familiar location (e.g., grocery store)

Difficulty remembering what type or year of car the individual owns or if he or she has had any recent accidents

Semantic memory Difficulty remembering what common traffic signs mean (e.g., yield sign, stop sign, railroad crossing) and common rules of the road.

Procedural memory

Difficulty remembering how procedurally to turn the key to start a car, to put the car in gear, or to apply pressure to the correct pedal to stop or start the car

Prospective memory

Difficulty remembering to follow through with the “intention” of putting gas in the car or doing routine car maintenance


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Executive Function

• Executive functions provide control over information processing and are a key determinant of driver strategies, tactics, and safety (Rizzo & Kellison, 2010).

• Many cognitive assessments that have been shown to have some value in predicting driving abilities are geared toward executive function (Anstey, et al., 2005).

• Executive function skills are most challenged in novel situations

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Executive Function Difficulties


Initiation Difficulty initiating moving the foot to the gas at the appropriate speed when a traffic light turns from red to green

Problem solving and decision making

Difficulty problem solving how to get out of a parking lot or garageDifficulty problem solving what to do if they cannot get over in a turn laneDifficulty problem solving what to do when sirens come from behind

Planning, sequencing, and anticipating

Difficulty anticipating that another vehicle may turn in front of him or herDifficulty planning for a lane change Difficulty anticipating the need to brake as other traffic ahead is slowing down or stopped

Flexibility in thinking and generation of alternatives

Difficulty thinking of what to do if miss a turn – where to turn around.Difficulty considering options of what to do if the car breaks down in traffic or where to get gas if outside of the ordinary route

Impulsivity Impulsively making a lane change without checking for other vehicles


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Visual Spatial and Visual Perceptual

• Visual perceptual tests show moderate to high associations with driving outcome measures (De raedt & Ponjaert-Kristofferson as cited in Anstey, et al, 2005)

• Visual perception and processing skills are needed to read road signs, judge distance and recognize/react to pedestrians and other vehicles (Baker, 2006)

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Speed of Processing

• Slow processing can interrupt processes of working memory and being able to store information in a way that it can be easy to retrieve. (Levy, 2005)

• Speed of processing also influences the rate at which an individual can produce a motor or verbal response to a given stimulus (Bryer, Rapport, & Hanks, 2006).

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Type of Visual Spatial/Perceptual/Processing Deficit


Depth perception or spatial relations

Difficulty accurately judging or perceiving gap distance when making a lane change

Difficulty perceiving travel distance between cars or necessary stopping distance

Difficulty perceiving the position of the car in a parking space, resulting in ineffective parking

Topographical orientation

Can become disoriented or confused in even a common parking lot or when driving a familiar route

Visual Processing Speed

Person may be looking at the surroundings (traffic light, pedestrians, car in front of them) and take longer to process the incoming information to react (e.g. put on the brake)

Person may be scanning the environment for where to turn and not process the sign quicker enough to make a turn.


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Video Clip #2

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Objectives

• To gain a better understanding of evidence based assessment approaches in driving rehabilitation

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Key Points

• Know website resources available to you that might inform your decision making

• Understand the neurology Approach to evaluating driving risk• Know the different fitness to drive approaches used by

clinicians when assessing older adults with dementiaDriving Questionnaires/Caregiver AssessmentsSingle Test ApproachesCombination of TestsMulti-Domain Models

• Know basic statistics on determining FTD and how they may guide you

• Know the concept of the probability calculator and how it might impact your decision-making

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Clinician Medical Guidelines

http://www.cma.ca/dri

versguide

http://www.austroads.com.au/assessing-fitness-to-drive/

Updated, Evidenced-BasedAlso Refer to Your Own State Guidelines

http://geriatricscareonline.org

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Signs of Unsafe Driving? Alz Association

• Hitting curbs• Using poor lane control• Failing to observe traffic signs• Making slow or poor decisions in traffic• Driving at an inappropriate speed• Becoming angry or confused while driving• Making errors at intersections• Confusing the brake and gas pedals• Returning from a routine drive later than usual• Forgetting the destination during the trip

Dementia and Driving Resource Center Alz Associationhttp://www.alz.org/care/alzheimers-dementia-and-driving.asp

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Dementia and Driving Toolkit

Byszewski A, Aminzadeh F, Robinson K, Molnar F, Dalziel W, Man-Son-Hing M, Hunt L, Marshall S.

When it is time to hang up the keys: the driving and dementia toolkit – for persons with dementia (PWD) and caregivers – a practical resource [letter].

BMC Geriatrics 2013;13(1):117.

http://www.rgpeo.com/media/30695/dementia%20toolkit.pdf

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What Should Be in an Evidenced-Based Driving History?

• Driving Behaviors• Informant Rating• Exposure• Personality• Violations• Crashes• Cognitive Impairment• Functional Impairment• Others?

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Neurology Approach to Evaluate Driving Risk in Dementia

Iverson et al. Practice Parameter Update:

Evaluation and Management of Driving Risk in

DementiaNeurology

2010.

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Robust Steps in Determining FTD

• STEP 1: Adopt a Framework or Model

• STEP 2: Decide on an Outcome

• STEP 3: Take a Driving History and/or Perform a PE

• STEP 4: Make Test Characteristics Your Friend

• STEP 5: Clinical Judgment

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Driving ScreensAssessment Batteries

• Driving Questionnaires

• Single Test Approaches

• Combinations of Psychometric Tests

• Multi-Domain Models

Dickerson et al, 2014, 2013 Driving Tools Used by DRS

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Driving Questionnaires-Part I• Driving Cognitions Questionnaire (Ehlers et al, 2007)

Evaluates Anxiety• Adelaide Driving Self-Efficacy Scale (George et al, 2006)

Evaluates Confidence• Impulsiveness, Venturesome, Empathy Test (Owsley et al,

2003)Evaluates Personality Traits

• Driving Cognitions Questionnaire (Ehlers et al, 2007)Evaluates Fear While Driving

• The Driving Habits Questionnaire (Owsley et al, 1999)General Questions Regarding Behaviors

• Fitness to Drive Screening Measure (Classen et al, 2015)Predicts road test performance

• Assessment Readiness Mobility Transition (Meuser et al, 2011)Evaluates readiness for driving cessation

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Driving Questionnaires-Part II

• Driving Confidence Rating Scale (Baldock et al, 2006)Evaluates Confidence

• The Driving Confidence Rating Scale (Marottoli et al, 1998)Evaluates Confidence

• Driving Comfort Scales (Myers et al, 2008)Evaluates Confidence

• DriveSafe and DriveAware (Hines, et al, 2014)Evaluates Driver Awareness

• Driving Anxiety Scale (Parker et al, 2001)Evaluates Anxiety

• Self-rated Driving Abilities (Paradis et al, 2006)Evaluates Insight

• The Driving Behavior Questionnaires (Reason et al, 1990)Evaluates risk for crashes

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Single Test Approach• Trailmaking (Molnar, et al 2013)• UFOV (Ball, et al 1991)• SIMARD (Dobbs, et al 2011)• ANT (Weaver, et al 2009)• Dynavision (Klavora et al , 1998)• Other

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Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352: 692-9

Do Single Test FTD Approaches Work?

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CANADIAN GERIATRICS JOURNAL, VOLUME 16, ISSUE 3, SEPTEMBER 2013

Review of 47 Driving Studies Using Trailmaking B“Verified” use of 3 minutes or 3 errors ruleRecommendations1.Determine sample size needed to prevent Type II/Beta Error2.Determine clinically useful cut-offs using AUC/ROC3.Consider multiple cut-offs or trichotomization4.Explore different scoring methods of Trailmaking B

Trails (B-A) or Trails B/ATrails B-A has been described as reflecting “the attention and set switchingcomponents of Trails B independent of psychomotor components.Color Trails may overcome literacy barriersConsider adding errors

Papandonatos GD, et alJ Am Geriatr Soc. 2015

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Combination of Psychometric Tests• DHI (Staplin, 2013)• DriveAble (Dobbs, et al, 2013)• Rockwood (McKenna et al, 2007)• ADReS (Ott et al, 2013)• NorSDSA(Nouri et al, 1993)• Other

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Predictive Values of Neuropsychological Tests and Test Batteries for Road Test

Performance Test(s) Sample Outcome

measureSensitivity Specificity Accuracy

(% Correctly Classified)

Computerized mazes

Normal + AD (CDR .5-1)

Road test NA NA 68.6

Computerize mazes+ Hopkins Verbal Learning+Age

Normal + AD (CDR .5-1)


Maze Navigation

Normal + AD (CDR .5)


Maze Task MCI + mild AD

Road test 77.8 82.4 77.4

Driving Scenes of NAB

Normal + AD (CDR .5)


Eight test battery

Mixed dementia

Road test 80.0 61.5 76.2

Carr D and Ott B. JAMA 2010; 303(16):1632-164

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Likelihood Ratios

• LR+ is simply the % of “sick” people with a given test divided by the % of “well” people with same result• Ex: LR+ = Sens/(1-Spec): LR+ 2-5 small, 5-10 moderate,

>10 large • Ex LR- =(1-Sens)/Spec: LR- .2-.5 small, .1-.2 moderate, <

.1 large • LR’s are useful across a wide range of frequencies

• Predictive values of tests are driven by the prevalence of dx• Uses all four cells of the 2x2 table• Can apply to a specific patient• LR’s are ratios of probabilities• 95% confidence intervals can calculate the precision of the

estimate.

Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005; 365: 1500-5

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Computerized Tests of Driving PerformanceThe DrivingHealth Inventory with UFOV

Peak valid at-fault OR

Visualization of missing information 4.96(MFVPT; Visual Closure)Directed visual search 3.50(Trail-Making B)

Working memory 2.92(Delayed Recall)Information processing speed 2.48

(Useful Field of View, subtest 2)Lower limb strength 2.64(Rapid Pace Walk)Head/neck flexibility 2.56

(Recognizing Clock Time)

Staplin L, et al. MaryPODS revisited. Journal of Traffic Safety, 2003: 389-397

Dobbs AR. Accuracy of DriveABLE. Canadian Family Practice 2013: 59: e158-161.

Staplin, et al. J Safety Research 2003Ball et al. JAGS 2005

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Multi-Domain Tests

• 4 C’s (O’Connor et al, 2013)• PC (Barco, Carr et al, 2011, 2014)• CanDrive (Marshall et al, 2013)• OT-DORA (Unsworth et al, 2011)• AMP (Dickerson, 2011)• Other

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The 4 C’s:

N=161, hospital based driving evaluation program, outcome marginal and fail on road test

O’Connor MG, et al. JAGS 2010; 58: 1104-8

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ResultsScores of 9 or greater-on the 4Cs identified 84% of participants whowere at risk for poor performance.AUC=0.81 for pass vs. marginal and fail, 0.70 comparing pass and marginal to fail

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Recent Studies in the Literature

• Papandonatos, GD, et al. JAGS 2015• Trailmaking A and B tests compared across sites• Test A scores greater 48 secs indicate risk• Prediction modest and need to validate own sites

• Bennett JM, et al. JAGS 2016• MMSE should not be used for FTD• Single tests not reliable• Composite computerized battery recommended

• Piersma, D PLOS one 2016• Neuropsychological testing was best FTD predictor in

AD participants• Combining clinical interviews, driving simulation and

psychometric testing resulted in accuracy of 93%

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Short Break!

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Recruit and telephone

screenDementia sample

n=99

Performon theRoad

Evaluationwith outcome

of pass/fail

Determine clinicaltest

Predictors andpredictive

model for the individuals with

dementia

Recruitment Assessment Analysis

The Design

Perform clinicalvision, motor,and

cognitivetesting

Mail outQuestionnaires

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Vision Assessment

Motor Assessment

CognitiveAssessment

Road Evaluation

Clinical Testing for Driving

•Neck ROM•UE/LE ROM•UE/LE Strength•Rapid Pace Walk •LE Sensation•9 Hole Peg•Brake Test

•Visual Acuity•Visual Fields•Humphreys FDT•Pelli Robson Contrast Sensitivity

•Clock Drawing Test•Mesulam Test•Trails A and B•Snellgrove Maze Test•DHI/MVPT•DHI/ UFOV•Road Sign Recognition•Rules of the Road

Testing ProtocolOutcome MeasureRoad Evaluation

1 hour

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Vision Assessment

Motor Assessment

CognitiveAssessment

BREAKRoad

Evaluation RecommendationMeeting

Outcome MeasureRoad Evaluation

1 hour

Clinical Testing for Driving2 hours

Pass/Fail Status Note: Marginals were collapsed into pass category for statistical analysis

Testing Protocol

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Demographics of Dementia Sample Based on Road Test Outcome

Characteristic

TotalSample(N=99)

Avg+SD/Range

PassRoadTest

(N=34)(35%)

FailRoadTest

(N=65)(65%)

P‐Value

Age(years)

74.2+9.0(52‐89)

73.4+9.3(52‐84)

74.7+8.9(52‐90)

0.49

Gender(%M)

63% 68% 61% 0.56

Education(years)

14.8+3.3(8‐20)

15.1+2.8(8‐20)

14.6+3.5(8‐20)

0.50

Race(%AA) 12% 10% 13% 0.71

Carr DB, et al. Predicting Road Test Performance in Drivers with Dementia. 2011 JAGS;59:2112-17

Male

Well Educated

Mainly Caucasian

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Psychometric Measures of Dementia Sample Based on Road Test Outcome

Measure

TotalSample(N=99)

Avg+SD/Range

PassRoadTest

(N=35)(35%)

FailRoadTest

(N=65)(65%)

P‐Value

ShortBlessedTest (SBT)*(N=99)

8.9+6.9(0‐28)

5.8+5.3(0‐24)

10.5+7.2(0‐28)

0.003*

SMTMazeTest(secs)*(N=96)

49.5+35.1 35.2+12.3 62.5+43.9 0.001*

CDT‐Freund(0‐7)*(N=98)

4.9+2.3(0‐7)

6.2+1.2(2‐7)

4.2+2.5(0‐7)

0.0004*

TrailsA*(secs)(N=98)

68.1+39.5(20‐88.5)

45.8+17.2(19.5‐89.0)

79.9+42.8(19.6‐151)

0.0007* *p<0.05

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Psychometric Measures of Dementia Sample Based on Road Test Outcome

Measure

TotalSample(N=99)

Avg+SD/Range

PassRoadTest

(N=35)(35%)

FailRoadTest

(N=65)(65%)

P‐Value

TrailsB*(secs)(N=99)

196.9+86.0(42‐301)

151.8+75.7(42‐301)

226.9+79.6(61‐301)

0.0002*

AD‐8Total*(N=99)

5.3+1.7(2‐8)

4.3+1.5(2‐7)

5.8+1.6(3‐8)

<.0001*

MFVPT(#incorrect)(N=74)

3.9+2.8 3.1+2.7 4.5+2.8 0.16

UFOV(msec)*(N=56)

276.4+148.1 216.8+129.0 342.9+136.5 0.012*

*p<0.05

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Alzheimer’s Detection: AD8

TOTAL AD8 SCORE

Consistent problems with thinking and/or memory

Difficulty remembering appointments

Difficulty handling complicated financial affairs (e.g. balancing checkbook, income taxes, paying bills)

Forgets correct month or year

Trouble learning how to use a tool, appliance or gadget (e.g. VCR, computer, microwave, remote control)

Repeats questions, stories or statements

Reduced interest in hobbies/activities

Problems with judgment (e.g. falls for scams, bad financial decisions, buys gifts inappropriate for recipients)

N/A,Don’t know

NO,No change

YES,A change

Remember, “Yes, a change” indicates that you think there has been a change in the last several years cause by cognitive (thinking and memory) problems

AD 8 is a copyrighted instrument of the Alzheimer’s Disease Research Center, Washington

University, St. Louis, Mo.The AD8 is not a substitute for clinical judgment.

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Clock Drawing Task (CDT)

Time_____ One hand points to 2 (or symbol representative of 2)_____ Exactly two hands____ Give point if there are no intrusive marksNumbers_____ Inside the clock circle_____ Only numbers 1-12, no duplicates or omissionsSpacing_____ Numbers spaced equally or nearly equally from each other _____ Numbers spaced equally or nearly equally from the edge of the circle

Subjects are verbally instructed to draw a clock, put all the numbers in, and set the time at ten minutes after eleven. The instruction is also written and visible at the top of the page in 16-point font. Instructions may be repeated verbatim as needed. No cues are allowed. When the subject indicates they are finished, the question “Now tell me what time this clock says?”is asked. Self correction is permitted.

Freund, B., Gravenstein, S., Ferris, R., et al. Drawing clocks and driving cars.J Gen Intern Med. 2005; 20:240–244

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Trails A Snellgrove Maze®

Maze Task1) Not language based 2) Not covered by Psychological Practice Acts 3) Supported by additional studies

For information about the Snellgrove Maze Task® please contact Dr Carol Snellgrove at; [email protected]

14

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Dementia SampleROC CURVE for Trails A, AD-8, CDT

(AUC=.84 blinded n=99)

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Probability of Failing Road Test Calculator

How much uncertainty are you willing to accept?How good do our tests need to be?

where

and

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CASE STUDIES

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Acknowledgements• Our Participants and

informants• Our Referral Sources• Memory and Diagnostic

Center Steve Ice, Independent

Drivers LLC Washington University OT

Students: Caleb Krenk Jacob Rosen

• MoDOT/Highway Safety • Leanna Depue• Jackie Rogers• Bill Whitfield

Washington University Driving and Research Center:Ann Johnson , Program CoordinatorMike Wallendorf, PhD, StatisticianKatie Rutkoski, OTR/LKathy Dolan, OT/LLily Hu, Data Base Manager

• Jefferson Barracks VAPat Niewoehner, OTR/L

• Department of Psychology, UMSLDr. Thomas Meuser

• SLUDr. Marla Berg-Weger

Documents

DISCLOSURES (2014-Present) Epidemiologyc.ymcdn.com/sites/ · • Insidious onset and gradual progression ... • Prosopagnosia • Prolonged color after-images Crutch et al Alzheimer’s