The Driver with Dementia: How Far Can They Go and For

How Long?David B. Carr, M.DAssociate Professor of Medicine and Neurology

Clinical Director

Division of Geriatrics and Nutritional Science

Alzheimer’s Disease Research Center

Medical Director, The Rehabilitation Institute of St. Louis

Disclosures Funding Support

• National Institute on Aging (NIA)• AAA Foundation• Missouri Department of Transportation• LongerLife Foundation

Consulting Relationships• American Medical Association (AMA)• ADEPT• SeniorSMART

Speakers Bureau• St. Louis Alzheimer’s Association

Drug Industry Sponsored Trials• None

Investment/Stock/Equity• None

Objectives for Today’s Lecture

Something Old: 20 minutes/20 slides• Studies on Driving and Dementia

Something New: 20 minutes/20 slides• WU Dementia and Driving Efforts

Something Borrowed: 20 minutes/20 slides• Future Research Efforts

Something Blue: Last slide• A solution for demented drivers

In 60 minutes or less!!

Something Old: Dementia/Driving

Dementia• The Spectrum

• The Numbers

• Rating Severity

Driving• Crashes

• Road Test

• Functional Abilities

• Cessation

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

Affects > 4 million people in the U.S. (20 million world-wide) Results in > 100,000 deaths per year Costs > $100 billion annually

Alzheimer’s Disease

16

14

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2

4

6

8

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2000 2010 2020 2030 2040 2050

45.8

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11.3

14.3

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4 Million AD Cases Today—4 Million AD Cases Today—Over 14 Million Projected Within a GenerationOver 14 Million Projected Within a Generation

Year

Clinical Dementia Rating (CDR) Table

Very Mild

Important Driving Outcomes

Crashes Road Tests Simulators Cessation Alcohol Caregiver assessment

Number of Licensed Drivers

Older Adults in Motor Vehicle Crashes

http://search.cga.state.ct.us/dtSearch_lpa.html

Exposure: Vehicle Miles Traveled

Anticipated Finding of 2005 Survey

d

The Issue of Low Mileage Bias

Langford J, et al. 2006 Accident Analysis and Prevention, 28(3), pp. 574-578

Summary of Crash Rates/Dementia

Group Crashes/driver/year

National Crash Rates Older Drivers (65+ yrs)

4%

National Crash Rates Young Drivers (16-25yrs)

12%

Control subjects in studies cited

~ 4%

Drivers with dementia

~8%

Motor Vehicle Crashes/CDR OBJECTIVE: To determine whether there is a difference in crash rates and

characteristics between drivers with dementia of the Alzheimer type (DAT) and nondemented older persons who were controls.

SETTING: Alzheimer's Disease Research Center at Washington University in St. Louis, Missouri. Subjects were enrolled as volunteers in a longitudinal study of aging and DAT.

PARTICIPANTS: 58 nondemented older drivers and 63 drivers with DAT which was diagnosed using validated clinical diagnostic criteria and was staged by the Clinical Dementia Rating (CDR) Scale. (CDR = 0.5) or mild (CDR = 1) stages.

MAIN OUTCOME MEASURE: 5-year retrospective analysis of state-recorded crash data.

CONCLUSIONS: In our pilot study, individuals with very mild or mild DAT who continued to drive seemed to have crash rates similar to those of the controls.

Carr DB. Et al. JAGS. 48(1):18-22, 2000.

Dementia and Driving Crash Studies ~30% of demented drivers will have a crash when

followed over 3 years ~50% of the drivers with dementia stop driving within

3 years of disease onset Crash risk increases with the duration of driving and

males appear to be at higher risk Studies indicate that at least 30% of older adults

with dementia that present to subspecialty clinics will still be driving

Possibly 20% of drivers over age 80 years that present for license renewal may be demented

Driving exposure is probably less with demented drivers in comparison to older adults

Limitations of Crash Data:Association or Causation?

Washington University Road Test Closed course test Open road test Qualitative score 0-108 Quantitative score

• Safe, Marginal, or Unsafe Traffic Skills

• traffic signs• negotiating intersections• changing lanes• signaling• left turns• maintaining speed

*Hunt et al, Archives of Neurology 1997;54:707-712

Characteristics of Study Participants

Clinical Dementia Rating

0(nondemented)

N=56

0.5(very mild DAT)

N=36

1(mild DAT)

N=29

Age (y) 76.8 8.6 74.2 7.6 73.1 8.2

% Female 48 23 50

Education (y) 14.9 3.3 13.7 3.7 13.4 3.2

Short Blessed Test Score (0-28)

1.4 2.1 4.8 5.9 14.2 6.7

Years driving 55.0 13.5 57.0 40.2 51.6 14.5

Hunt et al. Arch Neurol 1997;54:707-712

Driving Performance

Control Very Mild Mild

Safe 78% 67% 41%

Marginal 19% 14% 18%

Unsafe 3% 19% 41%

Longitudinal Study

Study Conclusions

Clear relationship between impaired driving and dementia severity

Diagnosis alone is not the best predictor• 41% of mild DAT drivers failed

Some mild DAT individuals remain safe drivers testing• variable rate of decline

At-risk drivers: repeat drive evaluations 6-12 months CDR 1 level (mild dementia) appears to be the

transition phase

Driving and Dementia: When is it time to hang up the keys?

Green Light• No red flags• Monitor at intervals

Yellow Light• Red flags• Refer for driving evaluation

Red light• Driving Cessation/Retirement

Dubinsky, R. et al. Practice parameter: Risk of driving and Alzheimer’s disease Neurology 2000;54:2205-2211 Reger MA, et al. Neuropsychology2004; 18: 85-93

Something New

Studies Stakeholders Education Questionnaire Fitness-to-Drive

AARP Website, 2007

Top 10 Strategies to Help Drivers Retire

1) Hiding/filing down the keys2) Do not repair the car3) Remove the car by loaning, giving or selling4) Disable the car5) Replace keys6) Raise concern about losing life savings7) Ask non-family member to talk with driver8) Ask physician to “prescribe” driving retirement9) Use a contract (see At the Crossroads guide)10) Initiate the revocation process

Washington University St. Louis ADRC

• Clinicians assessed older adults in the Alzheimer's Disease Research Center (ADRC) for the presence and severity of dementia.

• The diagnosis of DAT was comparable to the DSM-IV Manual (APA)

• We identified 143 DAT subjects in our data base who were driving at entry between 1981 and 2000, but who stopped driving according to collateral source report at a subsequent follow-up.

• We identified active DAT drivers of comparable age, dementia status, and length of time in the data base, who were still driving.

Carr DB et al, Gerontologist 45: 824-827, 2005

Sample CharacteristicsVariable Active Drivers

(n=65)

M, SD

Stopped Driving

(n=158)

Age (yrs) 79.5 (6.6) 78.3(7.9)

Education (yrs) 13.1 (2.9) 13.7(3.5)

Female (%) 50 62

White (%) 97 93

# Meds 2.9(2.3) 2.8(1.9)

Short Blessed 8.2(6.8) 8.5(5.9)

Acuity OD 20/38(35) 20/35(38)

Acuity OS 20/31(12) 20/45 (85)

Sum of Boxes 3.2(2.3) 3.3(2.0)

Psychometric Tests

Variable Active Drivers

(n=65)

Stopped Driving

(n=158)

Factor Score -2.00(1.77) -2.08(1.36)

Logical memory 3.95 (3.00) 3.46(2.50)

Block design 21.09(10.61) 19.39(9.24)

Digit symbol 29.51(12.87) 28.25(12.99)

Trails A (secs) 70.14(38.05) 70.4(37.83)

Trails B (secs) 154.67(37.84) 157.57(32.54)

Discussion• Cognitive impairment/unsafe driving behaviors were the most

common reasons cited for driving retirement• The majority of drivers had very mild DAT and mild cognitive

impairment at the time of driving retirement• Psychometric tests were no different between active drivers and

recently retired drivers• Non-cognitive factors (e.g. psychosocial issues), are likely

important in the decision to stop driving• More research is needed on “when to say when” in the driver

with DAT• More pertinent may be the question “how to say how” to stop

driving

Driving Questionnaire Study LongerLife Foundation: Activities in Late -Life

• Nancy Morrow-Howell, PI Focus on Activities and Activity Portfolios Background

• 20,000,000 older adults driving in 2006• Driving life expectancy• Negative outcomes with driving cessation• Primary goal was to document “at-risk” activities• Secondary goal was to document

– Decline in traffic skills– Barriers in the process of driving cessation– Key decision-makers in driving retirement– Psychological impact

RQ1• What are the negative consequences of driving retirement in older adults

with dementia referred to MDC? H1

• Caregivers will document a reduction in out-of-home activities and an increase in depressive symptoms.

RQ2• Do caregivers observe impaired traffic skills in demented patients that are

evaluated in MDC? H2

• When provided a specific list, caregivers will document the presence of impaired traffic skills.

RQ3• What are the barriers to driving retirement in MDC patients with dementia?

H3• Patient characteristics may delay driving retirement.

Methods Site

• Patients were drawn from referrals to the Memory Diagnostic Center (MDC), a dementia specialty practice of Washington University School of Medicine

• Five neurologists, one geriatrician, and six nurse clinicians

• Referrals to MDC are made by primary care physicians and from the community

• Evaluations are usually for cognitive, behavioral, and mood disorders

• Less than 1% are unable to identify a collateral source

Methods Sample (Inclusion Criteria)

• Patients with a history of driving • First time diagnosis of dementia either on

initial or subsequent visit to MDC• 2001-2006• Collateral source with an address• Approved by Human Studies• Consent obtained from both the Informant

and patient via mail.

Driving Questionnaire (DQ)

DQ mailed to 564 patient-informant dyads in August 2006 to those patients who were evaluated between 2001-2006 in MDC

Subsequent Exclusions

• 18 patients never had a history of driving when the charts were abstracted by the nurse clinician

• An additional 19 charts were off-site This left 527 patients in our MDC sample 119 questionnaires were returned response rate of 23%

• 65% spouse, 25% child, 10% other

• average age 64 years (+12.9)

Table 2: Driving Behaviors

Questionnaire (N = 119) Var iable N % Active Drivers 34 28.7 Valid License 68 56.7 Rated as poor or unsafe 20 16.7 Rated as fair/questionable 43 35.8 Distant areas (>15 miles) 39 32.5 Far areas (>100 miles) 21 17.5 Crash in past year* 6 17.6 Days of driving per week* 4.7 +2.0 SD N=34 Active Drivers

Table 2 (cont): Driving Behaviors Questionnaire (N = 119)

Variable N % Monitoring for traffic 36 30.2 Maintaining speed 30 25.2 Turns/Intersection 25 20.8 Backing up 22 18.3 Staying in Lane 21 17.5 Traffic Signs/Signals 17 14.2 Parking 13 10.8 Yielding 11 9.2 Gas/Brake Pedals 8 6.7 1 or More 85 70.0

Table 3: Negative Consequences (At-Risk Activities)

(N=93) Stopped Activity Reduce Activity Variable N % N % Shopping 42 45.2 40 43.0 Working 30 32.2 15 16.1 Meetings 24 25.8 43 46.2 Social Visits 23 24.7 40 43.0 Health 23 24.7 12 12.9 Trips 20 21.5 21 22.5 Religious 17 18.2 16 17.2 Recreation 16 17.2 21 22.5 Restaurants 16 17.2 26 30.0 Movies 12 12.9 16 17.2 Civic 12 12.9 15 16.1 Cosmetics 10 11.0 12 12.9

Table 3 (cont): Negative Consequences (Psychological Impact)

(N=79 of 85) Worse No Change Variable N % N %

Depression 37 46.8 35 44.3 Anxiety 27 34.1 35 44.3

Motivation 32 40.5 36 45.6 Social Interest 37 46.8 35 44.3

Activities 41 51.9 31 39.2

***Other columns not listed are “better”, “unable to predict”

Table 4 (cont): Driving Retirement (Education)

Questionnaire (N = 85) Var iable N % None below 56 65.9 OT evaluation 10 11.8 Other* 9 10.6 36 Hour Day 8 9.4 Social worker 2 2.4 Educational info organization 0 0 *No write in candidates under “other”

Discussion The number of active drivers that present to MDC with dementia is

consistent with reports from other sites Non-DAT drivers were present in this sample Informants are aware of abnormal driving behaviors and rate some

patients driving skills as fair to poor Crashes were documented in the active group of drivers at a rate

higher than our MAP sample Those active drivers are making frequent trips and a significant

minority are driving far distances

Discussion (cont). There are “at-risk” activities in MDC demented drivers There appears to be a psychological effect on some drivers

after retirement Family and physicians were most influential in the decision to

stop driving in this sample Patient and caregiver characteristics or personality traits

appear to play a role in delaying driving retirement Educational resources and social workers were rarely utilized

by caregivers

Research on Fitness-to-Drive: CVA Fitness-to-Drive in Dementia/Stroke: Timeline

• Funded by the MoDot/LongerLife Foundation• Started October 1st, 2007• Purpose: To identify patient characteristics that predict failure on a

standardized road test (WURT) and/or at-fault crash data• Human Studies approval (9/07)• Telephone Screening (10/07)• Identify and hire study coordinator (10/07)• Identify and hire driving evaluator (10/07)• Identify and hire additional OT’s (11/07)• Create family and patient questionnaire (11/07)• Final selection of off-road tests (11/07)• Modification of the WURT (11/07)• Trial testing of off-road and on-road tests 12/07• 1/07 start assessments

Screening

INCLUSION• Active License• History of a CVA with any type of deficit• Physician referral for a driving evaluation• Age 25 years or older• NIHSS scores between 1-13• TOAST Classification

Annie Johnson, Research Patient CoordinatorCenter for Applied Research ScienceCampus Box 8009, 660 South Euclid AvenueSt. Louis, Missouri 63110-1093(314)362-0881 phone, (314)747-1404 faxjohnsonann@msnotes.wustl.edu

Screening REASON FOR EXCLUSION

• not interested• too young <age 25 • advanced disease • current major depression • unstable disease • severe orthopedic/musculoskeletal impairments• severe visual, hearing, or language impairment• no informant• Medications causing sedation• less than 10 years driving experience• participant refuses• Drivers license not active• Failed recent (past year) driving evaluation

Expanded Fitness-to-Drive Study Create a set of standards for driving evaluations (OT’s)

• History (DHQ, Destinations, etc)• Physical Exam (DHI, Muscle Strength, etc)• On-the-road performance testing (WURT, DMV, etc)

Recruit OT’s across the state of Missouri• Urban• Rural

Create a common data base that would be shared by sites• Desktop• Web-based

Develop disease specific fitness-to-drive models• Diseases: Dementia, CVA, other• Outcomes: Road Test, Cessation, Crashes, At-fault Crashes, etc

Statistical Methods Independent variables: continuous, categorical Dependent variables: continuous, categorical Use t-tests for continuous, chi-squre for categorical Inter-rater and intra-rater reliability and perhaps measures of test

stability Determine unadjusted correlations with pass/fail Stepwise logistic regression for those variables that were significant,

along with important demographics Models will be created to determine the combinations of

independent variables that best predict road test failure ROC curves to be created with the AUC to reflect graphically and

quantitatively the ability of the model to discriminate those that fail from those that pass

Something Borrowed: Future Efforts

• Neurological Disease and Driving

• Functional Abilities and Driving

• Heterogeneity

• Simulators

• Functional Brain Imaging

Driving Studies by Diagnosis*

DX Total MVA’s SIM ROAD RETIRE

CVA 18 2 6 8 2

BI 12 1 2 7 2

SC 2 0 0 2 0

PD 7 2 2 1 2

DAT 33 3 5 13 9

Searching Medline last 10 years MESH headings; driving, automobile driving, traffic accidents, rehabilitation, cva, brain injury, sc, ms, pd,

dementia: English

Clock Drawing Task/Driving

119 community-dwelling older adult driversCDT showed a high level of accuracyAnalysis revealed a CDT score of 4 or less, had a

likelihood ratio of +27.58 for predicting unsafe driving (sensitivity 64%, specificity 97%)

Outcome measure was failure on a driving simulator

3 points for using two hands correctly, 2 points for using correct numbers, 2 points for appropriate spacing

Freund et al, Drawing Clocks and Driving Cars. J Gen Intern Med 2005; 20:240-44

Summary and Conclusions from Maryland Pilot Older Driver Study

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

Neuropsychological Assessment Battery

Brown LB, Stern RA, Cahn-Weiner DA, et al. Driving scenes test of the Neuropsychological Assessment Battery and on-road driving performance in aging and very mild dementia. Arch Clinic Neuropsychol 2005;20: 209-15

Driving and non-DAT Dementia

Alzheimer’sDisease

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Frontotemporaldementias

Lewy bodydementia

Vascular dementia

Non-DAT dementia and driving De Simone V, et al. Driving abilities in frontotemoral

dementia patients. Dementia and Cognitive Disorders 2007; 23: 1-7• 15 FTD and 15 healthy controls on a simulator

• FTD patients higher speed, missed stop signs, MVA’s

Fitten LF, et al. Alzheimer and vascular dementias and driving. JAMA 1995; 273: 1360-5• 12 VD and 26 healthy controls on road test

• VD patients were more impaired on the road test

• Correlates with short term memory, visual tracking, MMSE

Dr. Rizzo and colleagues: U of Iowa

Rear-end collisions are the most common crash Study to test REC avoidance 61 drivers with DAT and 115 controls 89% of drivers with DAT had unsafe outcomes

compared to 65% of controls• REC or risky avoidance behavior

• Abrupt slowing increased the odds of a REC

• Unsafe outcomes were predicted by psychometric tests

Uc EY, et al. J of Neuro Science 2006: 251: 35-43

The Neural Correlates of Driving

• fMRI/SPECT and driving: 12 normal subjects did active and passive driving

• Driving impairment correlated with both a reduction of right hemispheric cortical perfusion (temporo-parietal region) as well as decrease in perfusion of the frontal cortex

• Left sensorimotor cortex active (pre and post central gyrus)

• Mainly BA 19 occipital areas and BA 7 parietal cortex bilaterally are involved

• Vermis and both cerebellar hemispheres

• Other area activity is suppressed

• Active driving produced increased activity in a number of brain regions including temporal, frontal, hippocampal, and subcortical regions.Ott BR, et al. Dement Geriatr Cogn

Disord 2000; 11: 153-60

The Future

Neurological Diseases OT vs. DMV vs. Rehab vs. Physician settings Fitness-to-Drive Outcome Measures Rehabilitation Efforts Statistical Approaches Simulators Others?

Something Blue: The Real SolutionDriving Restriction is the Answer

Acknowledgments(1): WUSTL ADRC

• Clinical Core– John Morris– Jim Galvin– Virginia Buckles– Mary Coats– Vicki Weir– MAP/MDC Clinicians/Staff

• Psychometric Core/Psychology– Martha Storandt– Jan Duchek

• Biostat Core– Betsy Grant– Cathy Roe– Staff

• Educational Core– Jim Galvin– Barbara Kuntemeir

School of Social Work• Nancy Morrow-Howell

Program of OT• Carolyn Baum• Peggy Barco• Susan Stark• Holly Hollingsworth• Lisa Connor• Jami Croston

Neurology• David Holtzman• Mauricio Corbetta• Rob Fuscetola

Division of Geriatrics/NS• Sam Klein• Ellen Binder• Stan Birge• Dennis Villareal• JoAnn Wilson

Civil Engineering• Gudmundur Ulfarrson

Acknowledgments(2): The Village St. Louis

• Tom Meuser– Center for Aging, UMSL

• Marla Berg-Weger – SLU School of Social Work

• Pat Niewoehner– Jefferson Barracks VAH

• Mike Right– VP AAA St. Louis

• Shel Suroff– CARD

• Katie McLean– Alzheimer’s Association

• Independent Drivers– Steve Ice

• Alzheimer’s Association

St. Louis• TRISL

– Barbara Jacobsmeyer– Gerry Hefele– Jackie McClanahan– Stacy Luters

Missouri• Leanna DePue/Jackie Rogers

– MoDOT

• Michael Taylor– Rusk

External Advisors• Linda Hunt

– Pacific University

• Loren Staplin– Transanalytics

Why is the need for research urgent?