Disclosure. Learning Objectives

(1)

Geriatric Grand Rounds

Tuesday, April 7, 2009 12:00 noon

Dr. Bill Black Auditorium

Glenrose Rehabilitation Hospital

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The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

The Medically At-Risk Driver

Centre: Addressing a Preventable

Public Health Issue Through

Partnerships and Collaboration

Dr. Bonnie Dobbs

Director- The Medically At-Risk Driver Centre

Director of Research-Division of Care of the Elderly,

Department of Family Medicine

Glenrose Hospital Grand Rounds April 7, 2009

Disclosure

I have no relationship that could be perceived

as placing me in a real or apparent conflict of

interest in the context of this presentation.

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Learning Objectives

•

To learn about the mission and goals of the

Medically At-Risk Driver Centre (MARD

Centre)

•

To increase understanding of the need for

an integrated approach to addressing the

medically at-risk driver issue

•

To become aware of opportunities for

partnerships and collaboration to address

this preventable public health issue

(2)

Addressing a Preventable Public

Health Problem

•

MVCs in Canada in 2006

– 2,604 preventable fatalities (~ 7/day)

– 144,756 preventable personal injuries

1

(~ 397/day)

– 15,281 preventable serious injuries

2

(~ 42/day)

•

MVCs in Alberta in 2006

– 453 preventable fatalities (1.24/day)

– 25,964 preventable injuries (~ 71 per day)

1 _{‘Personal Injury’ collisions include all reportable motor vehicle crashes which resulted in}

at least one injury but not death within the timeframes set out in “Fatal collisions”.

2 _{Admitted to hospital for treatment or observation}

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Fatalities and Injuries

• Due in part to ‘high risk and

medically unfit drivers’

(Alberta Traffic

Safety Plan, 2008)

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Medical Conditions and Driving

FOR IMMEDIATE RELEASE: November 9, 2004 SB-04-32

National Transportation Safety Board CALLS FOR GREATER OVERSIGHT OF DRIVERS WITH HIGH RISK MEDICAL CONDITIONS

Conclusions of NTSB (2004)

• Significant number of illnesses affect driving • Extent not well defined

• Need for the development of procedure to collect, evaluate and report data regarding the impact of drivers' medical conditions

• Many physicians involved with patient care are not knowledgeable about reporting policies or about the evaluation of patient’s fitness to drive • Need for training in medical schools and continuing medical education • Law enforcement personnel are generally unaware that medical impairments

can affect driving

• No uniform process to identify, report, assess, license or counsel drivers with high-risk medical conditions.

• Need for an integrated, comprehensive system

(3)

Medical Conditions and Driving

• Medical conditions that affect driving

can occur at any age

• Many are, however, age associated in

that they are more likely to occur with

age (cognitive impairment)

• Many can negatively impact the ability

to drive

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Crash Rates Based on Exposure

0 1 2 3 4 5 6 7 8 9 10 16 17 18 19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Driver Age Group

Source: FARS 2001 and NHTSA 2001

Driver Fatality Rate (per 100 million VMT)

Fa ta lity Rat e

‘Red Flags’

Red Flags*

• Cardiovascular disease(e.g., congestive heart failure, cardiac arrhythmia)

• Metabolic disease(e.g., diabetes, hypothyroidism)

• Cerebrovascular disease(e.g., stroke, arteriosclerosis)

• Renal disease(chronic renal failure)

• Neurological disease(e.g., head injury, Parkinson’s Disease, Multiple

Sclerosis, tumor, narcolepsy, sleep apnea)

• Dementia(e.g., Alzheimer’s Disease, multi-infarct dementia, frontal temporal

dementia, Pick’s Disease)

• Respiratory disease(e.g., chronic obstructive pulmonary disease, respiratory

failure)

• Psychiatric illness(e.g., schizophrenia, depression)

• Medications (e.g., anti-depressants, other medications having prominent

central nervous system effects)

*From B. Dobbs (2005) DOT/NHTSA report

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Increased Crash Risk

(At-Fault Crashes)

┼

Condition

Relative Risk

•

Visual Acuity

1.5*

•

Diabetes

1.5*

•

Pulmonary

1.3*

•

Psychiatric

1.8*

•

Epilepsy

2.0*

•

Neurological

2.2*

•

Musculoskeletal

1.8*

•

Cognitive Impairment

3.3*

┼_{Diller et al., 1999 (Unrestricted drivers compared to control group)}

* Significantly different from control group

(4)

A crash caused by a medically

impaired driver results in social,

economic, and personal costs

:

9

Casualty crashes of drivers 65+: Projected to increase by over 200% by 2026 (versus a 25% projected increase for drivers under age 65).

9

Projected tripling of crash costs associated with older driver crashes

9

The costs of older driver crashes in Alberta are projected to be a quarter billion dollars, between 2005 and 2020

Projections 2001-2026

Projected Change in Casualty Crashes by Driver Age (2006-2026) 0 50 100 150 200 250 300 <20 20-24 25-34 35-44 45-5455-64 65-74 75-84 85+ Age Range P e rc en t C h an g e Fatalities Injuries

Source: L’Écuyer, et al. , 2005 - CMRSC XV.

Fatalities and Injuries

• In 2000, ~ 40% of fatal crashes

were alcohol-related

• Projected that by 2025-more than

25% of all fatal crashes may be

age-related

(Hu et al., 2000)

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

The Consequences are Real

• Elizabeth Kidnie

• 42-year-old mother of three

• Hit by a car driven by a 85

year old driver

• Dragged for nearly half a

kilometer

• Ontario, Canada

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Santa Monica Farmer’s Market Crash

•

10 killed

•

63 injured

•

86 year old

driver charged

with 10 counts of

manslaughter

•

Convicted of 10

counts of

manslaughter

July 16, 2003

(5)

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Response from Mr. Weller’s

Lawyer

• At sentencing:

– Judge said Mr. Weller “displayed an

enormous indifference to human life”

– Lawyer argued for leniency due to client’s

poor health (“mini-strokes/neurologically

impaired”)

– Judge place Mr. Weller on probation

Clearly A Need

• Targeted approach

– High risk medical conditions

• A comprehensive/integrated approach

• Involvement of multiple stakeholders

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Medically At-Risk Driver Centre:

An Alberta Solution

• An important shift

– Away from an inappropriate focus on

senior drivers

– To an appropriate focus on medical

impairments

• Allows for appropriate identification of

the issues and targeted interventions

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

What is the MARD Centre?

A University of Alberta based research

centre that is committed to:

– the discovery and development of

evidence-based solutions to identify and

assess medically at-risk drivers, and to

– provide advancements in support for those

who can no longer drive.

(6)

What does the MARD Centre

not do?

• Not a licensing entity

• No involvement with licensing decisions or driving

assessments

• Driver Fitness and Monitoring should be consulted for

these issues

– http://transportation.alberta.ca/DriversVehicles.htm

• Not targeting the removal of elderly drivers from our

roadways because of age or the removal of a license

based on diagnosis

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

What does the MARD Centre

do?

• Research and knowledge translation activities

leading to:

– The discovery of techniques and/or improved

solutions for identifying medically at-risk drivers

– New protocols for the assessment of drivers

identified as medically at-risk

– Provision of support to individuals and families to

enhance safety and mobility

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Framework for Research Activities

• Focus on partnership and collaboration

with University

and

Community based

stakeholders

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

A Focused and Integrated Approach

• Broader Involvement • Evidence-Based Screening Tools • Coordinated System

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

– Protection of those who are safe to drive – Protection from those

who are unsafe – Risk Management/

Legal defensibility

Identification

Assessment

Support

Psychosocial Mobility Medical Community Law Enforcement •Assist with transition (Individual and family) •Alternate Mobility –Awareness –Implementation

Families and Friends Individuals Licensing Authorities

(7)

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

Traffic Safety Community

Edmonton Southside Primary Care

Medically At-Risk Driver Initiative

(Dobbs, B., Daly, S., Carstensen, B., Zirk, H., & Dobbs, A.)

• SS Primary Care Network

– ~ 60 physicians

– Clinics/individual practices

– Multidisciplinary team

– Non-fee for service

– 2 clinics with high percentage of 65+

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Targeted to the Primary Care

Setting

Family physicians well placed for

identifying medically at-risk drivers

• First point of contact

• Continuity of Care

• Patient preference

• Family expectations

• Societal expectations

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Increasing Pressure for Physician

Involvement

• Increasing pressure and a growing

mandate for physicians to address

medical fitness to drive

• Pressure likely to increase as more and

more patients enter their senior years

where medical impairments are most

likely

(8)

Edmonton SS PCN Primary Care

Medically At-Risk Driver Initiative

• Phase 1:

Education

• Phase 2:

Implementation of MARD Protocol

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca (Dobbs, B., Daly, S., Carstensen, B., Zirk, H., & Dobbs, A.)

Phase 1 Results

Change in Knowledge/Attitudes

0 20 40 60 80 100 % Ch an g

e Medical Conditions &Driving

Beliefs re: Determination of Stopping Driving Decision Making re: Driving Competence

Post-Workshop vs. Pre-Workshop Responses

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Barriers to ‘Engaging’ in Issue

0

2

4

6

8

10

Fr

equency of

R

esponse

Time Tools/Knowledge Discomfort with Issue Compensation

Most Frequently Reported Barriers

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Phase 2

Change in Practice

– Chart data extraction

• Pre-Intervention

(One year prior to workshop and implementation of

protocol)

– 3 conditions: Epilepsy, Dementia, Alzheimer’s

disease

• Post-Intervention

(One year following workshop and implementation

of protocol)

(9)

CME Courseware

• Internationally Peer

Reviewed

Courseware

• CME credits (CFPC)

• Tutorial, DVD’s,

interactive break-out

sessions

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

The SIMARD®

• A valid and reliable screening tool for

the identification of Medically At-Risk

Drivers

(Dobbs, 2008)

– Easy to administer and score

– Inexpensive

– Short (~ 5 minutes)

– Patient and administrator friendly

– Valid (high predictive properties)

– Reliable (inter- and intra-rater)

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

•

Revised and updated edition of

Medical Conditions and

Driving

•

Scientific Review and

Integration of the Literature

•

Release Summer 2009

Dobbs, B.M. (2005). Medical conditions and driving: A review of the literature (1960-2000). DOT HS 809 690.Washington, DC: U.S. Department of Transportation.

(10)

New Research

• Targeted medical conditions

• Candrive Common Cohort Study

– 7 sites across Canada including Edmonton

– Following 1000 older drivers for 5 years

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

Cues for Law Enforcement

• Developed roadside cues

for the identification of

medically at-risk drivers

• Edmonton Police Services,

Calgary Police Services,

RCMP, Sheriffs

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

(11)

Licensing Authorities

• Department of Transportation

• Driver Fitness and Monitoring

• BC OSMV

– Restricted licensing study

– OSMV Guide to Drive Project

– CCMTA

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

Individuals

• Self-assessment tools increasingly promoted as a

safety enhancing strategy

•

Drivers 55 Plus: Self-Rating Form

•

Validity? Reliability

• Study looking at relationship between scores on

Drivers 55 Plus: Self-Rating Form

and on-road

performance

•

96% of those with dementia (and failed the road test)

rated themselves as ‘safe’ to drive

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

(12)

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

(13)

Driving Cessation Support Groups

•

Theoretically based support

groups for individuals with

dementia and their

caregivers

•

Implemented in SS PCN on

an ongoing basis (March,

2009)

•

DCSG National Group

Leader Training Workshop

(February, 2009)

Help When You Can No

Longer Drive

Driving Cessation Support Groups

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

Mobility

• Importance of Alternate Transportation for

Quality of Life and Well Being

• Alternate Transportation for Seniors: A

Review of the Literature, Survey of Service

Providers in Edmonton and Surrounding

Area, and Development of an On-Line,

Searchable Resource

(Dobbs, Bhardwaj, Hallet, & VanderMeulen,

2009)

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Findings from Report

• 33 Alternate Transportation Service Providers

in Edmonton and Area

– Serve an average of 94 clients

– ~ 3,100 seniors in Edmonton and Area

Municipalities have access to ‘formalized’

alternate transportation service provision

– Extrapolating from the data (ultra-conservative

estimate), there are an estimated 9,200 seniors

with unmet transportation needs

(14)

Compendium of Alternate

Transportation Provision for

Seniors - Alberta

• Similar methodology

• All alternate transportation service

providers for seniors in Alberta (rural

and urban)

• Report completed in March, 2010

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

Alternate Models of Transportation

• Working with government and

community partners to assist in the

implementation of more responsive and

dignified alternative transportation for

seniors

The Medically At-Risk Driver Centre University of Alberta www.mard.ualberta.ca

A Focused and Integrated Approach

•

Functionally-Based

Assessments

•

Evidence-Based,

Standardized

Protocols

Legal defensibility

Identification

Assessment

Support

Families and Friends Individuals Licensing Authorities

Opportunities for

Partnership/Collaboration

For more information

www.mard.ualberta.ca