Agenda

1. Aging and Driver Fitness: A Curriculum to Benefit Highway Patrol Driver ExaminersApril 7, 2010 Marla Berg-Weger, PhD, Saint Louis University Cindy Anders, MSG, MO Highway Patrol

2. Agenda • Background (Berg-Weger) • Curriculum Implementation (Anders) • Key Findings & Take-Home Messages

3. Training Highway Patrol Driver Examiners • 14% of drivers today are age 65+; this number is expected to double in the next 20 years (NHTSA, 2001) • A growing subset of these drivers will experience changes in health and function that impact on fitness to drive. • Those involved in driver licensing, testing and on road enforcement may be the first to observe this impact on an individual level. • A general law enforcement curriculum is now available through NHTSA, but this does not cover the specific learning needs of driver examiners and license office clerks who test/certify older drivers as fit and safe. • Local specificity is also important, as customs and laws vary. We chose to target the learning needs of Highway Patrol Driver Examiners in Missouri as a first step.

4. Translation of the Literature • Can we translate the basics so as to sensitize and support the work of driver examiners with respect to the older driver? • The presence of a cognitive, vision and/or motor condition is not sufficient to determine fitness to drive. • Persons age and function differently, so an individualized approach works best. • Individual evaluation, including a driving history, testing, etc., can allow for reasonable risk stratification with respect to driver fitness. • Careful, sensitive questioning and observation are effective tools in the evaluative process.

7. License Renewal & Older Drivers • Missouri • Drivers who are ages 70 and over receive a 3-year driver license that expires on the applicant's date of birth in the third year after date of issuance • Drivers aged 21-69 may obtain a 6-year driver license (initiated July 2000). • All renewal applicants must take and pass a vision (20/40) and road sign recognition test • Unfit drivers may be reported by health professionals, law enforcement, license office staff, family members, and others • All on-road testing is conducted by State Highway Patrol Driver Examiners. Testing may (or may not) include vision and road sign recognition.

8. About the Curriculum • Targeting the learning needs of Highway Patrol Driver Examiners and Police Officers in Missouri • Developed by members of the St. Louis Consortium for Older Driver Education & Research (SCODER) • In cooperation with the Missouri State Highway Patrol (MSHP) • Funded by a grant from the Division of Highway Safety, Missouri Department of Transportation (MODOT)

9. Curriculum Available On-Line http://www.umsl.edu/~meusert/Driving/Stakeholder.html

10. Goals of Missouri Project • Train Highway Patrol Driver Examiners to: • Conduct a non-clinical mental status evaluation. • Observe impact of cognitive, vision and motor deficits on function. • Document relative data regarding on-road testing to enhance their reports and support medical review. • Apply curriculum to train license office staff and police in subsequent phases.

11. Steps in Curriculum Development Reviewed Published Guides & Other Evidence Focus Groups Drafted Slides & Supporting Materials (including two video case examples) Validated Curriculum (pre/post)

12. Step 1 • Driver License Bureau, Missouri Department of Revenue • Missouri State Highway Patrol • Office of Social & Economic Data Analysis, University of Missouri • Older Drivers Project, American Medical Association • DriveWell, American Society on Aging • National Highway Traffic Safety Administration • AAA Foundation for Traffic Safety

13. Step 2 • Focus groups with driver examiners used to guide the development of the curriculum • Needs emerged from focus groups: • Examiners are not receiving training on aging and driving. • Basic information on aging needed, especially on dementia and skills for interacting with persons with cognitively impaired individuals. • Vision changes and what to look for. • How to document observations. • How to communicate concerns and refer for assistance.

14. What we heard… • “The doctor should be doing something” • “We can’t just fail them” • “Drivers should be required to take vision & written test before road test” • “We are the final bad guy, everyone else just passing them off” • “We need training” • “They don’t notice the signs, I swear they look at them but they don’t pay attention” • “He put the seat belt through the steering wheel & snapped it” • “Getting the gas & brake mixed up is a big one” • “We owe the public” • “The family said they don’t think he should drive, I want to say so why don’t you do something” • “If we could give out resources for transportation that would help”

15. Step 3 - Curriculum • Officer & Examiner Stories • Missouri Law & Statistics • Health & Functional Status in Aging • Dementia • Vision Loss • Motor Deficits • Observing Age-Related Changes • Cited Driver Worksheet • Documentation • Discussion & Evaluation

16. Step 4 • Piloted curriculum (2 hour workshop) with Highway Patrol Chief Examiners (~20). Revised based on verbal and written feedback. • Offered curriculum to State Highway Patrol Officers & Local Police (LETSAC Conference ~200). Collected pre/post evaluation data. • Train-the-Trainer (Cindy Anders trains group at UMSL) • Training of Examiners Statewide (~140) • In-Service Training for Highway Patrol Officers in MO (~1,500) – Fall 2010

17. Real World…

18. HB-1536 Reporting Process Highway Patrol Driver Examiners Department of Revenue Department of Revenue DMV in other States On-Road Test Score & Our Written Observations & Recommendations (e.g., restriction, more testing)

19. Learning Objectives of Curriculum At the end, participants will understand: • Older driver safety statistics in Missouri. • How age-related changes in health and functional status may impair driving ability and increase crash risk. • An approach to observing and describing such changes in older drivers. • How to document such changes in support of a citation and the license review process.

20. Basic Principles of Documentation • Describe your first hand experiences and observations, starting with the beginning of your encounter. • “He repeated the same comment three times over a 10-minute period.” • “She reported that a red traffic signal was green and started to enter the intersection until I intervened to stop her.” • Avoid general statements (“he seemed unsure”), unless followed by specific examples to back them up. • Avoid making medical diagnoses. • It is OK to list diagnoses told to you, but attribute them to the older driver or other source (e.g., if a family member was present).

21. Example Narrative A brief, but effective narrative. A general statement (comprehension problem) is backed up by specific examples. What other descriptive words could have been based on his actions?

22. Use the worksheet to focus your thinking and observations. Check (√) items that you observe, making extra notes in the margin or on the back to clarify items for later. Record answers to orientation and memory questions as given, making note of errors. Cited Driver Worksheet

23. Case Example – Driving Skills Test • Mrs. Mary Brown, age 74, was cited by the Director of Revenue to take a Driver Skills Test. • She is a retired factory worker and lifelong resident of Florissant, MO. • She reports a minor problem with her distance vision (“I think I need new glasses, but I still see OK”) • She is quite anxious about being tested, but tries her best to be cooperative during the examination.

24. Video Clip

26. Mary Brown - Review • Normal Cognition • Full oriented and recalled everything asked of her. • Had difficulty naming items in the car, but self corrected. • Unable to parallel park due to anxiety and poor vision. • Any appearance of impairment was due to situational anxiety. • Impaired Vision • Read the driver license number incorrectly. • Could not read sign on nearby building. • Reported needing new glasses. • Normal Motor / Range of Motion • Fails Driving Skills Test – Excessive Points • Errors in parallel parking, drove too close to parked vehicles, stopped late at intersection (failed to see stop sign), difficulty merging into traffic.

27. Narrative on Form 232 Mrs. Brown was a pleasant, willing participant in the driving skills test. She appeared moderately anxious, as evidenced by rapid breathing, high pitched tone of voice, and many comments on her performance. She wore glasses, but appeared to have difficulty seeing both near and far objects. For example, she misread her driver license number and she could not read signs on nearby buildings. She reported being at the Hazelwood test facility, and she stated her name, address and phone number without difficulty. She gave the correct date and time. She walked to her vehicle, entered it, and fastened her seatbelt properly. She pointed correctly to controls named by the Examiner, and she named common objects giving incorrect names initially, but self-corrected later. During testing, she frequently drove too close to the curb and parked cars. She appeared confused when asked to parallel park between cones, and asked three times to explain what I wanted her to do. I discontinued this maneuver after a few minutes. At the last intersection on the course, she appeared not to see the stop sign and continued driving until I instructed her to stop. She failed due to excessive points.

28. Discussion with Trainees • Can you see yourself interacting with an older driver in this way? • What types of observations are you more likely to focus on? • Are you comfortable writing down more of your observations in your narrative? • Do you see any potential challenges or pitfalls? • What if the driver became resistant or hostile (“I shouldn’t have to answer these questions in a driving test”)? • Are there times when you would choose not to run through the Cited Driver Worksheet?

29. Evaluation Study (pre/post) • Sample Characteristics • A total of 166 individuals (~83% of trainees) completed one or two questionnaires in support of the validation study. • Most respondents were male (77%) and employed as either municipal police officers or state troopers (72%) with ten or more years of professional experience (73%). • Three quarters of respondents reported that at least 20% of those they served were adults aged 65 or older.

30. Quality Indicators • Overall quality of the program was rated 4.5 (SD = 0.65) on a 1-5 Likert scale (5 = Excellent). • Fifty-five percent of respondents rated the program as excellent in this regard. • Other indicators received similar marks: • Comprehensiveness (4.5, SD = 0.61) • Applicability to personal learning needs (4.4; 0.69) • Quality of handouts (4.5, 0.6).

31. Knowledge Change • 86% demonstrated increased knowledge • Statistically significant (p <.01) mean knowledge score increased from 13.3 (SD=1.9) to 16.6 (SD=2) • No differences based on years of experience or exposure to older adults on the job • 64% reported they are very likely to use the new Cited Driver Worksheet (CDW) • Currently, 100% now use the CDW

32. Implications & Discussion • Policy • Do we need unified standards for older driver licensing with respect to medical fitness to drive and maintaining appropriate mobility/independence? • Education • All stakeholders could benefit from education on aging and driver fitness • We believe that both local and national efforts must be undertaken. • Research • Does improved training of driver examiners, license office staff and police officers make a difference in terms of on-road safety?

33. Thank you for your kind attention! • Questions or Comments? • Cindy Anders, MSG (Cynthia.Anders@mshp.dps.mo.gov) • Tom Meuser, PhD (meusert@umsl.edu) • David Carr, MD (dcarr@im.wustl.edu) • Marla Berg-Weger, PhD (bergwm@slu.edu) • Pat Niewoeher, OTR/L, CDRS (Pat.Niewoehner@va.gov)