Practice Parameter update: Evaluation and management of driving risk in dementia

1. Practice Parameter update: Evaluation and management of driving risk in dementia Systematic review of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2010 ;74:1316-1324 ד"ר רוזיצקי אהוד

2. Dementia and Driving • Patients with mild dementia are high-risk drivers. • As many as 76% of mild-dementia patients are still able to pass ORDT • MMSE result in no correlation or have a relatively low sensitivity for identifying an unsafe driver. There are conflicting results. • MMSE with driving history and additional cognitive testing- moderate sensitivity and specificity

3. The analytic process • the AAN invited neurologists, neuropsychologist , occupational therapist • Relevant articles 1970- 2006 • 502 studies selected from 6000. • only studies with lower risk of bias were considered for discussion

4. Global measures of Dementia in measuring driving ability • The CDR is established as useful for identifying patients at increased risk for unsafe driving. • However, a substantial number of patients with a CDR of 0.5-1 (41%- 85%) will be found to be a safe drivers by an ORDT. • MMSE ≤ 24 is possibly useful in identifying patients at increased risk for unsafe driving • Otherwise, tee correlation between MMSE scores and driving performance is unclear, as data are conflicting.

5. Self-assessment and caregiver’s assessment in evaluating driving risk • a significant discrepancies between self-rating as self and ORDT performance. • Caregiver’s ratings correlate modestly with ORDT performance. • A caregiver’s rating of marginal or unsafe is probably useful in identifying unsafe drivers. • A patient’s self-rating of safe is established as not useful for determining that the patient is safe to drive.

6. Driving history in evaluating driving risk in Dementia • There is association across all age groups between crashes and citations and unsafe driving. • A history of a crash in the previous 1 to 5 years or a traffic citation the previous 2 to 3 years is possibly useful in identifying patients with decreased driving ability. • A history of a crash is possibly more useful in identifying patients at risk for subsequent crashes than the presence of mild dementia alone.

7. Reduced mileage and situational avoidance in dementia driving risk • Driving mileage is significantly reduced in patients with mild dementia, due to external and self-imposed restrictions. • in mixed-population studies ( aged drivers and drivers with mild dementia), reduced driving mileage is possibly associated with an increased risk of poor driving performance. • In aged drivers, self-reported avoidance is possibly useful to identify drivers at increased risk. • the absence of self-reported avoidance is possibly not useful for identifying safe drivers.

8. Aggressive personality characteristics • Herrman et al reported that agitation and aggression were predictive of a refusal to discontinue driving. • Aggressive or impulsive personality characteristics are possibly useful to identify patients with increased driving risk.

9. Neuropsychological testing is assessment of dementia risk driving • Numerous studies described association between individual cognitive domains and driving safety. • While neuropsychological testing itself may better define Dementia severity, there is insufficient evidence to assess the benefit of neuropsychological testing in evaluating driving risk in patients with dementia

10. Interventions to reduce dementia driving risk • There is insufficient evidence to assess a benefit of interventional strategies ( licensing restrictions, driver training) for drivers with dementia.

11. Recommendations for characteristics identifying unsafe driving in dementia patient • Level A: CDR scale • Level B: A caregiver’s rating of a patient’s driving ability as marginal or unsafe. • Level C: A history of car crashes or traffic citations • Level C: Reduced driving mileage • Level C: Self-reported situational avoidance • Level C: MMSE ≤ 24 • Level C: Aggressive or impulsive personality characteristics.

12. Un-useful for identifying dementia patients at increased risk for unsafe driving • Level A: A patient’s self-rating of safe driving ability • Level C: Lack of situational avoidance

13. Clinical decisions • Professional and legal obligation to identify unsafe driving risking patients’ or public’s health. • there is no accurate or empirical feature to determine driving risk, clinicians are only capable of making qualitative estimates of driving risk.

14. Clinical decisions • Clinicians may present patients and caregiver’s with data showing that patients with mild dementia are at a higher risk for unsafe driving and strongly consider discontinuing driving. • VS. Categorical recommendation inspite high ORDT pass rates leading to premature driving cessation.