Dementia and Driving Checklist

1. Dementia and Driving Checklist Dr. W.B. Dalziel Chief, Regional Geriatric Program of Eastern Ontario Associate Professor, Division of Geriatric Medicine University of Ottawa Adapted: August 2008 by Catherine McCumber for GiiC Initiative

2. Participants will be able to: Screen asymptomatic patients for risk of dementia and possible driving concerns. Describe important issues with respect to dementia and driving. Assess patients with dementia for driving safety using a simple 10 minute safe driving assessment. Overview of driving cessation strategies Learning Objectives

3. Older Drivers: A public safety concern? Dramatic increase of the number of senior drivers in Ontario from just under 500,000 in 1986 to projected figure of nearly 2, 500,000 in 2028 (Hopkins, 2004) Studies consistently suggest that older drivers have mileage-based crash rates as high or higher compared to younger drivers When compared to younger drivers crashes among older drivers are more likely to occur (McGwin, 1999): In good weather During daylight hours At intersections When making turns The safety of older drivers has received heightened attention in recent years. This is mainly due to the demographic shifts of the aging population. This will result in a larger number of older drivers. Here are the facts. The number of older adults compared to younger adults will increase and the life expectancy will rise due to a better quality of life. In addition to the demographic shifts, the number of older adults that have a driving license has increased substantially during the last two decades. As suggested by McGwin (1999), the increase of the number of driving license holders is mainly a case of the woman catching up. Together with the demographic shifts this will lead to an increased number of older drivers on the road. Driver crash involvement rates per capita decreased with age, however, when studies compared crash rates to miles driven they found that crash rates actually increase with age. A study by McGwin and Brown (1999) concluded that older drivers are over-represented in crashes at intersections and crashes involving failure to yield the right way, unseen objects, and failure to heed stop signs or signals. Crashes occurring while turning and changing lanes were also more common among older drivers. In addition, Increase in the number of older drivers together with the expected increase in the number of kilometers traveled by older drivers (McGwin & Brown, 1999), will increase the number of accidents among older adults. When comparing crashes between older and younger (age 40 � 45) drivers reports found that older drivers were more likely to crash even in good weather and in day light. However, when looking at the causes of the crashes studies also found that alcohol as a contributive factor was much less a factor in older adults. Factors contributing to crashes among younger adults tht were not seen in older adults included speeding, and alchol. (Mcgwin, 1999) As people age they adopt safer driving techniques, going slower, only driving in day light, these strategies help to off set some of the handicaps seniors face due to age related changes � i.e slower reflexes, poorer eye sight, poor hearing. Thus, looking at when crashes do occur they tend to occur when seniors are most likely to be driving. i.e in good weather etc.The safety of older drivers has received heightened attention in recent years. This is mainly due to the demographic shifts of the aging population. This will result in a larger number of older drivers. Here are the facts. The number of older adults compared to younger adults will increase and the life expectancy will rise due to a better quality of life. In addition to the demographic shifts, the number of older adults that have a driving license has increased substantially during the last two decades. As suggested by McGwin (1999), the increase of the number of driving license holders is mainly a case of the woman catching up. Together with the demographic shifts this will lead to an increased number of older drivers on the road. Driver crash involvement rates per capita decreased with age, however, when studies compared crash rates to miles driven they found that crash rates actually increase with age. A study by McGwin and Brown (1999) concluded that older drivers are over-represented in crashes at intersections and crashes involving failure to yield the right way, unseen objects, and failure to heed stop signs or signals. Crashes occurring while turning and changing lanes were also more common among older drivers. In addition, Increase in the number of older drivers together with the expected increase in the number of kilometers traveled by older drivers (McGwin & Brown, 1999), will increase the number of accidents among older adults. When comparing crashes between older and younger (age 40 � 45) drivers reports found that older drivers were more likely to crash even in good weather and in day light. However, when looking at the causes of the crashes studies also found that alcohol as a contributive factor was much less a factor in older adults. Factors contributing to crashes among younger adults tht were not seen in older adults included speeding, and alchol. (Mcgwin, 1999) As people age they adopt safer driving techniques, going slower, only driving in day light, these strategies help to off set some of the handicaps seniors face due to age related changes � i.e slower reflexes, poorer eye sight, poor hearing. Thus, looking at when crashes do occur they tend to occur when seniors are most likely to be driving. i.e in good weather etc.

4. A Major Public Health Concern When compared with younger drivers, older drivers who are involved in a crash are 44% more likely to be the casual (i.e. At fault) driver. (Parker et al.,2000) When involved in a crash : Drivers 65 � 69 were 1.29 more likely to die when involved in a crash when compared to 40 � 49 yr old Drivers 85 and older were 3.74 times more at risk of fatal injury (Preusser, 1998) The majority of crash-injured seniors were driving the vehicle. Most crashes involving older drivers involve multiple vehicles vs single vehicles in the younger group (McGwin, 1999) Older drivers have a major impact on other road users. They increase the risk of morbidity and mortality of their passengers and other vehicle occupants. Elderly collision victims have an increase risk of fatality when involved in a crash because of their increased fragility. When looking at crashes we find that younger individuals tend t be in crashes that involve only one other car or damage to their own car. However, seniors tend to be involved more often in crashes involving several cars.Older drivers have a major impact on other road users. They increase the risk of morbidity and mortality of their passengers and other vehicle occupants. Elderly collision victims have an increase risk of fatality when involved in a crash because of their increased fragility. When looking at crashes we find that younger individuals tend t be in crashes that involve only one other car or damage to their own car. However, seniors tend to be involved more often in crashes involving several cars.

5. Police identify woman killed when car struck bus shelterKatie Daubs and Ben Costen , The Ottawa Citizen Published: Thursday, April 03, 2008 OTTAWA - An 84-year-old woman lost control of her Toyota Corolla on Wednesday, leveling a Lincoln Fields bus shelter and killing a 66-year-old woman inside. Articles like this has sparked much controversy and discussion regarding older drivers and the risk they may pose to other drivers and pedestrians. Articles like this has sparked much controversy and discussion regarding older drivers and the risk they may pose to other drivers and pedestrians.

6. Every 2 years all seniors, living in Ontario, over the age of 80 who wish to renew their license must participate in the Senior Driver Renewal Program The Senior Driver Renewal Program requires that every two years senior drivers aged 80 years and over The Senior Driver Renewal Program requires that every two years senior drivers aged 80 years and over

7. Senior Driver Renewal Program Renewal Process Payment of licensing fee A vision test A knowledge test Take part in a group education session a small number of drivers may also be asked to take a road test to have their in-car skills assessed. When they turn 80 drivers are notified by mail approximately 60 days before their licence expires and informed that they must complete the above stated on the slide. The individual should contact the Ministry of Transpiration Regional Scheduling Office in their area to make arrangements for their licensing renewal process: The vision test and the knowledge test are both preformed at their individuals local licensing office and you need to make an appointment for both. The group education session simply goes over the rules of the road and strategies for senior drivers. During this time the instructor may ask the individual to go on and do an actual on road test A point to consider however: the risk of developing dementia increases with age, however, there is a significant t proportion of individuals under the age of 80 who have dementia and are over looked in this program. In addition the renewal program is not designed to detect drivers with dementia and those with early dementia may pass without detection. Prior to 1996 all seniors had to do a road test which is considered the gold standard for assessing driving skills. However, it is unclear why this component was dropped we may surmise that the increased number fo senior drivers became too costly. Finally there is question as to what the 90 minute education session truly offers the senior. When they turn 80 drivers are notified by mail approximately 60 days before their licence expires and informed that they must complete the above stated on the slide. The individual should contact the Ministry of Transpiration Regional Scheduling Office in their area to make arrangements for their licensing renewal process: The vision test and the knowledge test are both preformed at their individuals local licensing office and you need to make an appointment for both. The group education session simply goes over the rules of the road and strategies for senior drivers. During this time the instructor may ask the individual to go on and do an actual on road test A point to consider however: the risk of developing dementia increases with age, however, there is a significant t proportion of individuals under the age of 80 who have dementia and are over looked in this program. In addition the renewal program is not designed to detect drivers with dementia and those with early dementia may pass without detection. Prior to 1996 all seniors had to do a road test which is considered the gold standard for assessing driving skills. However, it is unclear why this component was dropped we may surmise that the increased number fo senior drivers became too costly. Finally there is question as to what the 90 minute education session truly offers the senior.

8. Dr. Dalziel�s comments: Is it too time-consuming and complex to screen for early signs of dementia in a family physician�s practice? Dr. Dalziel�s comments: Is it too time-consuming and complex to screen for early signs of dementia in a family physician�s practice?

9. The Scope of the Problem (Hopkins, 2004) In this study Hopkins used Ontario Ministry of Transportation driving data and dementia prevalence data. He combine these two sets to determine the number of persons with potential dementia who are driving. He found that actual and project figures show that both the number of senior drivers in Ontario and the number of seniors with dementia are both increasing. When looking at these two data sets he determined that 2.5% of elderly are demented drivers. When look at the number of seniors drivers we can extrapolate this value to the above estimates. If we then look at In this study Hopkins used Ontario Ministry of Transportation driving data and dementia prevalence data. He combine these two sets to determine the number of persons with potential dementia who are driving. He found that actual and project figures show that both the number of senior drivers in Ontario and the number of seniors with dementia are both increasing. When looking at these two data sets he determined that 2.5% of elderly are demented drivers. When look at the number of seniors drivers we can extrapolate this value to the above estimates. If we then look at

10. Medical conditions and medications are the primary cause of decline in driver safety. Can make even the best of drivers unsafe to drive. Can affect drivers of any age: Increasingly likely as age ?s The safety concern is not the presence of diseases/disabilities but the severity and/or instability of conditions (including medication changes.) Driving Safety: It is Not Age but Disability Primary cause of driving declines = med conds It is not age that determines fitness to drive. We must look at the illnesses and the medical condition that is affecting the individual. In addition as we age and develop illnesses there tend to be increase in the number of medications that are added one on top of the other � in many ways it is not the persons fault that driving deteriorates as many of use would suffer with the increase in medical conditions and increase in medications regardless of age. In addition it is not the presence of an illness that means you can't drive. For example it�s not the person with mild Parkinson, or mild diabetes who can�t drive it�s when the person has developed an unstable or out of control diabetes or parkinsonism. This is when it posses a risk to driving. This same principle holds for medication use. It�s not because you are on a low dose of a certain medication that you can�t drive it�s when you are on a high does or changing or escalating does that poses a driving risk. So we need to consider � Medical conditons Severity Control and medication Control and dosePrimary cause of driving declines = med conds It is not age that determines fitness to drive. We must look at the illnesses and the medical condition that is affecting the individual. In addition as we age and develop illnesses there tend to be increase in the number of medications that are added one on top of the other � in many ways it is not the persons fault that driving deteriorates as many of use would suffer with the increase in medical conditions and increase in medications regardless of age. In addition it is not the presence of an illness that means you can't drive. For example it�s not the person with mild Parkinson, or mild diabetes who can�t drive it�s when the person has developed an unstable or out of control diabetes or parkinsonism. This is when it posses a risk to driving. This same principle holds for medication use. It�s not because you are on a low dose of a certain medication that you can�t drive it�s when you are on a high does or changing or escalating does that poses a driving risk. So we need to consider � Medical conditons Severity Control and medication Control and dose

11. FAQ Answered � The Take Home Message The diagnosis of dementia does not automatically mean no driving The diagnosis of dementia does mean: You must ask if the person is still driving You must assess driving safety You must document driving assessment and follow your provincial reporting requirements Overview: Dementia and Driving 4% of the elderly population is driving with dementia Patients with mild dementia have up to five times more motor vehicle crashes; they have a 50% chance of a crash within two years of diagnosis On average, patients with dementia drive for two to three years after the first symptom of dementia occurs (Hopkins, 2004) Early on in dementia in the mild stages individuals can drive it is when they develop a moderate dementia that they are at high risk � so we must screen for driving capability and document for all dementia individuals Overview: Dementia and Driving 4% of the elderly population is driving with dementia Patients with mild dementia have up to five times more motor vehicle crashes; they have a 50% chance of a crash within two years of diagnosis On average, patients with dementia drive for two to three years after the first symptom of dementia occurs (Hopkins, 2004) Early on in dementia in the mild stages individuals can drive it is when they develop a moderate dementia that they are at high risk � so we must screen for driving capability and document for all dementia individuals

12. How good is the MMSE in predicting driving capacity? There is questionable correlation between driving safety and the MMSE. Functional abilities Instrumental Activities of Daily Living (IADLs) are better correlated. The Folstein MMSE does not correlate well at all with driving safety. The MMSE concentrates mostly on assessing for AD not driving ability A better correlation is with the degree of IADL impairment.The Folstein MMSE does not correlate well at all with driving safety. The MMSE concentrates mostly on assessing for AD not driving ability A better correlation is with the degree of IADL impairment.

13. It is critical to emphasize that driving capacity depends on a GLOBAL CLINICAL PICTURE: The MMSE (when adjusted for age and education) can provide a rough framework for assessing driving safety. Patients scoring under 20 are likely unsafe to drive (if education = Grade 9). The MMSE and Driving Capacity When assessing for driving capacity you need to look at a global picture and not just one test score. The assessment of driving safety is MULTIFACTORIAL depending on a global clinical picture. The MMSE (adjusted for age and education) can provide a rough guide to driving safety; MMSE < 20 means no driving (for those with = grade 9 education). When assessing for driving capacity you need to look at a global picture and not just one test score. The assessment of driving safety is MULTIFACTORIAL depending on a global clinical picture. The MMSE (adjusted for age and education) can provide a rough guide to driving safety; MMSE < 20 means no driving (for those with = grade 9 education).

14. Dementia and Driving Checklist Non evidence based � expert onion and peer reviewed Developed by Dr. W.B. Dalziel Chief, Regional Geriatric Program of Eastern Ontario Associate Professor, Division of Geriatric Medicine University of Ottawa Presented as Poster Presentation: DECIDE VAS � COG 2006: San Antonio Massoud, F., Dalziel, W.B, et al.

15. The Dementia and Driving Checklist A short practical �approach� to decide if senior drivers are Safe Uncertain Unsafe (caveat � driving risk is difficult to assess and no clear evidence based tools exist) The 10 item driving checklist is a quick guide to help family practitioners decided if a patient is safe or not to drive. Note: No in-office cognitive screening test , tool or battery of tests has been demonstrated to accurately predict collisions among patients with dementia. Therefore driving capacity assessments need to take a multi-factorial assessment approach. (Monlnar et a., 2006)The 10 item driving checklist is a quick guide to help family practitioners decided if a patient is safe or not to drive. Note: No in-office cognitive screening test , tool or battery of tests has been demonstrated to accurately predict collisions among patients with dementia. Therefore driving capacity assessments need to take a multi-factorial assessment approach. (Monlnar et a., 2006)

16. Type of Dementia FTD unsafe (disinhibition/judgement) LBD unsafe (hallucinations/fluctuations) AD, VAD, Mixed AD/VAD are safer �types of dementia�� (if no visuospatial problems) The first thing to look at is the type of dementia: Patients with Frontal Temporal or Lewy Bodies Dementia are unsafe regardless of their scores because they have clinical components of their illness that make them unsafe. The safer types of dementia are pure Alzheimer's, vascular, and mixedThe first thing to look at is the type of dementia: Patients with Frontal Temporal or Lewy Bodies Dementia are unsafe regardless of their scores because they have clinical components of their illness that make them unsafe. The safer types of dementia are pure Alzheimer's, vascular, and mixed

17. Severity: Generally, functional losses stratify severity better than MMSE (very mild is likely safe, mild is likely unsafe) Very mild: generally involves only mild losses, e.g., problems with 1 (NOT MORE) instrumental activities of daily living (IADLs) (i.e., SHAFT) S: Shopping H: Housework A: Accounting = finances F: Food preparation T: Transportation  (some patients with very mild or mild dementia  may still be safe to drive) Next we need to look at the severity of the dementia. As indicated functional loos is a better indicator of the severity of a dementia than the MMSE score. The key with this case is the loss of IADLs � the ability to manage finances, shopping and cooking. In the consensus statements regarding dementia and driving (3rd Canadian Consensus Conference on Diagnosis and Treatment of Dementia) � states that driving is contraindicated in persons who , for cognitive reasons, are unable to independently perform multiple IADLS. It is contraindicated if they lose the ability due to cognitive reason to perform even one ADL Dr. Hing added to the Canadian Medical Association consensus statements regarding driving - uses IADLs as s tool to also indicate severity of dementia: i.e. loss of 1 IADL represents mild dementia � loss of 2 or more IADLS or even 1 ADL represents a moderate dementia and they should not be driving Dr. Dalziel likes to point out on this slide that the IADLs assessed generally are around things that men don�t normally do. Most men don�t do any of these things except drive.Next we need to look at the severity of the dementia. As indicated functional loos is a better indicator of the severity of a dementia than the MMSE score. The key with this case is the loss of IADLs � the ability to manage finances, shopping and cooking. In the consensus statements regarding dementia and driving (3rd Canadian Consensus Conference on Diagnosis and Treatment of Dementia) � states that driving is contraindicated in persons who , for cognitive reasons, are unable to independently perform multiple IADLS. It is contraindicated if they lose the ability due to cognitive reason to perform even one ADL Dr. Hing added to the Canadian Medical Association consensus statements regarding driving - uses IADLs as s tool to also indicate severity of dementia: i.e. loss of 1 IADL represents mild dementia � loss of 2 or more IADLS or even 1 ADL represents a moderate dementia and they should not be driving Dr. Dalziel likes to point out on this slide that the IADLs assessed generally are around things that men don�t normally do. Most men don�t do any of these things except drive.

18. Family Concerns (? In car lately?): Collisions , near misses and/or damage to the car Getting lost, needing a �co-pilot� Missing stop signs/lights; stopping for a green light Right of way problems In this slide Dr. Dalziel likes to point out that many family members will not accurately answer these questions. For most people it is there natural inclination to protect the family member especially if it is the 80 year old woman talking about her spouse. For some the dementia patient who is driving is the only means of transportation for them. Dr. Dalziel points this fact out to the family / spouse. Indicating that it is important to answer truthfully due to the serious nature of this issue.In this slide Dr. Dalziel likes to point out that many family members will not accurately answer these questions. For most people it is there natural inclination to protect the family member especially if it is the 80 year old woman talking about her spouse. For some the dementia patient who is driving is the only means of transportation for them. Dr. Dalziel points this fact out to the family / spouse. Indicating that it is important to answer truthfully due to the serious nature of this issue.

19. Driving �PEARL� Dr. Dalziels final question to the family or spouse of the person driving is the �Granddaughter� question. � Would you feel comfortable allowing your grand daughter / son� drive alone in the car with the person� This question provokes a more accurate responseDr. Dalziels final question to the family or spouse of the person driving is the �Granddaughter� question. � Would you feel comfortable allowing your grand daughter / son� drive alone in the car with the person� This question provokes a more accurate response

20. Significant visuospatial problems: poorly done intersecting pentagons/number placement on clock drawing, etc. Reaction time: (dropping a 12� ruler between thumb and index finger � usually caught by maximum of 9� or so, give 2 tries) If there is significant irregularities in the intersecting pentagons or clock drawing. Caution here is not minor irregularities but rather if they are completely �off the wall� The �ruler test� is very non evidence based but it is very quick to do and useful to measure reaction time for driving. How it works Take a 12 inch ruler and ask the individual to try to catch it between their thumb and index finger while you hold it . You ask them if they are ready then drop the ruler most people catch it around the 9 inch mark. Give them 2 tries. If there is significant irregularities in the intersecting pentagons or clock drawing. Caution here is not minor irregularities but rather if they are completely �off the wall� The �ruler test� is very non evidence based but it is very quick to do and useful to measure reaction time for driving. How it works Take a 12 inch ruler and ask the individual to try to catch it between their thumb and index finger while you hold it . You ask them if they are ready then drop the ruler most people catch it around the 9 inch mark. Give them 2 tries.

21. RED FLAGS - Behavioural Issues Delusions Disinhibition Hallucinations Impulsiveness Agitation Anxiety Apathy Depression Problems with performing instrumental ADLs probably correlate better with driving safety then does the MMSE. Another important area to assess is behavioural issues particularly disinhibition, hallucinations and delusions, impulsiveness and anxiety. These behavioral issues in and of themselves are not reasons to take someone off the road but they need to be taken into consideration in the broader context of the assessment There are very few things that stand alone to remove a persons license expect for type of dementia and severity of dementia. Problems with performing instrumental ADLs probably correlate better with driving safety then does the MMSE. Another important area to assess is behavioural issues particularly disinhibition, hallucinations and delusions, impulsiveness and anxiety. These behavioral issues in and of themselves are not reasons to take someone off the road but they need to be taken into consideration in the broader context of the assessment There are very few things that stand alone to remove a persons license expect for type of dementia and severity of dementia.

22. Poor judgment/insight: e.g., what would you do if�: fire in neighbour�s kitchen approaching yellow light found addressed envelope on the ground. In addition to the behavioral issues you may go on to ask judgment questions like; If you saw a fire in a neighbors kitchen what would you do What do you do if you approach a yellow light What would you do if you found an addressed envelope Again the answers to these questions may cause you to worry and need to be taken into account with other aspects. In addition to the behavioral issues you may go on to ask judgment questions like; If you saw a fire in a neighbors kitchen what would you do What do you do if you approach a yellow light What would you do if you found an addressed envelope Again the answers to these questions may cause you to worry and need to be taken into account with other aspects.

23. Trails A and B: tests of visuospatial, executive function, attention and speed of processing (generally failed by failing to understand concept of test or by making errors, not by exceeding time limit) Points regarding the Trails A and B. A mini trails B is preformed on the MOCA (Montreal Cognitive Assessment) � The trails B on the MOCA is totally useless when looking at driving capacity The way the trails A and trails B have been validated for us is to do a sample trails A then do the Trails A, and do the sample Trails B then do the Trails B. The trails B on the MOCA hasn�t been validated for anything to do with driving. The trails A and B have great face validity when it comes to driving but has actually only been mildly correlating to driving capacity. The face validity stems from the need for executive function, visuospatioal skills, speed, attentionPoints regarding the Trails A and B. A mini trails B is preformed on the MOCA (Montreal Cognitive Assessment) � The trails B on the MOCA is totally useless when looking at driving capacity The way the trails A and trails B have been validated for us is to do a sample trails A then do the Trails A, and do the sample Trails B then do the Trails B. The trails B on the MOCA hasn�t been validated for anything to do with driving. The trails A and B have great face validity when it comes to driving but has actually only been mildly correlating to driving capacity. The face validity stems from the need for executive function, visuospatioal skills, speed, attention

24. Trails A Trails A tests visuospatial function and executive function Most people can pass this unless they have moderate dementia. The person is asked to simply connect the numbers in sequence Trails A tests visuospatial function and executive function Most people can pass this unless they have moderate dementia. The person is asked to simply connect the numbers in sequence

25. Trails B Trails B is a more difficult test than Trails A because it also tests divided attention (to alternate numbers and letters) Most experts feel Trails B is a useful specialized test to add when assessing driving safety (as it is the best pen and paper test for correlation with on-road driving performance�still only mild to moderate correlation) Typically, patients fail Trails B by making errors (perseverating with numbers or letters rather than alternating) or by quitting, although some will fail time normsTrails B is a more difficult test than Trails A because it also tests divided attention (to alternate numbers and letters) Most experts feel Trails B is a useful specialized test to add when assessing driving safety (as it is the best pen and paper test for correlation with on-road driving performance�still only mild to moderate correlation) Typically, patients fail Trails B by making errors (perseverating with numbers or letters rather than alternating) or by quitting, although some will fail time norms

26. Trails A + B Instructions: Trails A: Connect the numbers 1, 2, 3, 4, etc. in order until none are left (failure = mistake or time taken [sec.] <10th percentile) Trails B: Go back and forth between numbers and letters: 1 to A, then A to 2, then 2 to B, etc. (failure = mistake or time taken [sec.] <10th percentile) There are norms for the trails A and B: For trails B you have to divide your it by educationInstructions: Trails A: Connect the numbers 1, 2, 3, 4, etc. in order until none are left (failure = mistake or time taken [sec.] <10th percentile) Trails B: Go back and forth between numbers and letters: 1 to A, then A to 2, then 2 to B, etc. (failure = mistake or time taken [sec.] <10th percentile) There are norms for the trails A and B: For trails B you have to divide your it by education

27. Trails B Timing/Errors <2 min/<2 errors = GOOD 2-3 min/= 2 errors = OK dependent on other observations >3 minutes/2 errors = LIKELY UNSAFE Observations Slowness Hesitancy Self-corrections Poor focus

28. alcohol benzodiazepines antipsychotics muscle relaxants sedating antidepressants and antihistamines Anticonvulsants *Slide Courtesy of Dr. F Molnar Medications the concerns here is high doses or unstable/changing dosesMedications the concerns here is high doses or unstable/changing doses

29. Reference List of Drugs with Anticholinergic Effects Antidepressants Antipsychotics Antihistamines/ Antipruritics Antiparkinsonian Antispasmotics Antiemetics Miscellaneous Flexeril Lomotil Rythmodan Tagamet Digoxin Lasix On the left is a list of medications that we normally are concerned with due to their anticholinergic effects. But on the right are a list which we might not always think of but that also do in fact have high anticholinergic effect. Some are over the counter drugs like tagamet for ulcers, cough and cold medications are also often anticholinergic (obviously not as much and the list on the left but taken into combination may increase the anticholiergic effect).On the left is a list of medications that we normally are concerned with due to their anticholinergic effects. But on the right are a list which we might not always think of but that also do in fact have high anticholinergic effect. Some are over the counter drugs like tagamet for ulcers, cough and cold medications are also often anticholinergic (obviously not as much and the list on the left but taken into combination may increase the anticholiergic effect).

30. Vision/hearing Other medical/physical Finally you check vision and hear and then look at other medical conditions � cardiovascular disease, neurological disorders, etc.Finally you check vision and hear and then look at other medical conditions � cardiovascular disease, neurological disorders, etc.

31. This is just a one page summary of your findings. Based upon this information you now have greater ability to make an informed decision regarding safety to drive.This is just a one page summary of your findings. Based upon this information you now have greater ability to make an informed decision regarding safety to drive.

32. After Driving Assessment Reporting patients to the MOT who have dementia but based upon your assessment are currently safe to drive. Under Section 203 of the Highway Traffic Act physicians are required by law to report: Every legally qualified medical practitioner shall report to the Registrar the name, address and clinical condition of every person sixteen years of age or over attending upon a medical practitioner for medical services, who, in the opinion of such medical practitioner is suffering from a condition that may make it dangerous for such person to operate a motor vehicle. A diagnosis of mild cognitive impairment (MCI) or mild dementia requires you notify the MOT. If upon completion of your driving assessment you feel they are currently safe to drive you will indicate this fact in the doctor�s comments section including your intention to follow up in a specified period of time. Current research suggests that �driving evaluations be conducted every 6 months for drivers with very mild to mild dementia� (Molnar, F., et al., 2006: 295 � 297). If a patient then subsequently is involved in a crash the police will file a collision report with the ministry. If the attending police officer feels that there is some medical concern that may have contributed to the collision the collision report can be cross referenced with the Medical Conditions Report and the ministry then has the option to suspend the individual�s license pending a follow up physician assessment. Reporting patients with dementia to the Ministry of Transportation who even after your assessment it is not clear if they are safe to drive. Inform the patient that they should suspend driving until they are contacted byt the MOT. Complete the Medical Condition Report with your assessment. The ministry relies on the information provided on the Medical Condition Report to help identify individuals who are at significant risk, so that immediate action may be taken to ensure they do not drive (refer to �How to file a Medical Condition Report Effectively). If upon completion of their review the MOT are unclear if the patient is safe to drive the ministry will inform the patient in writing that their licence is temporarily suspended pending. Further evaluation by speciality services such as a neurologist or geriatric assessment. AND / OR A driving evaluation performed by a certified / approved driving evaluation assessment center. If a family physician is unsure of a patients driving safety should they independently refer their patients for a driving assessment? On-road driving assessments are expensive $500 or more. The MOT suggests that if a physician is unsure they should advise the individual to stop driving pending a review of the submitted Medical Condition Report by the MOT. The ministry will then review the report and if based upon the clinical information submitted in the report they feel the patient is unsafe to drive they will revoke the individual�s license without recommending an on-road assessment. This would save the individual the $500 fee. The MOT receives many unsolicited driving assessments where a patient has undergone a driving assessment upon advice from their physician and failed � resulting in having their license revoked. As the list is constantly changing the list of currently accredited facilities is not given out by the MOT. The MOT provides the individual with a list of the accredited on-road driving assessment facilities nearest them. Reporting patients to the MOT for immediate suspension or termination of their drivers license as they are unsafe to drive. Refer to �How to file a Medical Report (Effectively) to the Ministry of Transportation�. The MOT informs an individual in writing that their license has been revoked. The individual is also informed that they can seek re-instatement by being re-assessed by their family physician or seeking an on-road driving assessment. Reporting patients to the MOT who have dementia but based upon your assessment are currently safe to drive. Under Section 203 of the Highway Traffic Act physicians are required by law to report: Every legally qualified medical practitioner shall report to the Registrar the name, address and clinical condition of every person sixteen years of age or over attending upon a medical practitioner for medical services, who, in the opinion of such medical practitioner is suffering from a condition that may make it dangerous for such person to operate a motor vehicle. A diagnosis of mild cognitive impairment (MCI) or mild dementia requires you notify the MOT. If upon completion of your driving assessment you feel they are currently safe to drive you will indicate this fact in the doctor�s comments section including your intention to follow up in a specified period of time. Current research suggests that �driving evaluations be conducted every 6 months for drivers with very mild to mild dementia� (Molnar, F., et al., 2006: 295 � 297). If a patient then subsequently is involved in a crash the police will file a collision report with the ministry. If the attending police officer feels that there is some medical concern that may have contributed to the collision the collision report can be cross referenced with the Medical Conditions Report and the ministry then has the option to suspend the individual�s license pending a follow up physician assessment. Reporting patients with dementia to the Ministry of Transportation who even after your assessment it is not clear if they are safe to drive. Inform the patient that they should suspend driving until they are contacted byt the MOT. Complete the Medical Condition Report with your assessment. The ministry relies on the information provided on the Medical Condition Report to help identify individuals who are at significant risk, so that immediate action may be taken to ensure they do not drive (refer to �How to file a Medical Condition Report Effectively). If upon completion of their review the MOT are unclear if the patient is safe to drive the ministry will inform the patient in writing that their licence is temporarily suspended pending. Further evaluation by speciality services such as a neurologist or geriatric assessment. AND / OR A driving evaluation performed by a certified / approved driving evaluation assessment center. If a family physician is unsure of a patients driving safety should they independently refer their patients for a driving assessment? On-road driving assessments are expensive $500 or more. The MOT suggests that if a physician is unsure they should advise the individual to stop driving pending a review of the submitted Medical Condition Report by the MOT. The ministry will then review the report and if based upon the clinical information submitted in the report they feel the patient is unsafe to drive they will revoke the individual�s license without recommending an on-road assessment. This would save the individual the $500 fee. The MOT receives many unsolicited driving assessments where a patient has undergone a driving assessment upon advice from their physician and failed � resulting in having their license revoked. As the list is constantly changing the list of currently accredited facilities is not given out by the MOT. The MOT provides the individual with a list of the accredited on-road driving assessment facilities nearest them. Reporting patients to the MOT for immediate suspension or termination of their drivers license as they are unsafe to drive. Refer to �How to file a Medical Report (Effectively) to the Ministry of Transportation�. The MOT informs an individual in writing that their license has been revoked. The individual is also informed that they can seek re-instatement by being re-assessed by their family physician or seeking an on-road driving assessment.

33. Ensure that the driver�s full name is listed Ensure that the driver�s license is listed; if not available note the date of birth and residential address � this will facilitate the action the Ministry can take as it depends on quickly and correctly identifying the driver on the driver data base. Note the medical condition (s) and why in your opinion, these put the person at risk of driving. If the case is considered a high risk � note on the report: the driver unfit to drive. The MTO has a review process that identifies high risk cases and expedites them for appropriate action. Physicians need to indicate in their report that the person is unfit to drive and to include in the report sufficient detail on their patient�s medical condition that they deem to be high risk for driving; i.e. the patient has uncontrolled seizures, impaired memory, uncontrolled diabetes, advanced Alzheimer, etc. The review board can only go by the information that is provided by the physician. Include in the space provided in the report, relevant clinical data, results of investigations, frequency of episodes, medications, treatment and prognosis � this will help the MOT take appropriate action In cases of extreme risk, fax and call the MTO (416 �235 � 1773 or 1�800�268�1481) and relay to the staff person that it�s an emergency so threat an immediate license suspension can be issued. The normal time for an application to be reviewed is 2 � 4 weeks. If the report is faxed call to ensure report has been received. Incomplete reports and reports without a driver�s license number or date of birth may lengthen processing time unnecessarily NOTE: the phone line is ALWAYS busy � especially over the lunch hour anticipate a 20 minute wait on holdEnsure that the driver�s full name is listed Ensure that the driver�s license is listed; if not available note the date of birth and residential address � this will facilitate the action the Ministry can take as it depends on quickly and correctly identifying the driver on the driver data base. Note the medical condition (s) and why in your opinion, these put the person at risk of driving. If the case is considered a high risk � note on the report: the driver unfit to drive. The MTO has a review process that identifies high risk cases and expedites them for appropriate action. Physicians need to indicate in their report that the person is unfit to drive and to include in the report sufficient detail on their patient�s medical condition that they deem to be high risk for driving; i.e. the patient has uncontrolled seizures, impaired memory, uncontrolled diabetes, advanced Alzheimer, etc. The review board can only go by the information that is provided by the physician. Include in the space provided in the report, relevant clinical data, results of investigations, frequency of episodes, medications, treatment and prognosis � this will help the MOT take appropriate action In cases of extreme risk, fax and call the MTO (416 �235 � 1773 or 1�800�268�1481) and relay to the staff person that it�s an emergency so threat an immediate license suspension can be issued. The normal time for an application to be reviewed is 2 � 4 weeks. If the report is faxed call to ensure report has been received. Incomplete reports and reports without a driver�s license number or date of birth may lengthen processing time unnecessarily NOTE: the phone line is ALWAYS busy � especially over the lunch hour anticipate a 20 minute wait on hold

34. Notification About Driving Safety Name: _________________________________ �Date: __________________________________ �Address: _________________________________________________________________________ �� You have undergone assessment for memory/cognitive problems. It has been found by comprehensive assessment that you have ________________________ dementia. The severity is _________________. � Even with mild dementia, compared to people your age, you have an 8 times risk of a car accident in the next year. Even with mild dementia, the risk of a serious car accident is 50% within 2 years of diagnosis. Additional factors in your health assessment raising concerns about driving safety include: �__________________________________________________________________________ �__________________________________________________________________________ �__________________________________________________________________________ �_________________________________________________________________________ � As your doctor, I have a legal responsibility to report potentially unsafe drivers to the Ministry of Transport. Even with a previous safe driving record, your risk of a car accident is too great to continue driving. Your safety and the safety of others are too important. � ___________________________ M.D. __________________________ Witness

35. Giving up Driving

37. Why is it so difficult to tell a patient they are unsafe to drive? Cessation of driving has been shown to increase symptoms of depression for a period of up to 6 years (Marottoli, 1997) Violates individual autonomy (Perkinson, 2005) Impedes access to proper nutrition, medical care, and opportunities for social engagement (Marottoli, 2000) The loss of a license may also mean the difference between living at home and having to move to an institution or other accommodation

38. Why do family members delay discussing driving cessation even after dementia diagnosis? The patient lacks insight into their driving difficulties due to the disease process Family lack of insight into dementia and driving Families may fear an increase in caregiver burden following the termination of driving (Perkinson, 2005) Studies show that in fact family members primarily shoulder the burden of limiting or stopping driving in dementia patients (The Hartford Group, 2000)

39. Telling patient they are unsafe to drive Before the appointment, consider asking that the spouse or caregiver be present. Ask that someone bring the patient to the appointment versus patient driving. Be firm and non-negotiable in your instructions that they do not drive. For some patients they drove to the appointment. With their license suspended how are they to get home? Before the appointment, consider asking that the spouse or caregiver be present. This is to provide emotional support as well as ensuring the family understands the persons need to stop driving / implement driving retirement strategies. (CMA Driver Guide 7th ed.) When making the appointment ask the spouse (or family member if spouse doesn�t drive) to bring the patient to the appointment. Discuss your concerns about driving with the patient and their caregivers. Be firm and non-negotiable in your instructions that they do not drive. For some patients they drove to the appointment. With their license suspended how are they to get home? Before the appointment, consider asking that the spouse or caregiver be present. This is to provide emotional support as well as ensuring the family understands the persons need to stop driving / implement driving retirement strategies. (CMA Driver Guide 7th ed.) When making the appointment ask the spouse (or family member if spouse doesn�t drive) to bring the patient to the appointment. Discuss your concerns about driving with the patient and their caregivers. Be firm and non-negotiable in your instructions that they do not drive.

40. Telling patients to stop driving Provide a written statement to the patient of your reasons to challenge their fitness to drive. Often patient will talk about his or hers past good driving record. Acknowledge that accomplishment in a genuine manner, but return to the need to stop driving. (CMA Drivers Guide 7th ed). Provide a written statement to the patient of your reasons to challenge their fitness to drive. This letter should also communicate your legal obligation and intention to notify the Ministry of Transpiration of your recommendation to suspend the person�s license. Give a copy to the patient & caregiver, and keep a copy for the chart as well. (see sample letter). Explain your concern for his / hers safety and the safety of others. Stress that the unthinkable can happen. Some individuals may be more receptive to stopping driving based upon concomitant medical disorders (such as impaired vision). Avoid arguing with the person (who may have limited insight). Often patient will talk about his or hers past good driving record. Acknowledge that accomplishment in a genuine manner, but return to the need to stop driving. Sometimes saying �medical conditions can make even the best drivers unsafe: also can help to refocus the discussion (CMA Drivers Guide 7th ed).Provide a written statement to the patient of your reasons to challenge their fitness to drive. This letter should also communicate your legal obligation and intention to notify the Ministry of Transpiration of your recommendation to suspend the person�s license. Give a copy to the patient & caregiver, and keep a copy for the chart as well. (see sample letter). Explain your concern for his / hers safety and the safety of others. Stress that the unthinkable can happen. Some individuals may be more receptive to stopping driving based upon concomitant medical disorders (such as impaired vision). Avoid arguing with the person (who may have limited insight). Often patient will talk about his or hers past good driving record. Acknowledge that accomplishment in a genuine manner, but return to the need to stop driving. Sometimes saying �medical conditions can make even the best drivers unsafe: also can help to refocus the discussion (CMA Drivers Guide 7th ed).

41. Enlisting Family help if you suspect the patient won�t comply with stopping driving Hide keys Substitute a door key for the ignition key Put notification letter from physician or MOT in obvious location and refer to it to remind patient they can�t drive. Disable the car � i.e. simplest way is to remove the battery Remove the car � i.e. have a family member borrow it and never bring it back; or, have a tow truck tow it in for repairs and never return it. (LePore, 2000) Buy a new alarm for the car to inform you if they attempt to drive Keep tabs on driving � i.e. jot down mileage of odometer Hide keys or make the keys non functional by filing them down If the door and ignition keys are different substitute a door key for the ignition key Put notification letter from physician or MOT in obvious location and refer to it to remind patient they can�t drive. Ie. � remember the doctor told you can�t drive .� or �MOT revoked your license� Disable the car � i.e. simplest way is to remove the battery Remove the car � i.e. have a family member borrow it and never bring it back; or, have a tow truck tow it in for repairs and never return it. (LePore, 2000) Buy a new alarm for the car to inform you if they attempt to drive Keep tabs on driving � i.e. jot down mileage of odometer and check to ensure the vehicle has not been driven; ensure they are not borrowing friends car to driveHide keys or make the keys non functional by filing them down If the door and ignition keys are different substitute a door key for the ignition key Put notification letter from physician or MOT in obvious location and refer to it to remind patient they can�t drive. Ie. � remember the doctor told you can�t drive .� or �MOT revoked your license� Disable the car � i.e. simplest way is to remove the battery Remove the car � i.e. have a family member borrow it and never bring it back; or, have a tow truck tow it in for repairs and never return it. (LePore, 2000) Buy a new alarm for the car to inform you if they attempt to drive Keep tabs on driving � i.e. jot down mileage of odometer and check to ensure the vehicle has not been driven; ensure they are not borrowing friends car to drive

42. If the person with dementia is currently safe to drive. Reinforce that the need for driving cessation as inevitable. Discuss the steps involved to maintain a drivers license given a dementia diagnosis. physician has a legal obligation to inform the Ministry of Transportation of any condition that may affect driving . They must come back for a complete driving assessment every 6 months (3rd CCCDTD). This may include a costly on road assessment (approximately $500) as well. You may wish to point out that the individuals car insurance may change with a dementia diagnosis For those who wish to continue driving you can provide them with �Tips� for safe driving� Arrange to have family or spouse present in addition to patient to talk about the need for driving cessation as inevitable. Emphasize hopefulness of the short term situation but be firm about driving cessation planning. Reinforce to the family and patient that you and your team are committed to a long term relationship with the family and patient. That you will continue to be available for the questions that will come later(Friedland, 1997) Discuss the steps involved to maintain a drivers license given a dementia diagnosis. Your physician has a legal obligation to inform the Ministry of Transportation of any condition that may affect driving under the Ontario Highway Traffic Act s. 203. Dementia falls into this category. Though the person is currently safe the MOT must be informed of their condition. Dementia is a progressive disease and although they are currently safe their condition will change. They must come back for a complete driving assessment every 6 months (3rd CCCDTD). This may include a costly on road assessment (approximately $500) as well. You may wish to point out that the individuals car insurance may change with a dementia diagnosis Not all patients are comfortable or willing to give up their driving status when faced with a dementia diagnosis. For those who wish to continue driving you can provide them with �Tips� for safe driving�Arrange to have family or spouse present in addition to patient to talk about the need for driving cessation as inevitable. Emphasize hopefulness of the short term situation but be firm about driving cessation planning. Reinforce to the family and patient that you and your team are committed to a long term relationship with the family and patient. That you will continue to be available for the questions that will come later(Friedland, 1997) Discuss the steps involved to maintain a drivers license given a dementia diagnosis. Your physician has a legal obligation to inform the Ministry of Transportation of any condition that may affect driving under the Ontario Highway Traffic Act s. 203. Dementia falls into this category. Though the person is currently safe the MOT must be informed of their condition. Dementia is a progressive disease and although they are currently safe their condition will change. They must come back for a complete driving assessment every 6 months (3rd CCCDTD). This may include a costly on road assessment (approximately $500) as well. You may wish to point out that the individuals car insurance may change with a dementia diagnosis Not all patients are comfortable or willing to give up their driving status when faced with a dementia diagnosis. For those who wish to continue driving you can provide them with �Tips� for safe driving�

43. Tips for safe driving 55 Alive programs Keep car in good running condition Have car adjusted to properly meet limitation needs �i.e CarFit through CAA Adjust your driving habits i.e. not at night,.. Co-Piloting Is Not the Answer Keep up with your driving fitness by taking a seniors specific accident prevention program such as �55 Alive� or similar program which is offered through most driving schools. Keep your car in good running order. Always ensure there is plenty of gas in the car Good working brakes Tire pressure Working signal lights and head lights Working and effective wipers Take your car in routinely for maintenance servicing Ensure your car is adjusted correctly to meet your needs. There are various programs such as CarFit , available through the Canadian Automobile Association, which is an educational program designed to ensure all of the elements of your car (i.e. seat belts, steering wheel, side mirrors) etc. are properly adjusted to better meet your physical need. Drivers with disabilities � various rehabilitation centers have occupational therapists that can provide adaptive equipment to compensate for some of the losses that occur due to aging. Example, louder directional signals (�clickers�), turning devices, seat belt adapters, full view inside mirrors, etc. (LePore, 2000) Obey the law: Always wear a seat belt Never drink and drive Don�t speed Keep fit and have your eyesight regularly checked. When driving Don�t be rushed � only move into an intersection after check for pedestrians, cyclists, hazards. Don�t allow other drivers to pressure you into sudden movements (CAA) Reduce distractions Stay alert Improve visibility � clean windshield and eye glasses Don�t drive at night Drive only on familiar routes Avoid busy intersections or the highway Avoid rush hour Avoid driving in poor weather conditions Some caregivers act as co-pilots to keep a person with dementia driving longer. The co-pilot gives directions and instructions on how to drive. By chance, this strategy may work for a limited time. But in hazardous situations, there is rarely time for the passenger to foresee the danger and give instructions, and for the driver to respond quickly enough to avoid the accident. Finding opportunities for the caregiver to drive and the person with dementia to co-pilot is a safer strategy.Keep up with your driving fitness by taking a seniors specific accident prevention program such as �55 Alive� or similar program which is offered through most driving schools. Keep your car in good running order. Always ensure there is plenty of gas in the car Good working brakes Tire pressure Working signal lights and head lights Working and effective wipers Take your car in routinely for maintenance servicing Ensure your car is adjusted correctly to meet your needs. There are various programs such as CarFit , available through the Canadian Automobile Association, which is an educational program designed to ensure all of the elements of your car (i.e. seat belts, steering wheel, side mirrors) etc. are properly adjusted to better meet your physical need. Drivers with disabilities � various rehabilitation centers have occupational therapists that can provide adaptive equipment to compensate for some of the losses that occur due to aging. Example, louder directional signals (�clickers�), turning devices, seat belt adapters, full view inside mirrors, etc. (LePore, 2000) Obey the law: Always wear a seat belt Never drink and drive Don�t speed Keep fit and have your eyesight regularly checked. When driving Don�t be rushed � only move into an intersection after check for pedestrians, cyclists, hazards. Don�t allow other drivers to pressure you into sudden movements (CAA) Reduce distractions Stay alert Improve visibility � clean windshield and eye glasses Don�t drive at night Drive only on familiar routes Avoid busy intersections or the highway Avoid rush hour Avoid driving in poor weather conditions Some caregivers act as co-pilots to keep a person with dementia driving longer. The co-pilot gives directions and instructions on how to drive. By chance, this strategy may work for a limited time. But in hazardous situations, there is rarely time for the passenger to foresee the danger and give instructions, and for the driver to respond quickly enough to avoid the accident. Finding opportunities for the caregiver to drive and the person with dementia to co-pilot is a safer strategy.

44. Steps for Planning for Driving cessation Keep tabs on patients driving Take drives regularly with patient Enlist help from others Routinely inspect car for scrapes Find alternatives to driving Driving: Keeping informed on driving ability Make arrangements to take a drive with the patient at various times. Don�t comment on the individuals driving while you are in the car. Take the opportunity to talk about driving after and based upon your observations. Enlist the help of other community resources, friends, neighbors, to keep family members and spouse informed about the patients driving. For example you may ask the clergy at the patient�s church to inform you if there are any reported concerns about the patients parking or driving when they go to church. You may contact the Grocery store manager to inform you of any complaints about senior motorists in the parking lot (Lepore, 2000). The key to making your feedback network effective is to routinely call your contacts. (Lepore, 2000) Routinely inspect the car for scrapes or dents.Driving: Keeping informed on driving ability Make arrangements to take a drive with the patient at various times. Don�t comment on the individuals driving while you are in the car. Take the opportunity to talk about driving after and based upon your observations. Enlist the help of other community resources, friends, neighbors, to keep family members and spouse informed about the patients driving. For example you may ask the clergy at the patient�s church to inform you if there are any reported concerns about the patients parking or driving when they go to church. You may contact the Grocery store manager to inform you of any complaints about senior motorists in the parking lot (Lepore, 2000). The key to making your feedback network effective is to routinely call your contacts. (Lepore, 2000) Routinely inspect the car for scrapes or dents.

45. Looking at alternatives to driving Alternate ways of getting there / Transportation Worksheet List all of the activities or errands you do routinely i.e., hair appointments, doctor appointments, banking, grocery store, visiting friends, Don�t� forget to include special one time events like birthday parties, dinners, etc. Identify how you currently get to these activities - car, bus, friends List ALL of the potential new ways you can either get to your destination. Also include ways that you could have the services provided to you � i.e. pharmacy delivery, in home hair dresser, etc Using a weekly / month calendar write down your events and your chosen new ways of getting thereAlternate ways of getting there / Transportation Worksheet List all of the activities or errands you do routinely i.e., hair appointments, doctor appointments, banking, grocery store, visiting friends, Don�t� forget to include special one time events like birthday parties, dinners, etc. Identify how you currently get to these activities - car, bus, friends List ALL of the potential new ways you can either get to your destination. Also include ways that you could have the services provided to you � i.e. pharmacy delivery, in home hair dresser, etc Using a weekly / month calendar write down your events and your chosen new ways of getting there

46. Resources Medical Fitness to Drive CMA Guide www.cma.ca Driving and Dementia Toolkit www.rgpeo.com www.CanDRIVE.ca

47. References Canadian Automobile Association. Helping Aging Drivers. http://www.caa.ca/agingdrivers/home_en.html Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (3rd) 2006. Alzheimer's and Dementia (2007) Vol 3 (4): 262-265 Champlain Dementia Network Physician Education Committee. Dementia Toolbox, Dementia Education for Family Physicians Program. Daubs, K,.Costen,B. Police identify woman killed when car struck bus shelter. Published Thursday April 03, 2008 in The Ottawa Citizen. Byszewski, A., Bush, A., Mckinlay,K., Guzman, D., Hunt, L., Marshall, S., Richardson, I. The Driving and Dementia Toolkit 2nd edition. The Dementia Network of Ottawa Carleton (2004): www.rgapottawa.com The Hartford Group: Family Conversations with Older Drivers. www.thehartford.com/talkwitholderdrivers Hopkins, R.W., Kilik, L., Duncan, J.A., Rows, C., Tseng, H. Driving and Dementia in Ontario: A quantitative assessment of the problem. Canadian Journal of Psychiatry (2004) Vol 49, No 7; July: 434-438 McGwin, G., Brown, D.B. Characteristics of traffic crashes among young, middle-aged, and older drivers. Accident Analysis and Prevention (1999);31: 181-198

48. Molnar, F., Patel, A., Masahll,S., Man-Son-Hing, M., Wilson, K. Systematic review of th eoptimal frequency of follow-up in persons with mild dementia who continue to drive. Alzheimer Dissease Association Disorder (2006) 20(4): 295-297. Parker, D., McDonald,L., Rabbitt, P., Sutcliffe, P. Elderly drivers and their accidents: the Aging Driver Questionnaire. Accident Analysis and Prevention (2000); 32: 751 � 759. Preusser, D.F., Williams, A.F., Ferguson, S.A., et al.Fatal crash tisk for older drivers at intersections. Accident Analysis and Prevention (1998); 30:151-159. Rapoport, M.J., Herrmann,N., Molnar, F.J., Man-Son-Hing, M, Marshall, S.C., Shulman, K., Naglie, G. Sharing the responsibility for assessing the risk of the driver with dementia. Canadian Medical Association Journal (2007) 177 (6): 599 -601. Yee, W.Y., Cameron, P.A., Bailey, M.J. Road traffic injuries in the elderly. Emergency Medicine Journal (2006);23:42-46