Assessing and Counseling Older Drivers

1. Assessing and Counseling Older Drivers Developed in cooperation with the National Highway Traffic Safety Administration as part of the AMA Older Drivers Project Discuss the collaboration of NHTSA and AMA. Describe the AMA staff, expert panel (advisory and external) and efforts that took place over several years to design the curriculum. Discuss the need for evaluation to improve this program. Ask them to fill out the program evaluation.Discuss the collaboration of NHTSA and AMA. Describe the AMA staff, expert panel (advisory and external) and efforts that took place over several years to design the curriculum. Discuss the need for evaluation to improve this program. Ask them to fill out the program evaluation.

2. Number of Licensed Drivers

3. Aging Demographics Aging Demographics 2007 36 Million Older Adults over age 65 yrs (12% US) 28 Million Licensed Drivers over 65 yrs (15% US) 2050 86 Million Older Adults over age 65 yrs (21% US) 66 Million Licensed Drivers over age 65 (25% US) Chronic Disease General Population 25 million people or about 1/10 citizens 1.7 million die each year Older adults 50% affected over age 65 years 37% report disease is severe 16% require assistance

4. Physician’s Guide to Assessing and Counseling Older Drivers Provides physicians with the tools necessary for assessing older patients for medical fitness to drive. The guide provides: A reference table of medical conditions and medications that may impair driving An office based assessment of functions related to the driving process A discussion of referral options for patients at risk for unsafe driving A chapter on counseling patients on driving retirement; educational materials A discussion of legal and ethical issues and state reporting laws The guide provides: A reference table of medical conditions and medications that may impair driving An office based assessment of functions related to the driving process A discussion of referral options for patients at risk for unsafe driving A chapter on counseling patients on driving retirement; educational materials A discussion of legal and ethical issues and state reporting laws

5. Physician’s Plan for Older Driver Safety(PPODS) Screen to determine if patient is potentially at risk Assess driving related functional skills (ADReS) Treat underlying causes of functional decline Refer for further evaluation and/or adaptive training Counsel on safe driving behavior/alternative options Follow-Up for signs of depression, isolation and compliance Script: Before we answer these questions, let us first review the steps in the PPODS algorithm. The patient has undergone screening, which included a medical history and identification of Red Flags. Following screening, the ADReS was used to assess driving-related functions for impairments that may affect the patient’s ability to drive safely. The next step is treatment of underlying causes of decline, and referral for further evaluation and/or adaptive training. These two steps will be covered in this module. Notes: Although DRS’s are often not available in rural areas, the numbers are growing and families would do well to consider this type of evaluation in order to maintain autonomy and evaluate safety.Script: Before we answer these questions, let us first review the steps in the PPODS algorithm. The patient has undergone screening, which included a medical history and identification of Red Flags. Following screening, the ADReS was used to assess driving-related functions for impairments that may affect the patient’s ability to drive safely. The next step is treatment of underlying causes of decline, and referral for further evaluation and/or adaptive training. These two steps will be covered in this module. Notes: Although DRS’s are often not available in rural areas, the numbers are growing and families would do well to consider this type of evaluation in order to maintain autonomy and evaluate safety.

6. Screening Older Adults for Driving Impairment Red Flags Case Finding Patient’s or family member’s concern Referral from the DMV Referral from colleague/health professional Identifying Medical/Co-Morbid Conditions Acute events with/without LOC Chronic medical conditions Medications When does the clinician start this process? There are several ways a clinician may be involved in evaluating older drivers. It should be noted that many older adults would like to be proactive in maintaining or improving driving skills, which is revealed by the enormous numbers that participate in AARP traffic safety course that is offered around the country.When does the clinician start this process? There are several ways a clinician may be involved in evaluating older drivers. It should be noted that many older adults would like to be proactive in maintaining or improving driving skills, which is revealed by the enormous numbers that participate in AARP traffic safety course that is offered around the country.

7. Medical Conditions that may Impair Driving in Older Adults Acute Conditions Cardiac Endocrine/Metabolic Psychiatric Neurological Medications Other Chronic Conditions Cardiac Endocrine/Metabolic Psychiatric Neurological Medications Other Busy clinicians are often faced with these diagnoses, but may not necessarily consider the impact on the driving task. Obviously, an impaired level of consciousness has the potential to render the driver immediately at risk and a period of stability will need to be observed before allowing a return to driving privileges.Busy clinicians are often faced with these diagnoses, but may not necessarily consider the impact on the driving task. Obviously, an impaired level of consciousness has the potential to render the driver immediately at risk and a period of stability will need to be observed before allowing a return to driving privileges.

8. Drugs Associated With Impaired Driving Ability*** Alcohol Anticholinergics Anticonvulsants Antidepressants Antiemetics Antihistamines Stimulants Antihypertensives Antipsychotics Benzodiazepines Muscle Relaxants Narcotic Analgesics NSAID’s There are a myriad of medication that have the potential to impact driving ability. Physicians should be cautious when prescribing these medications to older adults. Discussion of the risk benefit ratio should be made with the patient along with appropriate documentation. This is probably the area with the greatest medico-legal risk and physicians would do well consider mobility issues when prescribing these medications. Again, it should be noted that impacts in improvement in level of consciousness, reaction time, and overall attention may occur when discontinuing these medication in older adults. ***Impaired Driving Ability: Motor Vehicle Crashes and/or Impaired Performance on Driving Simulators and/or Road Tests Physicians Guide to Assessing and Counseling Older Drivers. AMA/NHTSA. 2003 Chapter 9, 165-9 Dobbs BM. Medical Conditions and Driving: Current Knowledge. DTNH22-94-G-05297 AAAM/NHTSA Section 13: Drugs 206-217There are a myriad of medication that have the potential to impact driving ability. Physicians should be cautious when prescribing these medications to older adults. Discussion of the risk benefit ratio should be made with the patient along with appropriate documentation. This is probably the area with the greatest medico-legal risk and physicians would do well consider mobility issues when prescribing these medications. Again, it should be noted that impacts in improvement in level of consciousness, reaction time, and overall attention may occur when discontinuing these medication in older adults. ***Impaired Driving Ability: Motor Vehicle Crashes and/or Impaired Performance on Driving Simulators and/or Road Tests Physicians Guide to Assessing and Counseling Older Drivers. AMA/NHTSA. 2003 Chapter 9, 165-9 Dobbs BM. Medical Conditions and Driving: Current Knowledge. DTNH22-94-G-05297 AAAM/NHTSA Section 13: Drugs 206-217

9. Screens that can identify previously undiagnosed illnesses Cognition/Attention Mini-Mental Status Exam Short Blessed Test Clock Drawing Test Sleep disorders Epworth Sleepiness Scale for Sleep Apnea Depression Geriatric Depression Scale Alcohol CAGE Questionnaire Dementia is very common in older adults and is often unrecognized and/or undetected by clinicians in a busy office setting. In addition, sleep disorders are not uncommon and a specific scale to assess the severity of daytime sleepiness may be helpful. Depression is common and easily detected by interview. Alcohol plays a major role in motor vehicle crashes and there is evidence to suggest the prevalence of problem drinking may be increasing for current aging cohorts.Dementia is very common in older adults and is often unrecognized and/or undetected by clinicians in a busy office setting. In addition, sleep disorders are not uncommon and a specific scale to assess the severity of daytime sleepiness may be helpful. Depression is common and easily detected by interview. Alcohol plays a major role in motor vehicle crashes and there is evidence to suggest the prevalence of problem drinking may be increasing for current aging cohorts.

10. Assess for deterioration in traffic skills and/or driving related functional abilities (ADReS battery) Impaired Traffic Skills Driving History Functional Abilities Vision Cognition Motor function The trainees should realize that the history and physical exam are still two of the most important pieces of assessing older adults, and this information can take you a long way.The trainees should realize that the history and physical exam are still two of the most important pieces of assessing older adults, and this information can take you a long way.

11. Assessment of Driving Related Skills (ADReS) ADReS is a brief, function-based, in-office assessment of driving-related abilities ADReS individual testing components have been correlated with crash risk ADReS battery results should not be the deciding factor in directing driving retirement decisions There has been national discussion and debate over this battery of tests. In fact, much of the criticism of the Older Driver Project has been on this aspect of office testing. We will discuss the strengths and weaknesses of this approach, and review the literature upon which they are based.There has been national discussion and debate over this battery of tests. In fact, much of the criticism of the Older Driver Project has been on this aspect of office testing. We will discuss the strengths and weaknesses of this approach, and review the literature upon which they are based.

12. Vision Visual fields confrontation testing: any deficit, refer to ophthalmology Visual acuity with the Snellen E Chart: acuity in any eye less than 20/40, refer to ophthalmology These are quick screens but can identify problems that are amenable to treatment or rehabilitation.These are quick screens but can identify problems that are amenable to treatment or rehabilitation.

13. Your view, OD, 20/40+ This is the macula of a woman whose visual acuity was better than 20/40, sufficient acuity to drive in any state, but she had already stopped driving on her own. Why?This is the macula of a woman whose visual acuity was better than 20/40, sufficient acuity to drive in any state, but she had already stopped driving on her own. Why?

14. Patient’s View, 20/40+ Here is her scotoma clearly superimposed on a driving scene, so you can see its impact. She does not perceive the scotoma as a black spot but rather as the absence of details or objects she knows must be there. She would have to scan quickly to see the whole object. Here is her scotoma clearly superimposed on a driving scene, so you can see its impact. She does not perceive the scotoma as a black spot but rather as the absence of details or objects she knows must be there. She would have to scan quickly to see the whole object.

15. Would you rather ride witha driver who has: 20/200 acuity ? or 20 degree field ? Script: So in summary, we have the general blur of cataracts, the central scotoma of macular degeneration, and the constricted visual fields of glaucoma, as three basic patterns. On the first day of a master’s program in orientation and mobility, students are often asked whether they would rather ride with a driver who has 20/200 visual acuity or a 20 degreee field, simulated here. As you know, we are very strict on acuity, but a third of the states don’t even check visual fields. Script: So in summary, we have the general blur of cataracts, the central scotoma of macular degeneration, and the constricted visual fields of glaucoma, as three basic patterns. On the first day of a master’s program in orientation and mobility, students are often asked whether they would rather ride with a driver who has 20/200 visual acuity or a 20 degreee field, simulated here. As you know, we are very strict on acuity, but a third of the states don’t even check visual fields.

16. Trail-Making Test, Part B Tests attention, working memory, visual processing, visuospatial skills, and psychomotor coordination Patient connects numbers and letters in alternating pattern Test is scored by time (sec) to complete and number of errors requiring correction Greater than 180 sec signals a need for intervention This test is quite impressive in correlating with impairment on performance based road tests, retrospective and prospective crash data, and driving simulator scores. The cut-off for the ADReS battery is based on the GRIMPS data from Maryland, a large data base that utilized at-fault crashes as the primary outcome measure.This test is quite impressive in correlating with impairment on performance based road tests, retrospective and prospective crash data, and driving simulator scores. The cut-off for the ADReS battery is based on the GRIMPS data from Maryland, a large data base that utilized at-fault crashes as the primary outcome measure.

17. Clock Drawing Test (CDT) CDT can assess: memory visual perception & visual spatial skills selective attention executive skills Draw clock face, numbers, and set time at 11:10 Errors on any of the components signals a need for intervention Script: Driving is a complex activity that requires a variety of cognitive skills. Drivers must use selective attention to prioritize stimuli, such as traffic signals and pedestrians, over less relevant stimuli such as roadside advertising. Drivers use divided attention to focus on the multiple tasks at hand while driving. Attentional decline may be more prevalent with age; with divided attention showing more pronounced changes than selective attention. Memory is another cognitive skill essential to driving. Not only must drivers recall how to operate their vehicle and get to their final destination, they also must be able to retain this information while simultaneously processing other information. Visual perception, visual processing, and visuospatial skills are necessary for the driver to organize stimuli into recognizable forms and know where they exist in space. Executive skills are necessary to analyze driving input and formulate appropriate driving decisions. For example, executive skills allow a driver to appropriately make the decision to stop at a red light, or stop at a green light when a pedestrian is in the vehicle’s path. Another aspect of cognition that is important to driving is insight. Patients who have insight are responsible in limiting their driving exposure or risks. With dementia or other cognitive impairments, insight is often a problem and those at risk are less likely to recognize a problem with driving. Notes: When patients with Alzheimer’s disease draw clocks, we often state they are like snowflakes and no two are alike. Unfortunately, so are the myriad of scoring methods for clock drawing that have been published. Thankfully, researchers have correlated components of the clock drawing task with performance based road tests and any errors may indicate the need for further assessment. Script: Driving is a complex activity that requires a variety of cognitive skills. Drivers must use selective attention to prioritize stimuli, such as traffic signals and pedestrians, over less relevant stimuli such as roadside advertising. Drivers use divided attention to focus on the multiple tasks at hand while driving. Attentional decline may be more prevalent with age; with divided attention showing more pronounced changes than selective attention. Memory is another cognitive skill essential to driving. Not only must drivers recall how to operate their vehicle and get to their final destination, they also must be able to retain this information while simultaneously processing other information. Visual perception, visual processing, and visuospatial skills are necessary for the driver to organize stimuli into recognizable forms and know where they exist in space. Executive skills are necessary to analyze driving input and formulate appropriate driving decisions. For example, executive skills allow a driver to appropriately make the decision to stop at a red light, or stop at a green light when a pedestrian is in the vehicle’s path. Another aspect of cognition that is important to driving is insight. Patients who have insight are responsible in limiting their driving exposure or risks. With dementia or other cognitive impairments, insight is often a problem and those at risk are less likely to recognize a problem with driving. Notes: When patients with Alzheimer’s disease draw clocks, we often state they are like snowflakes and no two are alike. Unfortunately, so are the myriad of scoring methods for clock drawing that have been published. Thankfully, researchers have correlated components of the clock drawing task with performance based road tests and any errors may indicate the need for further assessment.

18. Clock Drawing Task/Driving 119 community-dwelling older adult drivers CDT showed a high level of accuracy Analysis revealed a CDT score of 4 or less, had a likelihood ratio of +27.58 for predicting unsafe driving (sensitivity 64%, specificity 97%) Outcome measure was failure on a driving simulator

19. Motor Function Rapid pace walk Measures lower limb strength, endurance, range of motion, balance, and gross proprioception Patient walks 20 feet Scoring based on time to complete (sec) Completion time of greater than 9 sec impaired It may seem odd that a test of timed gait could correlate with motor vehicle crash risk. However, if you think about it, being able to walk quickly and efficiently is the “ultimate” stress test that requires integration of numerous physiologic systems such as proprioception, vestibular, and visual afferent pathways, central processing from the cortex, cerebellum, and brainstem, and finally efferent pathways such as the peripheral nervous and musculoskeletal systems. In fact, evidence based medicine indicates that lower extremity performance measures such as time gait, a progressive romberg, and chair stand-ups are more powerful predictors of future disability, nursing home placement, and death than many tests in the office setting we routinely check (e.g. blood pressure, cholesterol).It may seem odd that a test of timed gait could correlate with motor vehicle crash risk. However, if you think about it, being able to walk quickly and efficiently is the “ultimate” stress test that requires integration of numerous physiologic systems such as proprioception, vestibular, and visual afferent pathways, central processing from the cortex, cerebellum, and brainstem, and finally efferent pathways such as the peripheral nervous and musculoskeletal systems. In fact, evidence based medicine indicates that lower extremity performance measures such as time gait, a progressive romberg, and chair stand-ups are more powerful predictors of future disability, nursing home placement, and death than many tests in the office setting we routinely check (e.g. blood pressure, cholesterol).

20. Manual test of motor strength Shoulder adduction, abduction and flexion Wrist flexion and extension Hand-grip strength Hip flexion and extension Ankle dorsiflexion and plantar flexion Score grade 0 to 5 Clinicians should have set criteria in their mind øn how to evaluate muscle strength and grade accordingly.Clinicians should have set criteria in their mind øn how to evaluate muscle strength and grade accordingly.

21. Manual test of range of motion Neck rotation Finger curl Shoulder and elbow flexion Ankle plantar flexion Ankle dorsifexion Score: within normal limits; not within normal limits A goniometer is a nice tool to assess range of motion, but is not a typical instrument that physicians have experience with in the office setting. However, clinical exam can usually identify important joint limitations. Referral to physical therapy or exercise classes such as Tai Chi may be of benefit.A goniometer is a nice tool to assess range of motion, but is not a typical instrument that physicians have experience with in the office setting. However, clinical exam can usually identify important joint limitations. Referral to physical therapy or exercise classes such as Tai Chi may be of benefit.

22. Treat underlying causes of functional decline Examples of interventions that can improve key driving functional abilities Physical therapy for muscle weakness and/or to improve range of motion Discontinue sedating medications Improving visual function with ophthalmology intervention Examples of medical interventions that have been shown to reduce crash risk Cataract surgery Stopping sedating medications Sleep apnea treatment The literature on improving road safety with medical interventions, lags behind the numerous studies and interventions on fall prevention, but is growing. Physicians would do well to continue to identify and treat those reversible conditions that impair important driving abilities in the visual, cognitive, and motor domain since they can make an impact on mobility.The literature on improving road safety with medical interventions, lags behind the numerous studies and interventions on fall prevention, but is growing. Physicians would do well to continue to identify and treat those reversible conditions that impair important driving abilities in the visual, cognitive, and motor domain since they can make an impact on mobility.

23. What is the Next Step? Green Light No red flags Monitor at intervals Full speed ahead! Yellow Light Red flags/co-morbid illnesses Decline in traffic skills Deficits on ADReS battery Consider referral and caution! Red light Driving Retirement/Counseling Stop! After pursuing steps 1-3 of the POEMS algorithm, a clinician should have some sense of safety risk in regards to operating an automobile. Individuals may be on either side of the spectrum and not require further referral since they are deemed low/minimal risk or actually require immediate driving cessation. In those individuals where the risk appears elevated, a referral for a performance based road test may further assist in directing driving recommendations.After pursuing steps 1-3 of the POEMS algorithm, a clinician should have some sense of safety risk in regards to operating an automobile. Individuals may be on either side of the spectrum and not require further referral since they are deemed low/minimal risk or actually require immediate driving cessation. In those individuals where the risk appears elevated, a referral for a performance based road test may further assist in directing driving recommendations.

24. Older Drivers Project (ODP):2005 Evaluation Training of Trainers Multidisciplinary Teams Trained to Provide Educational Programs to Health Professionals 5 Modules / Speaker’s Kit 6 Teams Trained in 2003 (2 physicians, OT, DMV) 146+ Programs in 2004-2005, 7,700+ Trained Physician’s Guide to Assessing & Counseling Older Drivers (Schwartzberg, J, Phillips, L, Meuser,T, Carr, D, 2005)

25. Before training: % patients age 65+ Mean 57% Have you ever recommended that an older patient stop driving? 87% yes Is driving fitness a clinical issue in your practice? 79% yes Background on Practices Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities? Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities?

26. How often do you address older driver safety? 59% more often, 41% about the same How often does this come up? Daily 17%; weekly 37%; monthly 22%; less than monthly 17% Do you use the information in the Guide in your clinical practice? 58% yes, 33 % somewhat Have you recommended the Guide? 70% yes In the year since training: Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities? Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities?

27. 2008 Program Evaluation 8 Teaching Teams (Oct. 2006, and July, 2007) 22 presentations 12 different states 1 hour rounds (typically offered in hospital settings) 2 hour workshops.

28. Method

29. Results: Characteristics of Sample Family Practice (26%), Geriatrics (20%), Internal Medicine (18%), Trainees (students/residents) (12%) Ophthalmology (6%)

30. Results Quality of Training 93% “Just Right” content presentation and professional level. 97% learned a specific tool or strategy 66% desired additional training in the future. Grand Rounds vs Workshop 2-hour workshop were somewhat more likely to endorse an interest in obtaining additional training (Mann-Whitney U, p < .01).

31. Results: Knowledge Questions

33. Mean Change in Confidence Composite by Profession & Format

35. Developing a Web-Based Curriculum

36. Faculty Survey Sample: 41 Faculty Members Surveyed 20 Responded Questions in 4 areas: Prioritizing the curriculum Content changes Performance improvement in practice setting Future delivery methods

37. Prioritizing the Curriculum Areas more interesting to the audience than other Assessment (n=15)* Legal Issues (n=15)* Intervention (n=8) Referral (n=6) Vision (n=2)* * Listed as Most Interested Areas

38. Any changes in practices? Increased use of screening tools Increased referrals Increased comfort level with topic Increased reporting Increased awareness responsibility

39. Performance Improvement in Practice Setting Are there any methods in place in the practice to complete the following: a) Recognizing patients appropriate for Assessment of Driving Related Skills (ADReS) Screening

40. Performance Improvement in Practice Setting Are there any methods in place in the practice to complete the following: b) Other health professionals besides physicians for screening?

41. Performance Improvement in Practice Setting Are there any methods in place in the practice to complete the following: c) Referral process for Occupational Therapist or driver rehabilitation?

42. Are there any methods in place in the practice to complete the following: d) What worked and what didn’t work? Performance Improvement in Practice Setting

43. Performance Improvement in Practice Setting Are there any methods in place in the practice to complete the following: e) Process for reporting to State DMV?

44. Any methods in practice for documentation and billing? Many document screening with ADReS or components Some are able to document and code as office visits No difficulty with physician coding and/or reimbursement Much frustration with denial of reimbursement by DRS

45. Summary Subset of physicians and other healthcare professionals are hungry for this information Curriculum successful – 97% learned new techniques to use, confidence increased Challenges How can we make a web-based program exciting and interesting for each audience? How do you help them make changes in their practices?

46. Thank you for your kind attention Joanne G. Schwartzberg, MD www.ama-assn.org/go/olderdrivers Joanne.Schwartzberg@ama-assn.org Questions? Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities? Driver Rehabilitation Specialists have expertise in: Conducting targeted clinical assessments by gathering information on driving history, driving needs, license status, medical history and medications. The DRS conducts a thorough assessment of the patient’s vision, cognition and physical functioning. Following the successful completion of the clinical assessment, a DRS conducts an on-road assessment of the patient’s driving abilities. The DRS provides recommendations and trains clients in the use of adaptive techniques (i.e., no highway driving, daylight-only driving, limited radius), and/or prescribes adaptive equipment based on the results of the patient’s performance during the clinical and on-road assessments. Finally, a DRS counsels and advises the patient on any driving concerns and the appropriate mobility alternatives. Transition: This brings us to our final question: How can DRSs help patients maintain or regain their safe driving abilities?