NHTSA Driver Fitness Medical Guidelines

1. Dr Jamie Dow Medical Advisor on Road Safety Société de l’assurance automobile du Québec 30 August 2010 AAMVA Annual International Conference Saint-John, New Brunswick NHTSA Driver Fitness Medical Guidelines

2. NHTSA and AAMVA established the Driver Fitness Working Group (DFWG) in 2005 Aim: to develop evidence-based medical guidelines for drivers 2006 – DFWG organises the “Challenging Myths” conference in Austin, TX 2006 – 2008 Limitation of number of medical conditions Research Development of guidelines Background

3. The Grey (Silver) Tsunami Major increase in the >65 population QC 2003 – 10% 2009 – 14% 2030 - 24% Individual assessment US – ADA Canada – Grismer Stereotypical decisions based uniquely on a diagnosis are no longer acceptable Driver Fitness in 2010

4. Three types of medical conditions that may affect driving: Functional limitations (chronic) (permanent) Loss of function in a limb, cognitive Associated risk (acute) (episodic) Diabetes, epilepsy Substance use Drugs and alcohol, medications Driver fitness in 2010

5. The diagnosis is important The effects of the medical condition upon the driver are more important Drivers are individuals and the effects of a given medical condition will vary from one individual to another. Driver Fitness in 2010

6. Compensation Many people can compensate for a functional limitation imposed by their medical condition Some cannot Therefore, DMVs must provide a means of assessing the degree of compensation Does the degree of compensation for a functional limitation permit safe driving? Driver Fitness in 2010

7. “It used to be that a person with a medical condition that could influence driving fitness would be told that they were fit or unfit to drive solely on the basis of the diagnosis. Nowadays the diagnosis is the starting point and the person will be told that they may be unfit to drive and that they will have to undergo a functional evaluation in order to determine their driving fitness.” Driver Fitness in 2010

8. Example Visual fields Most jurisdictional standards require at least 1000 binocular vision, many require at least 1200 Below standard = unfit to drive 2 recent studies have demonstrated that most drivers with below-standard visual fields who claim they have compensated for the defect succeed in demonstrating safe driving (SAAQ: 93% success rate) Therefore: compensation for visual field defects is possible and must be allowed for in the application of visual field standards for drivers Driver Fitness in 2010

9. In most cases the physician is incapable of assessing the impact of a medical condition on driver fitness The physician should not be required to state if a driver is fit or unfit to drive Can identify potential problems and provide a diagnosis Off-road evaluations are poor predictors of on-road performance Most physicians have no knowledge or even awareness of road safety considerations in their practice Physicians’ role in driver safety

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11. Promote road safety Provide rationale for medical standards Research that may be used to justify medical standards when the standard is challenged Provide guidance to jurisdictions that are developing their own standards Allow for adaptations that recognise special circumstances Voluntary but describe best practices Informative Guidelines

12. Chapter 1 – Recommendations Medical Guidelines for DMVs Supported by scientific evidence Medical Guidelines for Clinicians and other Health Care Providers Recommendations for Drivers with At-Risk Conditions Chapter 2 – Physical Impairment Chapter 3 – Vision Chapter 4 – Medical Conditions Chapter 5 – Temporary Conditions NHTSA/AAMVA Driver Fitness Medical Guidelines (2009)

13. Appendix A – References for Chapter 4 Appendix B – Example Medical Examiner Form for a Driver Licence by a Physician Appendix C – Alternative Viewpoint on Assessing Driver Fitness NHTSA/AAMVA Driver Fitness Medical Guidelines (2009)

14. Vision Judgement Mental Processing Self-awareness Physical capabilities Safe Driving Skills

15. 3 groups Visual Physical impairment Medical Epilepsy (seizures) Diabetes Dementia Sleep disorders Medical Guidelines

16. Specific guidelines for: Visual acuity Visual fields Contrast sensitivity Hemianopia Colour sensitivity Age-related macular degeneration Slowed visual processing speed Cataract/Glaucoma Visual

17. No scientific support for current visual standards Visual acuity standards vary from 6/12 (20/40) to 6/30 (20/100) in North America No differences in crash rates that can be attributed to differing visual standards Adaptation (compensation) for visual acuity defects is possible although difficult Telescopic lenses (bioptics) Visual

18. All drivers >65 should be subjected to routine visual testing at permit renewal Low vision/field defects Provide opportunity to demonstrate safe driving Evaluate crash involvement for drivers with waivers Must be able to discriminate between different traffic lights Screening for visual processing speed? Visual Guidelines

19. Amputation Arthritis Cerebral vascular accident (CVA) Multiple sclerosis Parkinson’s disease Spinal cord injury Traumatic brain injury Physical impairment

20. Bottom line: If there is functional impairment that may affect driving it must be evaluated Must demonstrate safe driving May require modifications to the vehicle If the condition is progressive – periodic re-evaluation Even if it isn’t progressive, periodic controls are necessary Occupational therapist evaluation necessary Physical impairment

21. Learning to compensate for a physical impairment takes time. Temporary physical impairment (3 – 12 weeks) – not enough time to learn to compensate Therefore, temporary immobilisations that affect driving actions are incompatible with driving After resolution of the temporary condition – any functional sequellae that may affect driving? If so – functional evaluation is required Temporary physical impairment

22. Dementia Diabetes Obstructive Sleep Apnea (OSA) Seizures Medical Conditions

23. Cognitive functions that are vital for safe driving Judgement Self-awareness Divided attention Visual processing speed Medical conditions - dementia

24. Cognitive screening tests are poor predictors of on-road performance MMSE (Folstein), MOCA, Trails A and B, UFOV do not evaluate judgement or self-awareness Initial stages of dementia may be compatible with driving Diagnosis of dementia + crash = crash risk of 80% Suspicion of dementia or a cognitive defect should trigger a functional driving evaluation Medical conditions - dementia

25. Educate health professionals on the road safety implications of dementia (and other medical conditions) Ideally the health care professional will identify the medically-at-risk-driver before a road safety incident rather than reacting after the fact Driving requires autonomy, “co-piloting” or requiring assistance to drive is unacceptable Loss of autonomy = driving fitness assessment Medical conditions - Dementia

26. Crash rates associated with diabetes have diminished over the past 30 years Due to?: Better control, domestic glucometre, better patient understanding, micro-management Medical controls by DMVs Diabetes controlled by diet or hypoglycemic drugs – same crash rates as healthy drivers Diabetes treated with insulin - higher crash risk – more subject to hypoglycemic episodes? Medical conditions - Diabetes

27. Attention: lower blood sugar values do not necessarily imply higher risk of hypoglycemia Tolerance of low blood sugar values varies greatly from one individual to another Basing licensing decisions on blood sugar values is not a valid approach The diabetic driver must be able to manage their diabetes and regulate their driving to accommodate their condition Medical conditions - Diabetes

28. Require clinician certification of stability Hypoglycemic unawareness is incompatible with driving Drivers who suffer a hypoglycemic episode requiring third-party intervention should not drive until their clinician has declared them stable Medical conditions – Diabetes guidelines

29. Mainly concern the material in Chapter 4 – research and the researcher’s comments The researcher is a clinician who made recommendations to the DFWG based upon his research findings The guidelines in Chapter 1 appear to conform to ADA’S recommendations in its comments apart from its misunderstanding of the DMV’s role in driver licensing ADA’s objections

30. OSA + daytime drowsiness = limit driving until treatment has been shown to be effective Treatment = CPAP (Continuous Positive Airway Pressure) or equivalent Treatment requires at least 2 weeks to be effective and one night without treatment to become ineffective Pharmacological and oral treatments possible for less severe cases Untreated or untreatable OSA with daytime drowsiness + a crash= suspension Medical conditions – OSA

31. A history of seizures precludes unconditional licensing Unique seizure – requires neurological assessment before resuming driving Seizures caused by substance abuse – 6 months abstinence Following any seizure – unfit to drive for at least 6 months Epilepsy – requires periodic recertification Epilepsy with no seizure > 2 years and no anti-epileptic drugs – no requirement for annual recertification Medical conditions - seizures

32. Recommended format based upon the QC form Although longer than most jurisdictions’ forms, it has been well received by the QC medical community Mainly because of the new form and the SAAQ/College of Physicians workshops for physicians, physician reporting in QC has quadrupled over the last five years (3 500 – 15 000) The form does not ask if the driver is fit to drive, it asks if the physician has concerns about the driver’s fitness to drive Medical form

33. Driver fitness determination requires individual assessment of driving ability There are no hard and fast rules for many medical conditions Current medical standards in many jurisdictions have little or no grounding on scientific evidence A flexible approach is required for the application of medical standards for drivers The medical guidelines provide a rational approach that favours evidence-based standards (where possible) Conclusion

34. Dr Jamie Dow: 418-528-4984 jamie.dow@saaq.gouv.qc.ca NHTSA/AAMVA medical guidelines: Thank you