June 16, 2010

CANADA: New tools to help decide whether you're fit to drive

VICTORIA, British Columbia / Times Colonist / Health / June 16, 2010
Our Aging Drivers:
Doctors can give pen-and-paper test to gauge impact of dementia on driving

By Cindy E. Harnett, Times Colonist

Should an 89-year-old continue driving? Perhaps. It's not all about age, experts say. New tests will help decide.
Photograph by: Debra Brash, Times Colonist

We are such a car-dependent society that some people won't even consider retiring from driving -- but they should.


Some people with dementia are at extraordinarily high risk for being unfit to drive, yet others are safe. Two new screening tools will help doctors assess who's who.


If medical conditions rather than age affect safe driving, should we begin testing all drivers at age 40 when age-related medical conditions begin?

After a decade in development, two long-awaited methods to help doctors assess whether seniors are fit to keep driving will be made available this month.

One tool is a simple pen-and-paper test to identify whether drivers with a cognitive impairment or dementia are safe to drive. The other tool is B.C.'s new medical-fitness driver guidelines which define for doctors how certain medical conditions can adversely affect driving.

"I think they will both advance screening for medically at-risk drivers," said Steve Martin, B.C.'s superintendent of motor vehicles. "It will be a significant change and benefit."

New peer-reviewed research has led to the pen-and-paper test. Details are being published this month in the Journal of Primary Care and Community Health.

The test -- called the SIMARD, a Modification of the DemTect -- takes about five minutes to complete in a doctor's office and evaluates four abilities needed for driving: memory, attention, judgment and decision-making. To avoid skewing results, specifics about what's on the test are only being made available to doctors.

The B.C. government, in concert with the B.C. Medical Association, has committed to set up a pilot program for the test, possibly in Victoria, said Martin. Once doctors and government officials have assessed its effectiveness, it will be rolled out across the province.

"This is a new tool that hasn't been used anywhere in the world yet, so we are very excited about the potential, but we first want to implement it on a limited basis," Martin said.

More rigorous screening tools can't come soon enough for health professionals, who will be tasked with assessing driver fitness for a growing contingent of baby boomers who are hitting their senior years.

In 2025, one in four Canadians will be 65 or older. And according to the Alzheimer Society of Canada, by 2040 the number of people with Alzheimer's disease in Canada will more than double. Alzheimer's disease is the most common form of dementia.

The pen-and-paper test was developed by two University of Alberta researchers -- Bonnie Dobbs, director of the Medically At-Risk Driver Centre and associate professor in family medicine, and Don Schopflocher, an associate professor and research statistician.

"The medical and licensing community has been calling for a user-friendly, easily administered, highly predictive screening tool for 10 to 20 years," said Dobbs. "And that tool has now been developed. I'm very excited about it."

The reaction from the medical community "has exceeded my greatest expectations," Dobbs said.

Finding a new screening tool to detect which drivers shouldn't be on the road or should go for a road test was a quest that piqued the interest of both Dobbs and Holly Tuokko, director of the Centre on Aging at the University of Victoria, more than 10 years ago.

Tuokko became involved with CANDRIVE, the Canadian Driving Research Initiative for Vehicular Safety in the Elderly, a federally funded five-year study, now in its second year, that is working to create a better medical checklist and road tests geared to seniors.

As part of this longitudinal study, about 1,000 seniors aged 70 years and older are being followed in seven cities across Canada, for their medical fitness and ability to drive.

The CANDRIVE study is looking for its own screening tool to identify people who might be at high risk for a crash and should be referred for a road test.

"It's a much more formalized approach than now, where each individual physician is going by guess and by golly," Tuokko said.

Dobbs took a different path, helping to develop the SIMARD-MD pen-and-paper test after reviewing other screening tools designed to identify cognitive impairment.

SIMARD-MD is an abbreviation for Screen for the Identification of cognitively impaired Medically At-Risk Drivers: a Modification of the DemTect.

In developing SIMARD-MD, an earlier test called DemTect, developed by Germany's Dr. Elke Kalbe and his colleagues, proved to be especially useful. It is a screening test used to assist doctors in diagnosing patients with mild cognitive impairment and early dementia.

The SIMARD-MD determines the probability of a pass or fail on a road test with "a high degree of accuracy," said Dobbs. Patients who score in the middle of the pack and lower are advised to take a road test.

"Physicians are well situated to identify medically at-risk drivers," Dobbs said. "But the lack of valid tools has hampered their ability to determine with greater accuracy which of their patients with cognitive impairment may be at risk for declines in driving competency and which ones are safe to continue driving," Dobbs said.

However, neither the SIMARD-MD nor the province's new driver medical fitness guidelines are in themselves the answer.

There needs to be a similar tool for people with vision problems such as glaucoma and another tool to test drivers with motor impairments such as multiple sclerosis, Dobbs said.

"The SIMARD-MD is an incredible advancement in terms of helping physicians and driver licensing departments to make evidenced-based decisions," Dobbs said.

"So if we can do the same thing for sensory and motor impairments, it would round out the area of all functional abilities needed for driving."

In seven out of 10 Canadian provinces and in all three territories, it is mandatory for doctors to report medically unfit drivers to licensing authorities.

Under the new B.C. Motor Vehicles Amendment Act passed last month, psychologists, optometrists, medical practitioners, nurse practitioners and occupational therapists are required to report any patient, who may be unfit to operate a vehicle because of a medical condition.

The legislation also increases legal protection for those professionals if they are sued by an unhappy patient.

In B.C., the motor vehicle branch makes the ultimate decision on whether to yank a driver's licence.

However, doctors say they bear the brunt of the responsibility because they must assess their patients' driving fitness and then possibly report that patient to authorities.

It's a decision that can destroy the doctor-patient relationship, said Dr. Ian Gillespie, president of the B.C. Medical Association.

To help doctors make that assessment, a new 29-chapter guide, developed by the Office of the Superintendent of Motor Vehicles with the BCMA, will be available to B.C. doctors at the end of June.

Drivers must contend with myriad traffic signals that can be more difficult to judge as we age and struggle with medical problems. Photograph by: Debra Brash, Times Colonist, Times Colonist

After years in development at a cost of more than $1 million, the province is almost ready to release its new medical fitness driver guide via the BCMA website.

The guide's update is long overdue, said Gillespie. The province's last driver medical fitness guide was produced in 1997 and the update was delayed for either bureaucratic or budget reasons, Gillespie said.

B.C. is the only province with its own medical fitness driver guidelines.

Touted as having the most recent research on medically at-risk drivers in Canada, the guide lists numerous medical conditions and how they could affect driving.

"The rest of the country is watching us very closely and many other provinces will likely follow suit and adopt these guidelines," said Martin.

The Canadian Council of Motor Transport Administrators, which also produces driver fitness guidelines used by many provinces, has told the motor vehicles branch it will adopt B.C.'s new information.

The process of updating the new guide began in 2006, said Martin.

Dobbs was the guide's project researcher. Her 24 research papers based on a review of 2,400 articles, became the government's source of information, said Stephanie Melvin, assistant superintendent of motor vehicles.

It's no longer acceptable to prevent someone from driving because of their age or the name of their medical condition, said Martin. Instead, today's drivers are being judged by their ability to drive.

"It's part of the evolution of our approach in B.C. where we don't discriminate against broad classes of drivers based on a brush stroke that says, for example, everyone with this type of diabetes can't drive," Martin said.

"We really want to get behind the medical condition and what is it about that medical condition that affects their driving," he said.

All kinds of medical conditions can impair driving but there are broad areas of concern. Those include conditions that affect: vision such as glaucoma, motor control such as arthritis or Parkinson's, mental functions such as seizures or infections, and progressive neuro-degenerative disorders that affect the brain's ability to process and retain information.

The research behind B.C.'s guidelines followed a number of human rights rulings that said it's not acceptable to discriminate against classes of drivers based solely on things such as age or medical conditions.

"Almost any medical condition could affect driving, and almost any medication could affect driving," said Tuokko.

With every medical condition comes questions -- is the condition being controlled, what's it being controlled with, do those controlling agents affect driving, how many other conditions does the driver have, are there multiple medications, and do they impair driving? Tuokko said.

"This is where the physician struggles for good reason because it's a very complicated decision and driving is a very complicated task on top of that," Tuokko said.

Paradoxically, individuals with dementia, for example, are at high risk for driving impairments.

"But we also know that just having dementia does not make you unsafe to drive."

While B.C. tries to evaluate each driver on their ability to drive, other jurisdictions simply impose blanket bans on certain diseases. In California, for example, a driver diagnosed with Alzheimer's is prohibited from driving -- end of story.

The introduction of new guidelines, however, is just the first step.

Although some doctors have been clamouring for new guidelines, other doctors don't know may exist, said Gillespie.

When the guidelines come out, making physicians aware that they exist will be a priority, the BCMA and the motor vehicles branch say.

E-Mail: ceharnett@tc.canwest.com

Quick Facts
Testing shows that many older drivers take longer to perform motor activities. Weaker muscles, reduced flexibility and range of motion and conditions such as arthritis make it more difficult to:
- turn one's head
- grip and turn the steering wheel
- press the accelerator or brake
- reach the controls or open windows and doors

The number of seniors in Canada will double in 15 years, and an increasing number of those aging baby boomers will drive more often and longer than any generation before them. Are we ready?

As part of your driving retirement plan, consider:

- Making a gradual transition to quitting driving rather than an abrupt stop
- Restrict your driving to daylight hours, taking roads with less traffic, and mapping out your route to make more right-hand turns rather than potentially dangerous left-hand turns
- Maintain strength and flexibility throughout your body needed to do shoulder checks, turn the steering wheel and move your foot from gas to brake easily
- Move to a pedestrian friendly community
- Explore public transit in your area
- Explore the many volunteer transportation options or commercial driving services in your community which offer discounts for seniors or will set up special accounts
-Talk to family and friends about getting their help
- If your spouse is healthy, ensure they have a valid licence and gain experience driving
- Research shopping websites to order groceries and more
- Consider using a bicycle or buying a scooter if you can use one safely

- Journal of Primary Care & Community Health
- Physicians wanting information on the SIMARD MD.

© Copyright (c) The Victoria Times Colonist