Electronic letters to:

Commentary:
Mark J. Rapoport, MD, Nathan Herrmann, MD, Frank J. Molnar, MDCM, Malcolm Man-Son-Hing, MD, Shawn C. Marshall, MD MSc, Ken Shulman, MD, and Gary Naglie, MD
Sharing the responsibility for assessing the risk of the driver with dementia
CMAJ 2007; 177: 599-601 [Full text] [PDF]
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Electronic letters published:

[Read eLetter] Online cognitive tests are now needed to assess the risk of the driver with dementia
Sandy H. Straus   (20 December 2007)
[Read eLetter] Agree with the proposals
Pyari R Bose   (26 October 2007)
[Read eLetter] Older driver motor vehicle crashes
Ediriweera Desapriya   (19 September 2007)

Online cognitive tests are now needed to assess the risk of the driver with dementia 20 December 2007
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Sandy H. Straus
ESRA Consulting Corporation

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Re: Online cognitive tests are now needed to assess the risk of the driver with dementia

strauss{at}esracorp.com Sandy H. Straus

The difficulty in assessing drivers with dementia that Rapoport and colleagues described in a recent CMAJ commentary (1) is a global phenomenon. The authors suggest objective, office-based tools for driving assessment and for specialized testing of drivers with mild dementia. However, they do not mention the benefits of online cognitive assessment tools to augment such fitness to drive determinations.

The American Medical Association (2) recommends two tests for assessing the cognitive abilities of older drivers: The Clock Drawing Test and the Trail Making Test Part B. While useful, these cognitive tests and others, such as the Mini-Mental State Examination, are severely limited by paper-based administration. Such tests also introduce bias due to varying techniques of administering, scoring, interpreting, recording, and reporting. In addition to challenges to the doctor-patient relationship, many physicians lack the time, resources, and training to screen and counsel numerous patients for dementia using manual tests. Also, most paper-based cognitive assessment tests require a translator for speakers of languages other than English and exclude individuals who are unable to draw or hold a writing instrument. Still, some drivers, especially those with moderate-to-severe dementia, may not recognize the symptoms or seek medical evaluation and therefore continue to drive.

A lack of widespread use of online and uniform cognitive assessments pose obstacles to motorist safety when the incidence of dementia is expected to jump 400% worldwide over the next 20 years (3). In the USA, as well as many other countries, no federal or state laws specifically mandate cognitive screening tests for drivers (4). An occasional high- profiled accident that involves a dementia driver serves as a reminder of the importance of balancing medicine and transportation policy with public safety priorities.

Importantly, multimedia and interactive online test products, such as the Automatic Clock Drawing Test (TM) (Times2Tell (TM)) and the Online Trail Making Test (TM) are now available through SpecialtyAutomated Systems Corp., <http://www.specialtyautomated.com> in numerous languages. These revolutionize cognitive assessments that, until now, were restricted to paper or an obsolete software package. Powerful, online cognitive tests offer rapid, objective, autonomous, and standardized methods for screening drivers and predicting at-fault collision involvement (5). Instant scores and automatic feedback are provided. Supplementary online verbal learning and memory tests are available to describe brain function (6). Collectively, these are winning combinations for physicians, patients, driver’s license agencies, and motorists: Drivers with dementia and dementia-like symptoms, including speakers of languages other than English, and those with special needs, can be frequently observed for cognitive changes in real time. Online technologies may therefore be used as cost-effective measures to extend mobility as safely as possible.

To summarize, practices and studies involving the use of online cognitive assessment tools are now needed to detect and monitor drivers with dementia, to recommend medical follow-ups, and to improve road safety. Although dementia, the most common form of cognitive impairment, can occur at any age, the greatest risk factor is increasing age. Online screening tests, such as the Automatic Clock Drawing Test (TM) and Online Trail Making Test (TM), will ensure that drivers of all ages, and, in particular, older drivers, will not face discrimination or hardship with respect to age, culture, disability, education, language, or race.

REFERENCES

1. Rapoport, MJ, Herrmann, N, Molnar, FJ, Man-Son-Hing, M, Marshall, SC, Shulman, K and Naglie, G. Sharing the responsibility for assessing the risk of the driver with dementia. CMAJ 2007; 177: 599-601

[Full text] http://www.cmaj.ca/cgi/content/full/177/6/599

2. Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physician’s Guide to Assessing and Counseling Older Drivers. Washington, DC: National Highway Traffic Safety Administration; 2003.

3. Whitmer RA, Gunderson EP, Barrett-Connor E, Quesenberry CP Jr, Yaffe K. Obesity in middle age and future risk of dementia: A 27 year longitudinal population based study. BMJ 2005; 330: 1360.

[CrossRef] http://www.bmj.com/cgi/content/abstract/330/7504/1360

4. Straus, SH. Standardization and Computerization of the Clock Drawing Test: The Automatic Clock Drawing Test. Presentation at the dementia session of the 9th European Conference for the Advancement of Assistive Technology in Europe, AAATE 2007, 3- 5 October 2007, San Sebastian, Spain.

5. Straus, SH. Use of the Automatic Clock Drawing Test to rapidly screen for cognitive impairment in older adults, drivers, and the physically challenged. J Am Geriatr Soc 2007;55:310- 311.

[CrossRef] http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01055.x

[MedLine] http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=17302675

6. Straus, SH. Improving Medical Care and Knowledge Through New and Rapid Automated Cognitive Impairment Screening Tools, Ann Fam Med, 4 December 2006. http://www.annfammed.org/cgi/eletters/4/5/386

Conflict of Interest:

Sandy Straus, through ESRA Consulting Corporation, shares patents pending on Automatic Clock Drawing Test (TM) and Online Trail Making Test (TM) products. She is owner of ESRA Consulting Corporation and a co-owner of SpecialtyAutomated Systems Corporation, the company that manufactures two of the test instruments mentioned in this letter.
Agree with the proposals 26 October 2007
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Pyari R Bose

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Re: Agree with the proposals

dr_pyari{at}yahoo.com Pyari R Bose

I found this article very useful. In the absence of definitive tests to assess driving capabilities, its hard to make a decision on who can drive and who cannot. Its more so if the patient falls in the twilight zone between mild and moderate dementia. Ofcourse , eventually the dementia will progress and then its not a problem making a decision. Then we have the fairly obvoius ones. I had a patient who had dementia and arthritis of the hip. We had to tell him he cant drive though he was not very happy with it.Well sometimes we have have to take difficult decisions in the best interests of the patient and the society even though that might compromise doctor patient relationship.

Conflict of Interest:

None declared
Older driver motor vehicle crashes 19 September 2007
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Ediriweera Desapriya

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Re: Older driver motor vehicle crashes

edesap{at}cw.bc.ca Ediriweera Desapriya

Canada’s population is aging, which means that in coming decades there will be a significant increase in both the number and percentage of older people in the population. In fact, Statistics Canada (2002) estimates that by 2021 one in five Canadians will be at least 65 years old (1)-a statistic that is comparable to that of the United States, Australia, Japan and most European countries (2)

Many motorized countries, predicts substantial changes in the proportion of older individuals in the foreseeable future as the current population ages. Furthermore, the older population is itself ageing(3). As most individuals’ age, they experience some level of functional decline in sensory, physical and cognitive areas.

A recent OECD report shows that while older drivers tend to be safer than commonly believed, causing fewer crashes per capita or per number of motorists than other age groups, older people are also more vulnerable to injury or death. (3) Without new policies in areas ranging from supporting and assessing older drivers to developing safer roads, vehicles and infrastructure, the number of elderly road users injured or killed in crashes is likely to rise.

Rather than imposing mandatory driving tests once people reach a certain age, the OECD recommends community-based assessments involving doctors, police and social services as well as the family and friends of older drivers. At the same time, the report argues the need for a better approach to assessing and responding to the disabilities that can hamper safe driving (3). Family and friends may be in a good position to detect problems and intervene to assist the unsafe older driver to limit or stop driving. Family and friends often look to professionals for help and advice in these matters. Healthcare professionals influence the older driver in driving decision–making, and should play an important role in assessing driving abilities. However, mandatory physician reporting exists in few motorized countries.

A recent study comparing the motor vehicle crash and fatality rates among older drivers in Finland, where age-related medical screening is strictly enforced, and Sweden where there is no such screening conclude that age-related medical screening has no impact at all on the safety of older drivers (4).

Several other strategies can be envisaged that might be used to improve road safety among older drivers. For example, measures might be introduced that raise drivers’ awareness of the problems they are likely to encounter as they grow older, together with advice concerning how to recognize and deal with them (3). It might also be possible to make available to the older driver some way of more formally assessing their own capabilities. Alternatively, a system requiring some sort of assessment or test of driving abilities following a negative driving event could be introduced. Whatever measures are introduced, if they are to be workable it is important that they are deemed fair and acceptable to older drivers, many of whom rely on the private car for their personal mobility (5).

The data reported by Lorraine, McDonald and Sutcliffe (6) suggest that older drivers are not likely to find acceptable any measure that takes away from the individual the responsibility for deciding when and how to stop driving. Measures presented as promoting rather than restricting the personal mobility of older drivers are most likely to be met with approval (7).

References:

(1).Statistics Canada (2001) General Social Survey: An Overview. Catalogue Number: 89F0115XIE. Statistics Canada (2002) http://www.statcan.ca/english/Pgdb/People/Population/demo23a.htm

(2). Rosenbloom, S., Sustainability and automobility among the elderly: An international assessment. Transportation, 2001:28; 375-408.

(3). Organization for Economic Co-operation and Development (OECD) Ageing and Transport: Mobility Needs and Safety Issues. Paris: OECD. (2001)

(4). Hakamies-Blomqvist, K. Johansson and C. Lundberg, Medical screening of older drivers as a traffic safety measure: a comparative Finnish–Swedish evaluation study. Journal of American Geriatrics Society 1996: 44; 650–653.

(5). Martinez, R., Older drivers and physicians.JAMA1995:274; 1060- 1062

(6). Lorraine, D.P., McDonald P.R., Sutcliffe, P., Older drivers and road safety: the acceptability of a range of intervention measures Accident Analysis and Prevention 2003:35; 805-810

(7). Marottoli, R.A., Mendes De Leon, C.F., Glass, T.A., et al; Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Journal of American Geriatrics Society 1997:45; 202–206.

Conflict of Interest:

None declared