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Healthy people, amazing care. - Koorda moort, moorditj kwabadak.

Delirium, dementia and

can I drive Doc?

31st August 2019 Dr Joel Tate

Geriatrician, Armadale Health Service

Clinical Lead Choosing Wisely


Case 1: Assessment of Cognition

1. What factors may be contributing to her

presenting complaint?

2. Is it worthwhile assessing her cognition

today, how would you do this?

3. Are any investigations warranted?

4. How would you manage Irene from here?


https://www.mocatest.org/


Case 2: Dementia and driving

1. Does Fred’s new diagnosis of dementia preclude him from driving?

2. As Fred’s GP are you obliged to report his new

diagnosis to the Department of transport?

3. What approach would you take to bringing up your

concern about his ability to drive?

4. What questions might help you to assess his safety to

drive, particularly considering he is driving to Capel

weekly? and how could this be formally assessed?

5. If Fred does not follow your advice regarding driving,

are you legally allowed to break patient doctor

confidentiality by informing the Department of

Transport?


Occupational Therapy Driving assessment

Off Road Assessment

• Nil significant physical issues

• Cognitive limitations: – Motor planning

– Attention

– Memory

– Insight

– Speed of processing

On Road Assessment

Error’s in:

• speed modulation

• timely gap selection

• decision making

Recommendation: Suspension of his licence (Class C, HC & R)


Driving and Dementia


Austroads - Dementia

A diagnosis of dementia is associated with

a moderately high risk of collision

compared with matched controls.

However, the evidence does not suggest

that all people with a diagnosis of dementia

should have their licences revoked or

restricted.

Throughout all stages of their condition,

drivers require regular monitoring

regarding progression of the disease.


How dementia affects driving

errors with navigation, including forgetting routes and getting lost in

familiar surroundings

limited concentration or ‘gaps’ in attention, such as failing to see or

respond to ‘stop’ signs

errors in judgement, including misjudging the distance between

cars and misjudging the speed of other cars

confusion when making choices, for example, difficulty choosing

between the accelerator or brake pedals in stressful situations

poor decision making or problem solving, including failure to give

way appropriately at intersections and inappropriate stopping in

traffic

poor insight and denial of deficits

slowed reaction time, including failure to respond in a timely fashion

to instructions from passengers

Poor hand eye co-ordination


Collateral history Relatives may be a useful source of information

regarding overall coping and driving skills. They

may comment about the occurrence of minor

crashes, or whether they are happy to be driven

by the person with dementia.

Where the person is judged to be an imminent

threat to safety, all states and territories (except

NT) provide indemnity for health professionals and

other members of the public who notify the driver

licensing authority of at-risk drivers; the driver

licensing authority will then take the necessary

steps


Dementia diagnosis and driving

Not fit to hold an unconditional licence

A conditional licence may be considered by the

driver licensing authority subject to at least annual

review, taking into account: • the nature of the driving task

• information provided by the treating doctor regarding the level

of impairment of visuospatial perception, insight, judgement,

attention, comprehension, reaction time or memory and the

likely impact on driving ability

• the results of a practical driver assessment if required

• the opinion of an appropriate specialist may also be considered


Role of technology:

off road pre-testing

Pearson Clinical

Assessment – tablet

based

https://youtu.be/79E

sZE3LlvI

https://youtu.be/79EsZE3LlvIhttps://youtu.be/79EsZE3LlvIhttps://youtu.be/79EsZE3LlvI


Case 3: Acute Confusional State

1. Could this be natural progression of his Alzheimer’s Disease?

2. Are there any investigations you would

like to arrange?

3. What is the significance of positive

leucocytes on urinalysis for Cecil?

4. Can this patient be managed safely in the

community? What factors might prompt

you to consider referring to ED/Geriatric

Services.


Common:

13.9% women, 2.6% men,

23% inpatients. NEJM, Wise M. 2015

Sterile pyuria


Therapeutic guidelines

Initial assessment and

management of aged-care

facility residents with

suspected urinary tract

infection

Do not investigate or treat cloudy

or malodorous urine in aged-care

facility residents who do not have

other symptoms or signs of UTI

Augmentin now part of first line treatment


More on the Dipstick

Scottish Intercollegiate Guidelines Network 2012


Updates

Proof of cure no longer recommended (Therapeutic Guidelines 2019)

No role for dipstick in elderly hospitalised

Dipstick screening not indicated (unless pregnant or invasive urological procedure)

Cloudy, dark or

malodourous urine

not a reliable indicator

of UTI

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