The Elderly Driver:Functional Assessment

Richard Marottoli, MD, MPH, VA CT and Yale University

Shirley Neitch, MD, FACP, Hanshaw Geriatric Center, Marshall University, WV

Adapted from a satellite conference produced by Department of Veterans Affairs Employee Education Service and Office of Geriatrics and Extended Care, and Consortia of Geriatric Education Centers.

Mr. Jones is an 83 year old widower sent for follow-up after hospital discharge

• PMH: HTN, hyperlipidemia, hip fracture, OA, cataracts

• Function– Lives in own home– Independent in l/B ADL, uses cane– Daughter visits twice/week• Straightens house• Brings food to reheat

Driving

• 3-4 x/wk

• Mostly familiar places

• Minor crash 3 yrs ago

– Rear-ended at stop sign

• No navigation problems

Hospitalized 2 Weeks Ago

• Found on bathroom floor by daughter

• Awake but confused

• Unsure what happened, how

• ER: temp, +UA, renal insufficiency admitted for observation b/o ? LOC, hit head

Hospital Course:

• Confusion resolved w/ IV fluids, antibiotics

• Head CT: Infarct of ? age• Function: Needed assist w/transfers,

walker for ambulation• Disposition: STR; f/u appt. w/you

regarding driving, living situation• Home after 1 week at STR, returned to

baseline mobility

Types of Assessments

• Driving skills and behaviors can be assessed in different settings and at different levels of complexity:

– DMVs

– Rehabilitation Facilities

– Local or Regional Assessment Clinics

– Primary Care Provider Offices

Types of Assessments

– “ADReS” Assessment of Driving-Related Skills

– available in Physician’s Guide to Assessing and Counseling Older Drivers developed by the American Medical Association in cooperation with the National Highway Traffic Safety Administration, September 2003, Chapter 3.

– Seven component testing protocol– Much of the testing can be done by office

staff– Time required generally 10 min. or less

ADReS

– Visual Fields

– Visual Acuity

– Rapid Pace Walk

– Range of Motion

–Motor Strength

– Trail-Making Test, Part B

– Clock Drawing Test

• Seven Components:

ADReS

Component:

Visual Fields

How Tested:

Confrontation

Result Signaling Need for Intervention:

Any field cut

ADReS

Component: Visual Acuity

How Tested:

Snellen or Rosenbaum chart

Result Signaling Need for Intervention: Varies by state; most commonly, best

corrected vision of 20/40 required

ADReS

Component: Rapid Pace Walk

How Tested: Mark 10 foot distance; Time patient

walking 10 ft., turning, walking backResult Signaling Need for Intervention: Time > 9 seconds

ADReS

Component: Range of MotionHow Tested: Neck rotation, finger curl, shoulder &

elbow flexion, ankle plantar- &dorsiflexion ---Simulate driving position

Result Signaling Need for Intervention: Any clinically significant deficit

ADReS

Component:

Motor Strength

How Tested:

Shoulder, wrist, hand grip, hip, ankle

Result Signaling Need for Intervention: <4/5 in either upper extremity or right

lower extremity

ADReS

Component: Trail-Making Test, Part B

How Tested:

Standard form

Result Signaling Need for Intervention:

> 180 seconds

ADReS

Component:

Clock Drawing Test

How Tested:

Standard form

Result Signaling Need for Intervention:

Any abnormal element

Visit Information(2 Weeks Post Discharge)

• Hx: No new complaints, feels fine

• Meds: Beta blocker, thiazide, statin

• Exam: BP, HR WNL

Cataracts; OA changes hands/knees; good strength; independent transfers, stable slow gait with cane

ADReS Findings

• Visual Fields: Intact• Visual acuity: 20/40 ou• Rapid pace walk: 8 sec (w/cane)• ROM: Neck rotation, finger curl limited• Strength: 4+ - 5/5• Trails B: 135 sec• Clock: # spacing slightly off

Questions

1. What do you advise Mr. Jones regarding his driving? His living situation?

2. Are there other history, exam, or laboratory data that would be helpful at this point?

Follow Up Visit

• 9 Months later (1 no show in interim)• Accompanied by daughter who reports–More confused - oversees meds– House less clean, hygiene worse– Still drving - lost going to her house;

no known crashes, but ? new scrapes/ scratches on car

Follow Up Visit

• Mr. J:– No functional changes– Increase in urinary frequency,

occasional incontinence

• PE:– BP, HR higher compared with prior

visits, otherwise unchanged except unkempt appearance, stains on clothes

ADReS changes

• Rapid pace walk: 8.5 sec (8)

• Trails B: 165 sec (135)

• Clock: # spacing off, # on margin of clock, hand placement incorrect

• Fields, Acuity, ROM, strength unchanged

Questions

1. What do you advise Mr. Jones regarding his driving? His living situation?

2. Are there other history, exam, or laboratory data that would be helpful at this point?