Medically AtRisk Drivers Gina C Pervall MD Chief

Medically At-Risk Drivers Gina C. Pervall, MD Chief, Medical Advisory Board MDOT MVA BIAMD - March 2018

Disclosure I have no financial interest or affiliation with any entity producing, marketing, re-selling or distributing healthcare goods or services consumed by, or used on patients.

Objectives Ø Identify medically at-risk drivers Ø Understand MVA’s referral and review process for medically at-risk drivers Ø Knowledge of testing and assessments used by the Medical Advisory Board for fitness-to-drive Ø Resources

Maryland Drivers § Maryland has more than 4. 3 million licensed drivers § Largest group of licensed drivers is 50 – 59 years old § More than 17% of Maryland drivers are 65 years & older

Maryland Licensed Drivers By Age 2000 2017 800000 700000 600000 500000 400000 300000 200000 100000 Up & 90 9 -8 80 9 -7 70 9 -6 60 9 -5 50 9 -4 40 9 -3 30 9 -2 20 16 -1 9 0

Driving after Brain Injury § 70% individuals with TBI return to driving § 63% individuals with severe TBI were involved in subsequent crashes Bivona, et al. 2012

Driving after Brain Injury § CVA – No increased accident rate § TBI – Accident rate two-times higher compared to general population § Lack of adequate compensation for cognitive deficits § Premorbid conditions Shanke, et al. 2008

Driving after Brain Injury § Individuals with TBI who received driver rehabilitation had no higher rate of accidents compared to control group Schultheis, et al. 2012

Medically Fit Driver A safe driver has the ability reason, remember, and react quickly to any driving hazard, or to avoid a collision.

Warning Signs of Unfit Driver § Getting lost § Slow to make decisions § Not observant § Poor distance judging § Accidents/Near misses § Driving too fast/slow § Drifting across lanes § Parking difficulties

Medical Risk Factors § Physical/Functional Limitations § Mental/Cognitive Limitations § Visual Impairments § Impairing Medications

Brain Injury & Driving Disruptions Physical Impairments § Decreased Strength § Poor Coordination § Decreased Reflexes § Decreased Reaction Time

Brain Injury & Driving Disruptions Cognitive Impairments § Memory Deficit § Poor Divided Attention § Decreased Information Processing Speed § Poor Judgement/Insight

Brain Injury & Driving Disruptions Cognitive Impairments cont. § Inability to concentrate over long periods § Poor problem solving § Lack of awareness/insight

Brain Injury & Driving Disruptions Visual Impairments § Blurred Vision § Double Vision § Visual Field Deficit

Brain Injury & Driving Disruptions Medications § Narcotics § Benzodiazepines § Anticonvulsants § Antidepressants

MD Vehicle Law§ 16 -118 The Administrator may appoint a Medical Advisory Board of qualified physicians and optometrists to enable the Administration to comply properly with the provisions of this title regarding the physical and mental condition of individuals who seek to drive on highways in this State.

Medical Advisory Board § Comprised of physicians from various specialties § Reviews medical information of individuals with conditions that can impact their ability to safely drive § Assesses medical fitness to drive § Provides advice and recommendations to MVA § Does not make the final decision regarding driving privileges

COMAR 11. 17. 03. 02 § Physical and Mental Condition § Any physician and other person authorized to diagnose, detect, or treat a disorder that: § is characterized by lapse of consciousness; or § Results in corrected visual acuity that files to comply with the vision requirements…”

Lapse of Consciousness § Confusion § Cardiovascular Disease § Epilepsy § Cerebrovascular Disease § Narcolepsy § Alcoholism § Hypoglycemia § Drug Addiction

COMAR 11. 17. 03. 02 -1 § A licensee or an applicant for a driver’s license shall notify the Administration if the licensee or applicant is diagnosed with a “reportable condition”…

Reportable Conditions § § § § § Diabetes Epilepsy Seizure Heart Condition (LOC) Stroke Dizzy/Fainting/Blackout Traumatic Brain Injury Sleep Disorder Weakness/Shaking/Numbness Loss of Limb/Function § § § § Sleep Disorder Dementia Mental Health Condition Schizophrenia Alcohol Use Problem Drug Use Problem Corrected minimum Visual Acuity worse than 20/70 § Field of Vision less than 110 degrees

Medical Review Process

MVA Functional Capacity Test § Rapid walk - lower limb mobility § Useful Field of View (UFOV®) - divided attention § Delayed Recall - memory § Motor Free Visual Perception Test (MVPT) - spatial relationships § Trails B - visual search and sequencing, information processing speed, attention switching

Useful Field of View (UFOV ) 25

Motor Free Visual Perception Test

Motor Free Visual Perception Test

Trails B

FCT Results § No Deficit § No further testing/MVA Drive Test § Mild Deficit § MVA Drive Test § Moderate - Severe Deficit § OT/Driver Rehab

OT/Driver Rehab Assessments § Clinical Evaluation § Medical History § Physical Functioning § Cognitive Functioning § Behind-the-Wheel Evaluation § Objective Clarification § Immediate Feedback § Guidance

OT/Driver Rehab Report § No Deficits § Driving Deficits with Potential to Compensate § § Retraining Vehicle modification Geographical restriction Daylight only driving § Retire

MAB Review § Medical Information § Physician report, LOC affidavit, treatment report, etc. § MVA Screening/ Testing § Functional Capacity Test (FCT), Vision, Law, Drive Test § Referral Reports § OT/Driver Rehab Assessment

MAB Recommendation § Qualified to Drive WITHOUT Stipulations § Approved for driving and case closed. § Qualified to Drive WITH Stipulations § Approved with restrictions, adaptive equipment, periodic monitoring. § Not Qualified to Drive § Temporary/permanent suspension of driver’s license.

Resources Driver Assessments: at Home, the MVA, & by Professionals http: //www. mva. maryland. gov/safety/older/driver-self-assessment-tools. htm Functional Capacity Test Screening http: //www. mva. maryland. gov/safety/older/fct-screening. htm Referring Drivers to MVA Medical Review Process http: //www. mva. maryland. gov/referringdrivers. htm Safety for Older & Medically At-Risk Drivers http: //www. mva. maryland. gov/safety/older-driver-safety-safe-mobility. htm

Driver Wellness and Safety 410 768 7513 DWSMED@mdot. state. md. us Medical Advisory Board 410 768 7371 MAB@mdot. state. md. us

Case Review

30 year old healthy man was operating a fork lift during snow removal duty for his employer. The equipment malfunctioned causing the driver to be catapulted forward, hitting his head and cracking the windshield for the forklift. Brief LOC. Complained of headache, dizziness and confusion. Imaging in ER negative. Diagnosed with concussion and discharged from ER with recommendation for rest, analgesic for headache, and follow up with PCP.

Scenario 1 – Self-Report § Health Questionnaire § Physician’s Report § LOC Affidavit

Scenario 2 – Physician’s Report § Health Questionnaire § LOC Affidavit § FCT/MVA Drive Test § OT/Driver Rehab Assessment

Scenario 3 – OT/Driver Rehab Report Favorable Unfavorable § Health Questionnaire § Restrictions § LOC Affidavit § Driver Rehab § MVA Drive Test § Suspension

Scenario 4 – Law Enforcement Report § Emergency Suspension § Health Questionnaire § Physician’s Report § LOC Affidavit § FCT/MVA Drive Test § OT/Driver Rehab