Exploding the Myths and Meeting the Challenges of …...Exploding the Myths and Meeting the Challenges of Older Adult Drivers David B. Carr, M.D Alan A and Edith L. Wolff Professor

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Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science

Exploding the Myths and Meeting theChallenges of Older Adult Drivers

David B. Carr, M.D

Alan A and Edith L. Wolff Professor of Geriatric MedicineClinical Director

Division of the Geriatrics and Nutritional ScienceDivision of Neurorehabilitation

Medical DirectorThe Rehabilitation Institute of St. Louis/Parc Provence


DISCLOSURES (2014-Present)• Funding Support (last two years)• National Institute on Aging (NIA)• Missouri Department of Transportation• State Farm

• Consulting Relationships• American Geriatric Society (AGS)• AAAFTS• TIRF• Medscape

• Speakers Bureau• St. Louis Alzheimer’s Association

• Medical Director• Parc Provence• The Rehabilitation Institute of St. Louis

• Investment/Stock/Equity• None


PRESENTATION OBJECTIVESPart 1Older Driver Myth Busters: Real Risks in Late Life

Part 2Fitness to Drive Myth Busters: Medically Impaired Drivers

Part 3Meeting New Challenges of Older Driver ResearchHuman Factor Interventions to Improve Outcomes

Part 4Meeting New Challenges of Technologies/Older DriversVehicle Interventions to Improve Safety

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Question #1: True or False?

The majority of older adults no longerhave an active driver’s license in the

US after age 85 years….


• Aging Demographics• 2012• 40 Million Older Adults• 34 Million Licensed Drivers

• 2050• 86 Million Older Adults• 66 Million Licensed Drivers

• Motor Vehicle Crashes• 2012• 5,560 older adults were killed 214,000 were injured• 15 older adults killed and 586 injured in crashes on

average every day

FALSE: But Barely….

National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2010: OlderPopulation. Washington, DC: USDOT; 2013. Available at:

http://www.cdc.gov/motorvehiclesafety/older_adult_drivers/http://www-nrd.nhtsa.dot.gov/Pubs/811640.pdf. Accessed August 13, 2012.

https://www.fhwa.dot.gov/policyinformation/pubs/hf/pl11028/chapter4.cfmhttp://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/older-people


Question #2: True or False?The average older adult driver over

age 90 years has an increased motorvehicle crash risk when compared to

other age groups…

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FALSE: DEPENDS ON YOUR PERSPECTIVE

http://search.cga.state.ct.us/dtSearch_lpa.html



The risk of older adult drivers over 80years of being injured in a crash hasincreased over the past decade, likely

due to physical frailty…


FALSE ON PROBABLY SEVERAL ACCOUNTS…TYPE OF CRASH, VULNERABILITY, AGE

http://search.cga.state.ct.us/dtSearch_lpa.htmlhttp://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/older-people/2010

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Older drivers that put the most milesper year on the road are at thehighest risk for a crash due to

increased exposure…


FALSE, although the risk remains low…

Nasvadi GC and Wister A. Do Restricted Driver’s License Lower Crash Risk AmongOlder Drivers. The Gerontologist 2008 49; 474-484.

Langford J, et al. 2006 Accident Analysis and Prevention, 28(3), pp. 574-578



The majority of older adults remainactive behind the wheel with very littletime at the end of life without theability to drive a car…

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FALSE…there is quite a time without wheels

Foley DJ, et al. Am J Public Health. 92:1284-9, 2002.

Men over age 70 live about 6 years without drivingwomen 10 years


The Importance of the Automobile• The Transportation

Method of Choice• Autonomy• Identity• Social Connectedness• Psychological and

Physical HealthCorrelates

• Private cars accountfor over 90% of tripsmade by seniors


Mobility CounselingTransportation Alternatives

• St. Louis Options• Social Work Referral• CORP• Call-A-Ride• Good Shepherd• Metro• Bus• Taxi• ITNAmerica• Uber• Other

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SUMMARY OF DRIVING STATISTICSOLDER ADULTS

• Increasing Numbers of Older Drivers

• More Potential Drivers with Multiple Medical Diseases/Meds

• Increased Morbidity and Mortality Numbers in MVC’s

• The Most Vulnerable are Likely Low Mileage Drivers

• Growing transportation burden in the US on families,caregivers, and society to provide trips

• Pharmacists and Clinicians will be Increasingly Involved


FITNES-TO-DRIVESTAKEHOLDERS• Patient• Family and Friends• Health Professionals• Organizations• Patrol Officers• State DMV• Insurance• Community• Federal/NHTSA


FTD Outcomes• Cessation/Retirement• Crashes• Road Tests• Simulators• Others

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FTD Outcomes:Are Crashes All They Are Cracked Up To Be?


Clinician Medical Guidelines

http://www.cma.ca/dr

iversguide

http://www.austroads.com.au

Updated, Evidenced-BasedAlso Refer to Your Own State Laws/Statutes

http://geriatricscareonline.org

https://myaota.aota.org/shop_aota


Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352:692-9

Do Single Test FTD Approaches Work?

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Ott BR and Daniello LA. Aging Health 2010; 6: 77-85

Cognitively, What Does it Take To Drive a Car?


Driving History/Med Review

• Driving Behaviors• Informant Rating• Exposure• Personality• Violations• Crashes• Cognitive Impairment• Functional Impairment• Others?


MEDICATIONS

• Narcotics• Barbituates• Benzo’s• Antihistamines• Antidepressants• Antipsychotics• Hypnotics• Alcohol• Muscle Relaxants• Antiemetics• Antiepileptic

Hetland A, Carr DB. Annals of Pharmacology 2014

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Pharmacist/Client Resources


Computerized Tests of Driving PerformanceThe DrivingHealth Inventory with UFOV/DriveABLE

Peak valid at-fault OR

Visualization of missing information 4.96(MFVPT; Visual Closure)Directed visual search 3.50(Trail-Making B)

Working memory 2.92(Delayed Recall)Information processing speed 2.48

(Useful Field of View, subtest 2)Lower limb strength 2.64(Rapid Pace Walk)Head/neck flexibility 2.56

(Recognizing Clock Time)Staplin L, et al. MaryPODS revisited.Journal of Traffic Safety, 2003: 389-397Dobbs AR. Accuracy of DriveABLE.Canadian Family Practice 2013: 59: e158-161.


Likelihood Ratios• Be wary of ordering tests when

pretest probability is high or low-30-70%

• LR+>10 means a positive test isgood at ruling in the diagnosis

• LR<.1 means a test is good atruling out a diagnosis

• Extreme test values may yieldimprecise LR’s• Few patients having values high

or low does not give goodprecision

• LR’s closer to 1 are not very useful

Grimes DA, Schulz KF. Refining clinical diagnosis withlikelihood ratios. Lancet 2005; 365: 1500-5

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Cut-offs

Molnar F, et al. Clinical Medicine: Geriatrics 2008: 2; 1-11Molnar F, et al. Geriatrics and Aging 2009; 12: 83-92


Probability Calculator of Failing Road Test: Dementia

Carr DB, et al. JAGS, 2011


Community Collaborations• Medical Societies• Level of Care• Chore Workers• Research• Legal• Education• Support Groups• Adult Day Services• Others

• Primary Care• Subspecialist• Neuropsychologist• OT’s• ST’s and PT’s• Care Managers• Social Workers• Pharmacist• Others

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Brain Aging

Mild CognitiveImpairment

Stable orReversibleImpairment

Otherdementias

Alzheimer’sdisease

VascularDementia

Mixed Mixed

NormalCognition

ProdromalDementia

Dementia

From Golomb, Kluger, Ferris NeuroScience News, 2000

Older Driver Research: Aging vs. Disease?


Model of Alzheimer’s brain pathology

Holtzman DM, Morris JC, Goate AM (2011) Science Translational Medicine Vol 3, Issue 77


Presymptomatic Detection of AD:Biomarkers (PIB Imaging)

Cognitivelynormal

Amyloid –

Cognitivelynormal

Amyloid +

Alzheimerdementia

Amyloid +

Courtesy of Mark A. Mintun and John C. Morris.Reprinted with permission.Copyright 2010 Washington University, St. Louis Missouri.All Rights Reserved

3 years later,Alzheimer dementia

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Sperling et al., 2011, Alzheimers Dement 7:280-92(Modified from Jack et al., 2009, Brain 132:1355-65)

Hypothetical model of dynamic biomarkersOf AD with emphasis on the preclinical period

AmyloidCSF/PET

FDG PET/fMRI Tau

MRI CogClinical

Function


CLUES TO SPECIFICNEURODEGENERATIVE DISEASES

Alzheimer’sDisease

Rapidlyevolving

dementias

Frontotemporaldementias

Lewy bodydementia

Vasculardementia


• Core features• Cerebrovascular disease defined by focal signs/brain imaging• Dementia syndrome• Relationship between 1 and 2 within 3 months, or abrupt, or stepwise

• Supportive features• Early gait disturbance• Frequent falls• Early urinary symptoms• Pseudobulbar palsy• Personality and mood changes• Abnormal executive function!!!!!

VASCULAR DEMENTIA:Clinical Diagnostic Criteria

Roman 1993, NINDS-AIREN criteria

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Lancet Neurology 2010 9: 689-701


Physical Activity/Exercise

Barnes, DE. Whitmer RA, and Yaffe K.Physical Activity and Dementia: The need for prevention trials.

Exercise and Sport Sciences Review. 2007; 35(1) 24-29.


MEDITERRANEAN DIET

Solfrizi V, Panza F, Frisardi V, et alDiet and Alzheimer’s Disease Risk Factors or Prevention: Current Evidence

Expert Rev Neurother. 2011; 11: 677-708.

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HOW TO MAINTAIN SAFE DRIVINGIN LATE LIFE?

For Now, the 4 Legs of the Table MAY Hold You Up!!1. Cognitive/Social Stimulation2. Proper Nutrition3. Exercise4. Treat Risk Factors for Vascular Dx

And reduce stress!!!!


Fitness-to-Drive in Older Adults

MoDOT Funded Team WUSTLPeggy Barco, MS, OTR/L, BSWPI and Co-PI WUSMAssistant ProfessorProgram of Occupational Therapy

Mike Wallendorf, PhDSenior Statistical Analyst

James Stowe, PhDInstructorDivision of Geriatric Medicine

David Carr, MDProfessor of Medicine/NeurologyDivision of Geriatric Medicine

MoDOT Funded Team WUSTLAnnie JohnsonProject Coordinator, CCS

Katie Rutowski, BS, OTR/L, RALily Hu, PhDSystem Analyst and RedCap DatabaseProgram of Occupational Therapy

TRISLKathy Dolan, OTR/L

Independent Drivers, LLCStephen Ice, MOT/L, CDRS

Funded by the Division of Highway Safety/MoDOT 2007-2016


UPDATE ON DRIVING INITIATIVES AT WUSM• MISSION

• Fitness-to-Drive Models• AD• Stroke• Glaucoma• Other

• Interventions to Improve orMaintain Driving Skills• Driving Simulation• Exercise• Nutrition• Cognitive Training• Other

• Fitness to Drive Studies:Barco PI (MoDOT funded)

• Driving Simulation and Stroke:Stowe PI (TRISL Funded)

• Glaucoma and Driving:Bhorade PI (NIA Funded)

• Pre-Clinical AD and DrivingRoe PI (NIA funded)

• Trainees/Postgraduate TrainingPMR ResidentsProgram of OTADRCSLCOP

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UPDATE ON DRIVING COLLABORATION

• Inside WU• ED-Carpenter• Surgery/Trauma-Scheurer• PT-Lang/Earhart• Neurorehab-Corbetta/Carter• Nutrition-Pepino• Encephalitis-Day

• Outside WU/STL• UMSL-Meuser• SLU-Berg-Weger• JBVAH-Niewoehner• Goldfarb-Back• SLCOP-Hetland

• National• ADED-Brown• Brown-Ott• U Colorado-Betz• UAB-Owsley• AAAFTS-Dickerson, Davis, Stutts• Medscape-NHTSA• AGS-Pomidor• AOTA-Schold-Davis, Dickerson• KU-Akinwuntan, Devos• UNO-Rizzo

• International• U Iceland-Ulfarsson• TIRF-Vandalar, Mayhew• W Ontario-Claasen• Trinity College-O’Neill• CMA-Rappaport, Marshall, Molnar• Other…


MyCarDoesWhat.org National Safety CouncilBack up CameraAnti-lock brake systemBlind Spot MonitorAutomatic BrakingLane DepartureTire Pressure MonitorAdaptive Cruise ControlAuto Parallel ParkingBack-up WarningBike/Ped DetectionBrake AssistPush Button StartRear Cross Alert

• Curve Speed Warning• Drowsiness Alert• Electronic Stability Control• Forward Collision Warning• High Speed Alert• Hill Descent Assist• Hill Start Assist• Lane Keeping Assist• Left Turn Crash Avoidance• Obstacle Detection• Parking Sensors• Sideview Camera• Traction Control

https://mycardoeswhat.org

Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC

Rearview Camera Technology

200 people killed each year when reversing15,000 injuredSadly, most events are parents and their kidsNHTSA made it mandatory for new cars May 2018Requires 10 foot x 20 foot zone behind vehicleAutomakers did not fight this one…cost modest$50 for camera or $150 for camera and screenLess than 1% of purchase priceSpurred on my law suit from Consumers Union and KidsTransportation Safety Act of 2007

http://readwrite.com/2014/04/16/backup-cameras-law-2018-nhtsa-safety/

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Sideview Camera Technology

200 people killed each year when reversing15,000 injuredSadly, most events are parents and their kidsNHTSA made it mandatory for new cars May 2018Requires 10 foot x 20 foot zone behind vehicleAutomakers did not fight this one…cost modest$50 for camera or $150 for camera and screenLess than 1% of purchase priceSpurred on my law suit from Consumers Union and KidsTransportation Safety Act of 2007



http://readwrite.com/2014/04/16/backup-cameras-law-2018-nhtsa-safety/http://www.iihs.org/iihs/news/desktopnews/preventing-driveway-tragedies-rear-cameras-help-drivers-see-behind-them


ErgonomicsComfort TechnologyAdjustable steering wheelsAdjustable pedalsKeyless entry and ignitionMultiposition heated and cooled power seats with memoryCustomize instrument panel and reduce clutterMotorized trunk lids and liftgatesTop Technologies for Mature Drivers: AARPhttp://www.aarp.org/home-family/getting-around/driving-resource-center/top-ten-tech/]Smart features for older drivers: AAAhttp://seniordriving.aaa.com/SmartFeatures


http://www.autotrader.com/car-tips/choosing-a-car-with-comfortable-seats-210732

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Questions Posed by Dr. Coughlin• How do we safely introduce these increasingly

intelligent 'autonomous systems' to the driver?• What is the impact on insurer underwriting that must

address the possible paradox of active safety systemsintroducing new risks?

• Is driver education not just for kids anymore - do newvehicle technologies demand lifelong drivereducation?

• How do vehicle designers and engineers manage themarriage between consumer electronics and thedashboard to give drivers the mobile lifestyles theymay desire but not the distractions they mayintroduce?

file:///Users/DC/Desktop/WEEKEND/TALKS/COUGHLIN.pdf.webarchive


Top Technologies Requested by Older Drivers

Blind Spot Warning Systems

Crash Warning Systems

Emergency Response Assistance Systems

Drowsy Driver Alerts

Reverse Monitoring Sytems

Only 1/3 in survey report they have these technologieshttp://www.reuters.com/article/us-column-miller-cars-idUSBRE98G05I20130917


Understanding the Future of MobilityThree trends shaping personal and commercial mobility1. On-Demand Mobility 2, 3. Driverless/Electric Vehicles

On-Demand Mobility-based on mobile app/ease of scheduling and payment-ride sharing/car sharing global shift away from personalownership to shared in-demand model-cost of ownership, commute times, limits oninfrastructure expansion, converse resources, cutgreenhouse gases, millennial relationship with cars-India, only 5% own cars and roads are already jammed

https://techcrunch.com/2015/08/08/understanding-the-future-of-mobility/https://www.zacks.com/stock/news/207881/who-are-ubers-biggest-competitors

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Understanding the Future of Mobility

Three trends shaping personal and commercial mobility1. On-Demand Mobility 2, 3. Driverless/Electric Vehicles

Driverless Vehicles-Google, Apple, Tesla, Volvo, Mercedes, Ford-Not consumer driven but economic on-demand mobility-Uber CEO put in order for 500,000 Tesla cars-Removing driver in on-demand model less expensive-Safety regulations and crash data will slow progress-Cost initially will limit availability-Insurance coverage another barrier

https://techcrunch.com/2015/08/08/understanding-the-future-of-mobility/


Understanding the Future of Mobility

Three trends shaping personal and commercial mobility1. On-Demand Mobility 2, 3. Driverless/Electric Vehicles

Electric Vehicles-Concerns about greenhouse gas emissions-Gas price volatility-Advances in battery and electric motor technologies-Driving by on-demand mobility-Electric motors far more dependable, less maintenance,longer life expectancies, cheaper to operate-Designed to operate 24/7/365, not sit in a garage



Autonomous DrivingSmart Cars

Super Cruise-Cadillac

Traffic Jam Assist-Ford

Google Car-Lexus

Compact Electric Cars-Nissan, BMW

Urban Transport Cars-London, Dubai

http://www.foxnews.com/tech/2013/11/27/five-future-transportation-technologies-that-will-actually-happen.html

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Understanding the Future of MobilityBenefits-80% reduction in cost of transportation-Reduced pollution-Reduced stress and road rage-Dramatic decrease in accidents and traffic deaths-Gaining back lost time to commuting-Increase productivity-Freeing up lanes by eliminating park cars-Reclaiming home space allocated to home garages-Leaders of on-demand mobility need to build trust with;

consumers, regulators, insurers, investors



Different Perspectives

https://mysonisdreaming.com

http://www.garageconversion.org/garage-conversion-gallery/garage-to-room/


Edythe Kirchmaier from Santa Barbara105 year old woman relieved to pass driver’s test

-Started driving in Chicago/Model A Ford Coupe 1927

-Calvin Coolidge was president/Babe Ruth best season

-Volunteer at Direct Relief International

-Passed her driver’s test in 2013, license good until 2017

http://www.foxnews.com/us/2013/01/28/105-year-old-california-woman-relieved-to-pass-driver-test-with-flying-colors.html/

Documents

Exploding the Myths and Meeting the Challenges of …...Exploding the Myths and Meeting the Challenges of Older Adult Drivers David B. Carr, M.D Alan A and Edith L. Wolff Professor