exploding the myths and meeting the challenges of …...exploding the myths and meeting the...
TRANSCRIPT
1
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
2
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Question #1: True or False?
The majority of older adults no longerhave an active driver’s license in the
US after age 85 years….
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
• 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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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…
3
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
FALSE: DEPENDS ON YOUR PERSPECTIVE
http://search.cga.state.ct.us/dtSearch_lpa.html
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Question #3: True or False?
The risk of older adult drivers over 80years of being injured in a crash hasincreased over the past decade, likely
due to physical frailty…
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
4
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Question #4: True or False?
Older drivers that put the most milesper year on the road are at thehighest risk for a crash due to
increased exposure…
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Question #5: True or False?
The majority of older adults remainactive behind the wheel with very littletime at the end of life without theability to drive a car…
5
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Mobility CounselingTransportation Alternatives
• St. Louis Options• Social Work Referral• CORP• Call-A-Ride• Good Shepherd• Metro• Bus• Taxi• ITNAmerica• Uber• Other
6
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
FITNES-TO-DRIVESTAKEHOLDERS• Patient• Family and Friends• Health Professionals• Organizations• Patrol Officers• State DMV• Insurance• Community• Federal/NHTSA
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
FTD Outcomes• Cessation/Retirement• Crashes• Road Tests• Simulators• Others
7
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
FTD Outcomes:Are Crashes All They Are Cracked Up To Be?
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Budson AE, Price BH. Memory Dysfunction. NEJM 2005; 352:692-9
Do Single Test FTD Approaches Work?
8
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Ott BR and Daniello LA. Aging Health 2010; 6: 77-85
Cognitively, What Does it Take To Drive a Car?
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Driving History/Med Review
• Driving Behaviors• Informant Rating• Exposure• Personality• Violations• Crashes• Cognitive Impairment• Functional Impairment• Others?
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
MEDICATIONS
• Narcotics• Barbituates• Benzo’s• Antihistamines• Antidepressants• Antipsychotics• Hypnotics• Alcohol• Muscle Relaxants• Antiemetics• Antiepileptic
Hetland A, Carr DB. Annals of Pharmacology 2014
9
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Pharmacist/Client Resources
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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.
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
10
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Cut-offs
Molnar F, et al. Clinical Medicine: Geriatrics 2008: 2; 1-11Molnar F, et al. Geriatrics and Aging 2009; 12: 83-92
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Probability Calculator of Failing Road Test: Dementia
Carr DB, et al. JAGS, 2011
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
11
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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?
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Model of Alzheimer’s brain pathology
Holtzman DM, Morris JC, Goate AM (2011) Science Translational Medicine Vol 3, Issue 77
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
12
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
CLUES TO SPECIFICNEURODEGENERATIVE DISEASES
Alzheimer’sDisease
Rapidlyevolving
dementias
Frontotemporaldementias
Lewy bodydementia
Vasculardementia
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
• 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
13
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
Lancet Neurology 2010 9: 689-701
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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.
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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.
14
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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!!!!
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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
15
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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…
Department of Medicine and NeurologyDivision of Geriatrics and Nutritional Science
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/
16
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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/
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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://readwrite.com/2014/04/16/backup-cameras-law-2018-nhtsa-safety/
http://www.autotrader.com/car-tips/choosing-a-car-with-comfortable-seats-210732
17
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
18
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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/
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
https://techcrunch.com/2015/08/08/understanding-the-future-of-mobility/
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
19
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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
https://techcrunch.com/2015/08/08/understanding-the-future-of-mobility/
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
Different Perspectives
https://mysonisdreaming.com
http://www.garageconversion.org/garage-conversion-gallery/garage-to-room/
Department of Medicine and NeurologyDivision of Geraitrics and Nutritional Science/Knight ADRC
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/