DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD,

CGP

SeniorPharmAssist

Webinar #1Webinar #14

Keys To Safe Driving and Community Mobiity

Laura Juel OTR/L, CDRS

Julia Gamble MPH, NP

Disclosures No commercial support has influenced the planning of the

educational objectives and content of the activity. Any

commercial support will be used for events that are not CE

related.

There is no endorsement of any product by DUHS

associated with the session.

No influential financial relationships have been disclosed by

planners or presenters which would influence the planning of

the activity. If any arise, an announcement will be made at

the beginning of the session.

This program is supported by a Geriatric Workforce

Enhancement Program (GWEP) grant (U1QHP28708) from

the U.S. Bureau of Health Professions Health Resources and

Services Administration (HRSA).

Objectives

Identify 3 age related changes that may

impact driver safety.

Identify 3 potential ‘red flags’ in the clinic.

Provide an overview of the NC DMV

Medical Program and the medically at risk

driver.

Identify Durham, NC options for

transportation on buses or vans

Statistics

By 2030, drivers over the age of

70 are expected to triple.

In 2015 there were 6,165 people 65

and older killed in traffic crashes

in the United States,

18% of all traffic fatalities.

Older drivers are more

disproportionate to be involved in

fatal crashes (per miles driven)

Fatality rate for age 85 and older is

9x as high as 25-69 age range

NHTSA, 2017

Driving

Cars are viewed as physical

extensions of ourselves.

The ability to drive safely can be

challenged by changes in our

physical, emotional, and/or

mental conditions.

The ultimate instrumental activity of daily living, requiring

the integration of high-level cognition,

vision and motor function

Driving is a complex skill.

Driving represents freedom, control and

independence.

The Driving Task

Changes in body and mind can

impact driving abilities in

three functional areas;

See traffic and road conditions

Recognize these images, process them,

and decide how to react

Perform the physical movements required to

control the vehicle

Vision

Driving Implications:

Ability to see other vehicles,

traffic signals and signs,

lane markings, road

conditions, and pedestrians

Age-related changes in visual function;

particularly reductions in visual acuity, contrast

sensitivity and visual field loss have been

associated with driving ability and crash risk in

older adults

90% of information for driving comes in through the eyes

Wood, 2013

Common Eye Diseases

Cataracts- clouding of the eye lens making it difficult

to see clearly, halos around lights

Glaucoma- damage of optic nerve due to high

pressures. Early- peripheral vision loss, as disease

progresses- invades central field of vision

Macular Degeneration- deterioration to the retina

resulting in decreased central vision

Diabetic Retinopathy- damage to the blood vessels

in eye resulting in patchy or blurred vision, difficulty

seeing at night

Physical Abilities

Driving Implications:

Ability to get in/out of car

Ability to manage assistive

device

Ability to navigate parking

lots/streets at destination

Ability to perform physical

movements to control

vehicle (look over shoulder, turn

wheel, operate pedals)

Strength, flexibility, gross and fine motor control,

reaction time

‘Low Tech’ Adaptations

panoramic mirror

blind spot mirror

wedged seat cushion

Handy Bar deviceSeat belt grabber

Cognition

Driving Implications:

Ability to recognize traffic conditions and

destinations

Ability to process the

information and make

appropriate decisions

in a timely manner

Ability to understand and operate own vehicle

Memory, attention, recognition, reaction times,

problem solving and judgment

Red FlagsNot one test can accurately predict crash risk

MMSE < 24 strong predictor of crash risk

Montreal Cognitive Assessment (MoCA) more sensitive to

identify cognitive decline, < 23 = crash risk

Requires assistance with daily tasks; medication

management, meal preparation, managing finances.

Family members will not ride with them/gets lost in familiar

areas.

Other clinical factors associated with greater MVC risk;

depression, falls within the previous year, sleep apnea, and

lower baseline systolic blood pressure. Joseph et al, 2014

Medication Side Effects

Antidepressants, antihistamines:

blurred vision, drowsiness, motor

coordination

High blood pressure medications: impair driver’s

response by causing dizziness, fatigue, confusion

and/or sedation

Pain Killers and non-steroidal anti inflammatory drugs:

may cause confusion that results in dangerously

slow reaction times.

**Risk for medication side effects and interactions

increases with the number of medications taken

Things to Consider

Will this persons condition worsen over time?

Will medical attention improve their

situation? (eye exam, medications)

Medications (side effects)

Do they have the capability to

learn and follow through with

restrictions if needed.

ie: no highway driving

The Conversation

Discuss recommendations with client,

document discussion in the medical chart.

If they continue to drive against medical

advice then discuss with client that you will

report to DMV.

Ask early and frequently about plans… living situation, family

support, driver retirement- average person will outlive their

ability to drive by 7-10 yrs.

Driving cessation can negatively impact older adults’ health

and well-being

Wood et al. 2013

NC General Statue

Statue 20-9.1 (2016), after consultation with the client,

a physician, psychologist or medical provider may

disclose information of a persons physical or mental

disability or disease to be used “only for the purpose of

determining the qualifications of the patient to operate

a motor vehicle”.

The specific information provided to

NC DMV would be limited to

the client’s name, address, date of

birth and diagnosis.

DMV Medical Review Program

DMV is the official licensing agency

Medical Review provides oversight for

persons with medical or

psychological issues

Persons can be entered into this program

by medical providers, family members,

police, or local DMV offices

If you are not confident about completing a patients DMV

medical paperwork, a referral for a clinical driving evaluation

can provide some objective data to determine medical fitness to

drive.

NC DMV Restrictions

Corrective lenses

Daylight-driving only

Mandatory reporting for seizures

Seizure free 6 months on medication/1 year off

Homonymous hemianopsia- absolutely no driving

Limiting driving to speeds less than 45 mph speed and

prohibiting interstate driving

Limiting driving to/from places; work, doctor, church,

grocery store

Limiting driving within a specified radius of home

Duke Driving Program

Behind the wheel test may be

recommended based on outcome of

clinical evaluation ($150)

Provides some objective data related

to crash risk

2-2.5 hour clinical evaluation performed by an

Occupational Therapist- Driver Rehab Specialist

Comprehensive evaluation of physical abilities,

vision, thinking skills and reaction times

$200 fee for clinical driving evaluation

Self Driving Vehicles

Are we

there yet?

Community Mobility

GO Durham serves greater Durham with

connections to other cities in the Triangle

Regional call center provides trip planning and

up to the minute arrival time information – call

919.485.RIDE (7433)

Travel Training presentations are available

from Go Durham staff

Community Mobility

• Seniors (65 years and up) ride free on GO

Durham

• GO Durham cards are issued without a waiting

period

• ID cards issued at Durham Station

• Monday-Friday; 8:30–11 a.m. & 12:30-4:30 p.m.,

excluding holidays.

• Bring proof of age and/or your Medicare card

Community Mobility

Van Service Overview

Criteria to ride

How to apply

What is included in the service

How long can it be used

What is the cost

Who is the contact?

Other info?

Criteria to Ride

Medicaid Transportation • Medicaid, Durham County resident

GoDurham ACCESS • Disability which prevents use of fixed-route bus service

– Application & in-office evaluation required

Durham County ACCESS • Various Criteria (funding dependent)

– Can be job-related, location-bound

or health-related

Lincoln Community

Health Center Vans

• Lincoln Community Health Center

patients only

How Do I Apply

Medicaid Transportation • Apply via phone

• 5-20 minutes of questions

• Notification (approval/denial) immediate

GoDurham ACCESS • Download, complete and mail application

– 21-day approval timeline; notified via

phone call

– May be able to scan/email

Durham County ACCESS • Complete application

– Approval timeline varies; notified via

phone call

– Fax/email/drop off

Lincoln Community

Health Center Vans• No Application

– Call to schedule service

What is Included?

Medicaid Transportation • Van service to and from appointments

• Only billable Medicaid appointments

GoDurham ACCESS • Any type of trip

– Medical, mental health, substance

abuse, employment, education

– Leisure/Recreation

Durham County ACCESS • Any type of trip

– Medical, mental health, substance abuse,

employment, education

– Leisure/Recreation

Lincoln Community

Health Center Vans

• Medical trips to a Lincoln Clinic

– Specialist medical visit ordered/referred

by Lincoln providers are also covered

How Long Can I Use It

Medicaid Transportation • As Long as Medicaid is active

GoDurham ACCESS • Recertification requested occasionally

Durham County ACCESS • Varies, typically 1-3 months

– May need to recertify

Lincoln Community

Health Center Vans

• Indefinite

What Does it Cost?

Medicaid Transportation • No Cost

• Covered by Medicaid

GoDurham ACCESS • $2 one-way trip (cash fare)

– Ticket books available for $17

(ten tickets)

Durham County ACCESS • No Cost

Lincoln Community

Health Center Vans

• No Cost

How Do I Schedule a Trip

Medicaid Transportation • Call Transportation Line: 919.560.8607

• Get approval, schedule recurring trips

• Call authorized van service

GoDurham ACCESS • Call: 919.560.1551

– Can book recurring trips

– Dispatch Option 1, Reservations Option

2, Cancellations Option 3

Durham County ACCESS • Call: 919.560.1551

– Can book recurring trips

– Dispatch Option 1, Reservations Option

2, Cancellations Option 3

Lincoln Community

Health Center Vans

• Call: 919.956.4000

• At least 3 days before trip

Who Is My Contact

Medicaid Transportation • Processing Unit Assistant Supervisor

• Medicaid Transportation (919.560.8607)

• Lisa Webb 919.560.1840

GoDurham ACCESS • GoDurham ADA Specialist

• Tammy Pettiford

• (919.560.1555 x 36303)

Durham County ACCESS • Durham County Cooperative Extension

– Toni Glover aglover@dconc.gov;

919.560.0520

– Linda Thomas-Wallace

lathomas@dconc.gov; 919.560.8757

Lincoln Community

Health Center Vans

Other Information

Medicaid Transportation • Must have updated address before scheduling trip, if client moves

• No wheelchair support on one pre-approved van service

• Bus tickets are an option.

GoDurham ACCESS • Service to all areas of the City and areas of

the County within ¾ miles of bus stop

• Taxi option which allows same day

scheduling ($21 = $51 trip)

Durham County ACCESS • Best for short-term usage

(funding can run out)

Lincoln Community

Health Center Vans

What Makes it Different

Medicaid Transportation • Multiple steps to schedule• Wait time on either end of trip• Lack of Flexibility

GoDurham ACCESS

• Lack of flexibility

• Wait time on either end of trip

• Requires pre-scheduling

• More costly than discount bus pass

Durham County ACCESS• Lack of flexibility

• Wait time on either end of trip

Lincoln Community

Health Center Vans

• Lack of flexibility

• Wait time on either end of trip

Clinical Resources

FREE- Marketing material for conversations with older

drivers- https://www.thehartford.com/resources/mature-

market-excellence/family-conversations-with-older-drivers

Clinicians Guide to Counseling Older Drivers

https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/812228_clinicia

nsguidetoolderdrivers.pdf

NC General Statute

https://www.ncleg.net/Enactedlegislation/Statutes/PDF/BySect

ion/Chapter_20/GS_20-91.pdf

DMV Medical Review Program (guidelines, forms, restrictions)

https://www.ncdot.gov/dmv/driver/medical/

Wood, Joanne M. Evaluation of screening tests for predicting older driver

performance and safety assessed by an on-road test. Accident Analysis

and Prevention Jan 2013; 50: 1161-1168.

NHTSA/US Department of Transportation, Traffic Safety Facts, 2017.

https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/documents/2015_traffic_sa

fety_fact_sheet_older_population.pdf. Accessed 4/16/2018.

Philip, Joseph G, O’Donnell, Martin. Et al. The mini mental state

examination, clinical factors, and motor vehicle crash risk. Journal of

American Geriatric Society 2014; 62: 1419-1426.

Laycock, Keith. Driver assessment: Uncertainties inherent in current

methods. BC Medical Journal 2011; 53: 74-78.

References

Duke Driving Program

Laura Juel OTR/L, CDRS

Outpatient Occupational Therapy

Lenox Baker Children’s Hospital

3000 Erwin Road

Durham, NC 27705

Appointments: 919 684-2445

Duke Outpatient Clinic

General Internal Medicine

Julia Gamble MPH, NP

Continuing Education Credits

1 hour of CE credit is being offered for this webinar.

For the live webinar, to obtain the credit you must:

Add your name to the chat box (to verify attendance)

Complete the survey. The survey will open automatically at the end of the webinar and the link will be sent in a follow-up email.

If you did not register for this webinar and would like CE credit, contact gero@duke.edu