Assessing clinical fitness to-drive symposium, all slides

Assessing Clinical
‘Fitness-to-Drive’
Professor Priscilla Harries
Professor Carolyn Unsworth

Medical Fitness
To Drive: towards a joined-up
approach
Prof Desmond O’Neill
23 June 2015
National Office for Traffic Medicine
RCPI/RSA

What is Traffic Medicine?
• A relatively new specialism embracing all those
disciplines, techniques, and methods aimed at
reducing death and injury inflicted by traffic
crashes
• Also enabling /rehabilitative in trying to ensure
that transport mobility is not hampered, or
rendered unsafe, by remediable illness or
functional loss.

New area of scholarship
• ..never more than 1,000,000 cars…
…..limited by numbers that could be
trained as chauffeurs!
Gottlieb Daimler, 1901

National differences, social constructs and habits

Sources
• Evidence-based literature
– Laberge-Nadeau, Trucks and Diabetes, Diabetes Care, 2000;23:612-7
• Existing guidelines
– Austroads, CMA, DVLA, AMVA: FMCSA for Group 2
• Consensus statements
– American Diabetic Association, 2013
• ‘Grey’ literature
– TRB, AMA

Paradox
• Older drivers safest group
• We have learned much from
the misguided emphasis on
their safety

…a reduction of approximately 45% in the annual rate
of crashes per 1000 patients

Crashes/1,000/year by age
0.
2.25
4.5
6.75
9.
<30 30-44 45-59 60-74 ≥75
Chart Title
Baseline Subsequent

We are already making a difference
• General fitness
• Rehabilitation
• Medications
• Cataracts
• Car Adaptations

Main issues
• Suddenly disabling
– Syncope, epilepsy, ICDs…
• Physical constraints
– Parkinsonism, hemiplegia, vision
• Impaired self-regulation
– Imprudence, psychiatric illness, alcohol/drugs,
cognitive impairment…

Driving model
• Complex mix behaviour, personality, cognition
• Hierarchical model:
– Strategic
– Tactical
– Operational

Process
• GP and/or Consultant(s) assess
– ± OT/On-road assessment
• Advise driver
• Driver advises DLA for specified conditions
• DLA requests medical report
• Process for noncompliant and hazardous

Why me?
• Multi-morbidity
• Estimate of prudence
• DVLA system would use you anyway!
• Encourage second opinion and further assessment
• Guidelines protect

Schema
• Routine transportation inquiry
• Assessment
• Provisional decision pending full assessment
• Intervention(s)
• Societal obligations
• Review

Off-road assessment
• Gateway rather than terminus
• Align with modern concepts driving behaviour
• Informant history critical
• Avoid premature foreclosure

• Clinical Advice
• Restricted licence

Liaise with driver licensing authorities

• The demand for certainty is one
which is natural to man, but is
nevertheless an intellectual vice
Bertrand Russell

Driving as an IADL: screening fitness to drive – a concern for all occupational
therapists.
Assessing Clinical Fitness to Drive Research Symposium
Brunel University, London
23/06/2015
Dr. Tadhg Stapleton
Assistant Professor in Occupational Therapy
Trinity College Dublin

Trinity College Dublin, The University of Dublin
Why Occupational Therapy?
Community Mobility (including Driving) is an IADL domain of practice for OT
(AOTA Practice framework 2014)
Occupational therapists ideally suited to conduct clinical assessments of fitness
to drive given their focus on the interplay between health related functional
capacity and occupational performance (Harries & Unsworth 2013)
Basic OT training equips therapist with unique skills (incl. activity analysis and
task modification) that sets them up as a profession with necessary skills to
complete driving assessment (Lloyd et al 2001)
All OT’s have the training and skills necessary to address community mobility
as an IADL (Stav et al 2005)
However, advanced training is a necessary prerequisite for engaging in driving
training and assessment (Korner-Bitensky et al 2007, Unsworth 2007, Stav et al 2005)

Hunt LA, Yarett Slater D. (2012) Occupational therapy’s ethical obligation to address driving and
community mobility. In: McGuire MJ, Schold Davis E (eds.) Driving and Community Mobility: Occupational
therapy strategies across the lifespan (pp 101-113). Bethesda MD: AOTA Press.
“Occupational therapists have an ethical responsibility to consider
driving and community mobility in their initial evaluation and as part
of comprehensive occupational therapy services.” (Hunt & Yarett
Slater 2012, pp 102).
Client’s mobility needs (incl. driving) should be considered by the
occupational therapist as a facilitator of participation in daily living.
Relevant across the lifespan.
Professional and ethical reasoning required on the part of the
occupational therapist in evaluating, planning, intervention and
outcomes regarding driving and community mobility.
Occupational therapists must have the confidence to provide
information in all settings and with all relevant populations.

Is driving at risk of becoming a neglected IADL
among Occupational Therapists?
Canada wide telephone survey among 480 OT’s.
Only 1/3 of therapists (20% of those working in inpatient setting & 34% of
those working in community setting) identified driving as an area of
concern when presented with a case vignette that made specific mention to
the stroke client’s desire to return to drive.
The use of driving specific assessment was under 12%
Possible reasons for findings:
Lack of best standard practices
Pressure of the work setting, other more pressing concerns
Lack of a sense of competency regarding driving
Petzold, A., Korner-Bitensky, N., Rochette, A., Teasell, R., Marshall, S., & Perrier, MJ. (2010). Driving poststroke: Problem identification,
assessment use, and interventions offered by Canadian occupational therapists. Topics in Stroke Rehabilitation, 17(5), 371-379.

Context of Practice – not conducive? (Stapleton T (2012), PhD findings)
The focus of our setting really is firstly acute needs,
but also discharge planning which would really tend to focus around
managing more basic activities of daily living rather than dealing with
driving. In many cases it’s not really appropriate to address it,
there are more acute needs to be dealt with first. (OT 1)
First of all, here it is an acute care setting, so in essence really
the focus is on the diagnosis, the mechanism of the stroke and then
prevention of further stroke, assessment, rehab and discharge planning.
Sometimes driving doesn’t come up. The turnover is very quick, so
sometimes driving just isn’t a major focus. (OT 10)

Fear, inexperience. (Stapleton T (2012), PhD findings)
Because they are absolutely terrified of the repercussions of saying
that somebody is safe to drive, terrified of it. And I suppose, if I look
back when I started in the acute setting first of all when driving came
up as an issue - I was probably terrified doing my first assessment and
thinking this is a massive thing for this person, and if I'm going to be
making any call or decision on this. When I think about the first couple
of assessments I did compared to when you have more experience
doing them, a big difference, and you know it is a big call to make as
well so I just think people are terrified of it. (OT 15)

Supporting Frameworks

Developing Knowledge
RCPI Certificate in Traffic Medicine
A two-day training course designed and delivered by Dr.
Tadhg Stapleton and Dr. Anne Dickerson.
Three courses delivered – 122 OT’s completed
Funded thru a Knowledge Exchange and Dissemination
grant (KEDS) awarded by the Health Research Board
(HRB) to Dr. Stapleton.
Online Certificate Course launched in 2015. Designed
specifically for Medical Doctors and Occupational Therapists.
Includes an occupational therapy module. Delivered online
with a one day workshop. First course delivered with 10
occupational therapists attending.

Recommended three tiers of expertise training
Generalist Health
Professional Training
Expertise in screening to detect those at risk of
unsafe driving
Assist in accessing information on healthy
ageing and mobility
Advanced Occupational
Therapist Training
Expertise in assessing physical, cognition,
visual perception and behavioral aspects of
driving using standardized pre-road and on-
road tests
Advanced-Specialized
Occupational Therapist
Training
Highly specialized occupational therapist with
expertise in assessment, training/retraining of
driving skills, vehicle modifications, and
assistive technology for driving
Korner-Bitensky N, Toal-Sullivan D, Zweck C. (2007). Driving and Older Adults: Towards a national occupational
therapy strategy for screening. Occupational Therapy Now, 9 (4), 3-5.

.
Generalist
Non-driver
Impairments clearly
exceed threshold for
safe driving.
Able to Drive
No impairment
indicators to
report/restrict license.
Lower Risk:
Evidence is
Weak; Below
thresholds in
most areas.
Higher Risk:
Evidence is
Strong; Above
thresholds in
most areas.
Interventions for Generalists: Plan & Build Options for Mobility
Maximize Skills & Abilities
Self Awareness
Mobility preservation: Driving
Refer to specialized services
Develop transportation alternatives
Mobility preservation: Transition
Medical issues with increasing complexity
Occupational Therapy Intervention:
Evidence, Clinical Judgment, and Risk
Dickerson A. (2014). Driving with dementia: Evaluation, referral, and resources. Occupational Therapy in Health Care. 28(1), 62-76.
Used with permission
Dickerson & Schold Davis, 2013
Risk: Degree to which
impairment affects
fitness-to-drive is unclear.
On-road evaluation is justified.
Promote Driving Retirement, Mobility
preservation: Implement supportive
transportation
Normal Aging
GeneralistDRS Specialist

A Process of determining ‘Fitness to Drive’
Cascade approach to assessing fitness to drive (after Stroke);
– Neurological examination by Medical Doctor,
– Occupational Therapy assessment
– Decision by Physician + OT
Patient fit to drive
Patient not fit to drive
Patient needs to complete on-road test (Tan et al 2011)
Final decision on fitness to drive should ideally be informed by BOTH phases of the
assessment process, although the on – road would carry higher weighting (BUT not
everyone needs an on-road)

Theoretical Frameworks to guide practice
• Michon’s Model
• Strategic
Pre-Drive decision making, Planning, route planning,
need and purpose of trip, temporal and weather
considerations, personal factors/awareness –
(EXECUTIVE)
• Tactical
Decision making during the driving task, Mastery of
traffic situations, skills and behaviours to safely
negotiate vehicle in traffic, managing and planning
driving tasks ie overtaking, gap selection, negotiating
complex intersections – (COGNITIVE, PERCEPTUAL,
EXECUTIVE)
• Operational
Procedures and routines of driving, person machine
interaction, operating the controls, steering etc,
coordination between actions – (PHYSICAL)
Many concerns at a STRATEGIC and TACTICAL level for
people with cognitive deficits, possible that the
OPERATIONAL level may be intact (reliant more on physical
abilities), therefore the need to combine the off-road and
on-road assessment findings.
Hierarchial levels of driving behaviour
– Goals for Life and Skills for Living
– Goals and Context of Driving
– Mastering Traffic Situations
– Vehicle Manoeuvring
Laapotti S, Keskinen E, Hatakka M, Katila A. (2001).
Novice drivers’ accidents and violations – a failure on higher
or lower hierarchical levels of driving behaviour. Accident
Analysis and Prevention, 33, 759-769.

Content of Occupational Therapy Off-road
Driving Assessment
Driving History
Screening Assessment
– Physical
– Cognition
– Visual Perception
– Executive Functions
Functional Observations
Family Involvement

Cognition, Perception, & Executive Function
Stapleton T., Connolly D. (2010). Occupational Therapy Practice in Predriving Assessment Post Stroke in the
Irish Context: Findings from a Nominal Group Technique Meeting. Topics in Stroke Rehabilitation. 17(1), 58-
68.

Prospective clinical study findings (PhD Study) – T. Stapleton 2012
N = 46 stroke patients
referred for driving
assessment over a 22 month
period.
All completed occupational
therapy off-road assessment
and referred for on-road
assessment (n = 46)
Completed on-road driving
assessment
n = 35
Fit for Unrestricted driving (n
= 27)
Fit for Restricted Driving (n =
6)
Driving lessons
recommended (n = 2)
On-road driving assessment
not completed n = 11
Refused or cancelled on-road
assessment (n = 6)
Moved Jurisdiction (n = 2)
Deemed unsafe by driving
assessor (n = 1)
Medical deterioration (n= 1)

Stapleton T, Connolly D, O’Neill D (2015). Factors influencing
the clinical stratification of suitability to drive after stroke.
Occupational Therapy in Health Care. Early online. DOI:
10.3109/07380577.2015.1036192
Underlying clinical
reasoning
Stratification
Fit to Drive Not appropriate for
driving
Maybe Driving
Detailed assessment
Process of decision
making
Person centred
factors
Contextual factors
Yes
Refer for on-road
assessment
Expectation of
success
No
not fit for on-road
assessment

clinical decision making leading to stratification of
suitability to drive
Low Influence
Factors:
Age
Type of Stroke
Isolated physical
disability
Speech & language
deficits
High Influence
Factors:
Insight and
awareness
Unpredictible,
impulsive, unsafe
behaviours
Speed of
Processing
Cognition
Perception
Apraxia
Executive
Dysfunction
Process of
Assessment
:
Prolonged
contact
Response to
rehabilitatio
n
Mix of
assessment
approaches
Optimum
timing of
assessment
Overall
estimation
Other:
Individual
circumstance
Family Input
Contextual
Factors:
legislation
Guidelines
Institutional
Approach
Stakeholders
Involved

The Importance of Functional Assessment and
Observation
Two research articles examining the relationship between the AMPS
and the outcomes of on-road testing
Outcome of the on-road test was pass, restricted, fail
Analysis found significant differences in both motor and process scores
of those who passed and those who failed the on-road test.
Concluded that AMPS was able to discriminate between those who
passed or failed on-road testing.
But what if you are not AMPS trained?
Dickerson A, Reistetter T, Trujillo L (2010). Using IADL assessment to identify older adults who need a behind-the-wheel driving
evaluation. Journal of Applied Gerontology, 29(4), 494-506.
Dickerson AE, Reistetter T, Schold Davis E, Monahan M. (2011). Evaluating driving as a valued instrumental activity of daily living.
American Journal of Occupational Therapy, 65, 64-75.

Naturalistic Observations
I think it’s not from the assessments, it’s from seeing them in and out,
seeing them in the waiting area, the rehab assistant commenting on things to
me about them, the way they use the toilet, all of those things, it’s from that I
think, that’s probably the biggest indicator of the people that are going to
have difficulty getting back driving. (OT 3)
I’d look at them in a functional context like
‘ let’s go down and make breakfast’, and look at their planning, their
problem solving, dual tasking, putting in distractions, so turning on the radio,
having a conversation while they’re doing something, can they multitask
or do they have to focus on one thing. (OT 8)

Dickerson AE, Bedard M. (2014). Decision tool for clients with medical issues: A framework for identifying driving risk and
potential to return to driving. Occupational Therapy in Health Care, 28(2):104-202. (used with permission)

Dickerson AE, Bedard M. (2014). Decision tool for clients with medical issues: A framework for identifying driving risk
and potential to return to driving. Occupational Therapy in Health Care, 28(2):104-202. (used with permission)

Development of a clinical based occupational therapy driver screening and
assessment programme for clients with Stroke and Mild Cognitive
Impairment
A pre-requisite was the establishment of an agreed protocol and pathways
involving all the stakeholders, and ensuring buy-in by all the stakeholders
(OT, Physician, On-road Assessors)
The process was lead by Occupational Therapy (collaborative effort between
clinicians and academic)

Clinical Assessment
NEURO (Stroke)
Addenbrookes Cognitive
Examination (ACE III)
+/- Rivermead Behavioural
Memory Test
Rookwood Driving Battery
OT DORA (Unsworth et al 2011)
MCI/DEMENTIA
Addenbrookes Cognitive
Examination (ACE III)
Rivermead Behavioural
Memory Test
Rookwood Driving Battery
+/- OT DORA

Preliminary Outcomes (June 2012 to end 2013)
Stroke (n=36)
Decision made
based on OT Ax
alone (n=20)
Fit to Drive = 16
Fit to drive pending
other (healthcare)
Ax = 2
Unfit to drive = 2
Referred for on-
road test (n=16)
n
Pass
(Pass after lessons =
6)
11
Fail 1
Didn’t do on-road
Ax
2
Awaiting on-road
Awaiting lessons
1
1
MCI (n=58)
Decision made
based on OT Ax
alone (n=14)
Fit to Drive = 3
Unfit to drive or take
on-road test = 11
Referred for on-
road test (n=44)
10 didn’t complete
on-road and stopped
driving
3 refused on-road
? Still driving
Full Pass 19
Pass after lessons 5
Pass with
restrictions
3
Fail (following 2

Increase Knowledge base
Increase specialised skills
Awareness of structures and frameworks (guidelines and legislations)
Awareness of the contribution of Occupational Therapy (what it is and
what it isn’t)
Develop structured pathways (evidence based)
Liaise with other relevant stakeholders

I suppose sometimes I don’t know what I'm looking for insofar as I
don’t have a defined 'cut-off' in my head, so I wouldn't always work to
'cut-offs'. But I think building a picture of everybody together. I think
you need to become systematic, even if you’ve had that prolonged
contact it doesn’t mean you’ve really thought it through. So you
actually do still need to sit down and ask, “OK driving?, I'm going to
think about this now - where are my gaps?, where do I need to look
next?, where do I need to push them a little bit?" and that might be a
case of “okay we’ll build such and such into our next assessment”. (OT
12)

References
American Occupational Therapy Association (2014). Occupational therapy practice framework: Domains and process. (3rd ed.). American Journal
of Occupational Therapy. 68 (suppl 1)S1-S48.
Dickerson A. (2014). Driving with dementia: Evaluation, referral, and resources. Occupational Therapy in Health Care. 28(1), 62-76.
Dickerson AE, Bedard M. (2014). Decision tool for clients with medical issues: A framework for identifying driving risk and potential to return to
driving. Occupational Therapy in Health Care, 28(2):104-202.
Dickerson AE, Reistetter T, Schold Davis E, Monahan M. (2011). Evaluating driving as a valued instrumental activity of daily living. American
Journal of Occupational Therapy, 65, 64-75.
Dickerson A, Reistetter T, Trujillo L (2010). Using IADL assessment to identify older adults who need a behind-the-wheel driving evaluation.
Journal of Applied Gerontology, 29(4), 494-506.
Harries PA, Unworth CA. (2013). Clinical assessment of fitness-to-drive: positioning occupational therapy for workforce development. (Editorial)
British Journal of Occupational Therapy, 76(7), 299.
Hunt LA, Yarett Slater D. (2012) Occupational therapy’s ethical obligation to address driving and community mobility. In: McGuire MJ, Schold
Davis E (eds.) Driving and Community Mobility: Occupational therapy strategies across the lifespan (pp 101-113). Bethesda MD: AOTA Press.
Korner-Bitensky, N., Toal-Sullivan, D., & von Zweck, C. (2007). Driving and older adults: A focus on assessment by occupational therapists.
Occupational Therapy Now, 9 (5 Sept/Oct), 10-12.
Laapotti S, Keskinen E, Hatakka M, Katila A. (2001). Novice drivers’ accidents and violations – a failure on higher or lower hierarchical levels of
driving behaviour. Accident Analysis and Prevention, 33, 759-769.
Lloyd, S., Cormack, CN., Blais, K., Messeri, G., McCallum, MA., Spicer, K., & Morgan, S. (2001). Driving and dementia: A review of the literature.
Canadian Journal of Occupational Therapy, 68 (3), 149-156.
Petzold, A., Korner-Bitensky, N., Rochette, A., Teasell, R., Marshall, S., & Perrier, MJ. (2010). Driving poststroke: Problem identification,
assessment use, and interventions offered by Canadian occupational therapists. Topics in Stroke Rehabilitation, 17(5), 371-379.

Stapleton T. (2012). An Exploration of the Process of Assessing Fitness to Drive after Stroke within an Irish Context of
Practice. PhD Thesis, Trinity College Dublin.
Stapleton T., Connolly D. (2010). Occupational Therapy Practice in Predriving Assessment Post Stroke in the Irish Context:
Findings from a Nominal Group Technique Meeting. Topics in Stroke Rehabilitation. 17(1), 58-68.
Stapleton T, Connolly D, O’Neill D (2015). Factors influencing the clinical stratification of suitability to drive after stroke.
Occupational Therapy in Health Care. Early online. DOI: 10.3109/07380577.2015.1036192
Stav, WB., Pierce, S., Wheatley, CJ., & Schold Davis, E. (2005). Driving and Community Mobility. American Journal of
Occupational Therapy, 59(6), 666-670.
Tan KM, O’Driscoll A, & O’Neill D (2011). Factors affecting return to driving post-stroke. Irish Journal of Medical Science,
180, 41-45.
Unsworth, CA. (2007). Development and current status of occupational therapy driver assessment and rehabilitation in
Victoria, Australia. Australian Occupational Therapy Journal, 54, 153-156.

Assessing Clinical Fitness to Drive – Brunel University –
23rd June 2015
An overview of the work of the Forum
and Mobility Centres in the UK
Ed Passant
Chief Executive – Forum of Mobility Centres

Assessing Clinical Fitness to Drive – Brunel University – 23rd June 2015
Mobility Centres in the UK
• 16 Centres operating from over 50 venues
• Based in a variety of settings
• Health (NHS) Trusts
• Independent not for profit organisations
• Part of larger not for profit organisations
• Funded by Department for Transport in England and
devolved administrations in rest of UK

Forum of Mobility Centres
• The umbrella body for Mobility Centres
• Sets the standards for Mobility Centres
• Accredits the operations of Mobility Centres
• Shares best practice
• Develops education and training
• Develops new initiatives/services
• Liaises with funders and other stakeholders
• Responsible for policy, research and development
• A not for profit organisation (UK Charity) funded by
Department for Transport.

Mobility Centres in the UK
• Variety of referral routes:
• Client themselves (self referral): 32%
• Via a Health Professional: 17%
• Via other Agencies e.g. Motability, Access to Work, pilot scheme with the
Police: 20%
• DVLA – 31%
• Approx. 13,000 assessments 2014/15 – 10% increase estimated year on
year
• A range of services targeted at mobility needs of disabled people
• Driving Assessment
• Passenger Assessment
• Mobility Scooter and Powered Wheelchair Assessment
• Some centres deal with motor cycles, vocational drivers etc

Assessing Clinical Fitness to Drive – Brunel University –
23rd June 2015
Client Age Profile (2012-13 figures)

Assessing Clinical Fitness to Drive – Brunel
University – 23rd June 2015
Diagnostic Groups - Driving
Assessment (2012/13)

Medical Driver Licensing in the UK
• Self Declaration System – Drivers responsibility to inform
Driver and Vehicle Licensing Agency (DVLA) of relevant
Disability or Medical Condition
• High Volume – 750,000 Medical Licensing enquiries in
2012/13
• Clear Guidance and Rules set out in “At a Glance Guide”
• Hon. Advisory Panels to support work – Cardiology,
Neurology, Diabetes, Vision, Alcohol & Substance Misuse,
Psychiatry
• DVLA Medical Advisors receive medical reports but do not
meet or assess drivers

Driving Assessment
• DVLA Medical Advisers refer for a Driving
Assessment when medical information is not
conclusive
• Options:
• A standard driving test conducted by Driving and Vehicle
Standards Agency (DVSA)
• A Driver’s Medical Appraisal (DVSA)
• A Driving Assessment at a Forum accredited Mobility
Centre

Driving Assessment
• Driving Test – vision test plus record of on road
performance measured against agreed standard - no
clinical input.
• Medical Appraisal – as above - but some minor tuition
possible
• Driving Assessment – clinical process aimed at establishing
impact of disability or medical condition on the driving
task and possible methods of ameliorating this

Driving Assessment at Mobility
Centre
• Assessment Team:
• Clinical Staff – normally an Occupational Therapist
• Driving Staff – An Approved Driving Instructor
• Assessment Process
• Assessment of Visual Standards
• Physical Assessment
• Cognitive assessment
• On-road assessment
• A process roughly 2 hours 30 minutes in length
• Full written report - DVLA makes licensing decision

Assessing Clinical Fitness to Drive – Brunel
University – 23rd June 2015
Driving Assessment – Overall
Outcomes 2012/13

Assessment Staff Training and
Development
• Existing Skill Set:
• Occupational Therapist training – degree level (BSc
Hons), generally 3 year full time
• Approved Driving Instructor training - 3 levels (based on
60 hours minimum in car training)
• An assessment team – not “clinician plus brake
operative”
• In Centre Training:
• On average a further 6 months in-centre training (by
colleagues) in driving assessment specialty

Reasons for further training
• Problem of skills degrading when training solely delivered
in-centre
• Need for academic validation
• Need for an element of external generation of ideas and
approaches
• Need to deliver training to staff with a wide variation of
past educational experience
• Centralised training to assist consistency of client
outcomes
• Structured approach to continuing professional
development in the specialty of driving assessment

Co-delivered Study Routes with University
of Chester
• Strong track record in work-based learning based on
critical reflection
• Academic validation but strong workplace link
• Flexible approach to delivery of teaching sessions
• Possibility of growth and development of Study Routes,
e.g. further modules, catering for needs of non-
assessment staff, delivery of training for other industry
stakeholders etc
• Use of our modules as a bridge to full degree or
postgraduate qualifications.

Approval Process
• All Modules subject to formal approval by University of
Chester Academic Panel
• Tutor Group drawn from staff at Mobility Centres but
subject to approval by University of Chester as
Associate Tutors
• Formal teaching sessions developed and delivered by
Tutor Group and invited guest tutors
• Support from University in form of link tutor, second
marking, external examiners and professional
development of Associate Tutor Group

Study Route Development
• Initially three 20 credit modules at undergraduate or post
graduate level delivering a Certificate or Post Graduate
Certificate in “Driving Assessment and Outdoor Mobility.”
- One year course:
• Professional Role and Responsibilities
• Understanding Medical Conditions
• Assessment and Evaluation of Fitness to Drive
• Entry level dependent on past educational experience
• Centre Accreditation dependant on staff completing
study routes

Study Route Development
• After two years (approx 25 students per year) decision to
expand Study Routes by a further four modules. Additional
modules:
• Self Review and Negotiation of Learning
• The Use of Assistive Technology to Facilitate Safe Driving
• Understanding Cognition and Vision in relation to Fitness to Drive
• Assessment and Facilitation of Personal Community Mobility
• Level now a Certificate in Higher Education or Postgraduate
Diploma > 50% of a full Degree or Masters qualification

Benefits of the Study Routes
• High quality training and assignments leading to improvements in
assessment practice at a local and UK level
• Assists consistency of assessment outcome between centres
• Negligible drop out or failure rate
• Greater understanding between team members from different
backgrounds (clinical and driving)
• Stimulates debate and critique with our sector
• Greater links with researchers and other academics
• Greater level of face validity of our processes
• Clearer route for individual development and progression

Forum Expert Panel
• To inform the Education Programme and our general
practice
• Membership of 24 senior UK academics and clinicians with
some international involvement
• Development over time of stronger links with Study
Routes and Professional Development
• Exchange of ideas and co-operation between Panel
Members and institutions
• Joint research proposals and funding bids
• Dissemination of practice based expertise to inform
policy & research

European Developments
• Work with CIECA (The International Commission for
Driver Testing) to introduce European Standards for
Driving Assessment
• Updating and developing the “Handbook of
Disabled Driver Assessment”
• Second CIECA Workshop planned for October 2015
• Recognition of the fundamental difference between
assessment and testing

Professor Priscilla Harries
Professor Carolyn Unsworth
Dr. Miranda Davies
Dr. Hulya Golkap
Sue Newell
Development of a web-based
decision aid to assist
occupational therapists to
make optimal fitness-to-drive
decisions for disabled and
older drivers

Driving is an important and valued
IADL. It promotes independence, mobility & freedom
Health conditions and disability can impair driving
Occupational therapists are well placed to assess fitness-to-drive, and usually
conduct off & on-road assessments.
It is not clear what judgement policies OTDAs are using when making fitness-
to-drive recommendations
Evidence based training is needed to enhance workforce capacity
(Classen, 2010; Kortling & Kaptein 1996; Unsworth, 2007)
Background

Project advisors:
Service user group
Tamalina Al-Dakkak
Ann Bunce
Jon and Rodney Hutchings
Judith Sinclair
Hilary Strickland
Project advisory group
Professor Mary Gilhooly (Brunel University London)
Professor Mark Williams (Brunel University London)
Professor Peter Ayton (City University)

Objectives 1-2
Develop a consensus policy on fitness-to-drive from
experts.
Objectives 3-5
Use consensus policy in RCT to determine if we can
train novices and then develop decision aid.
Structure of the presentation

Task 1
Case scenarios
Task 3
Training Package
Task 2
Policy Capturing Study
Decision
Training
Aid
Study Design
Task 4
RCT
Task 5
Training aid Website

1. Create ‘driving’ case scenarios of older people and people with
disabilities who want to learn to drive, or resume driving for
assessment and identify what fitness-to-drive (fit, not fit)
decisions are made;
2. Statistically model and obtain consensus on how experienced
OTDAs make optimal fitness-to-drive decisions
Objectives

Social Judgment Theory method
45 experienced occupational therapy
driver assessors from the UK,
Australasia
Fitness-to-drive recommendations
made for a series of 64 case scenarios, on-line;
Design

Create ‘driving’ case
scenarios of older
people and people
with disabilities who
want to learn to
drive, or resume
driving for
assessment;

Cue Client Cue Level
Age 60 years old
Driving experience Client has been driving 3-7 years
Driving history Client has had a few minor scrapes in the last 12-
months
Current driving needs Client drives predominantly in the local / familiar area
Physical Skills Physical skills support safe driving
Cognitive & / or perceptual skills Minor cognitive &/or perceptual problems identified
but demonstrates capacity for learning & improvement
Sensory functions Sensory functions support safe driving
Driver behaviour Some behaviour problems identified
Road law knowledge & / or road
craft
Road law knowledge and / or road craft support safe
driving
Vehicle handling skills Vehicle handling supports safe driving
Driving instructor interventions Driving instructor provides one physical intervention
Medical prognosis Medically stable

Fit-to-drive– Unrestricted licence
Fit-to-drive– With conditions. For example, using
an automatic car.
Not fit-to-drive– Driver rehabilitation to be
completed (may require reassessment)
Not fit-to-drive– Suspend or cancel licence.
What is your recommendation for this client?
Please click on one of the boxes below to make
your recommendation:

Results
What fitness-to-drive
decisions are made;
Recommendation Number of cases
Not fit-to-drive: Suspend or
cancel licence
569 (20%)
Not fit-to-drive – driver
rehabilitation to be
completed
1529 (53%)
Fit-to-drive: With conditions 415 (14%)
Fit-to-drive: Unrestricted
licence
367 (13%)
Total
64 scenarios x 45 OTDAs
2880

Discriminant function analysis.
Information central to fitness-to-drive recommendations are:
physical skills,
cognitive and perceptual skills,
road law craft skills,
vehicle handling skills
the number of driving instructor
interventions.
Results
How do OTDAs weight different types of information
when making fitness-to-drive recommendations?

The three functions produced by the discriminant function analysis, showing the
correlations between cues and the fitness-to-drive recommendation (Structure Matrix).Functions
Cues 1
Discriminated clients
who were Fit-to-drive
from Not fit-to-drive
2
who were Not fit-to-
drive - require rehab,
from the other three
outcomes
3
who were Fit-to-drive or
Not fit-to-drive from the
middle two outcomes of
Fit to drive with
conditions, or Not fit-to-
drive - require rehab.
Physical skills .48* .43 .07
Instructor interventions .44* -.38 -.42
Road law/road craft .39* -.03 -.03
Cognitive & perceptual skills .39* .37 -.09
Sensory functions .33* .07 .20
Driving experience .14* .05 .06
Medical prognosis .12 .48* -.27
Driving Need .07 -.37* .10
Driving History .04 -.19* .10
Vehicle handling skills .39 -.29 .53*
Age .07 .15 .41*
Driver behaviour .32 -.08 -.38*

Agreement (consensus) between fitness-to-
drive recommendations was very high ICC=
.97(95% CI .96-.98).
Results
Do experienced OTDAs agree (level of
consensus) about the fitness-to-drive
recommendations made?

3. Produce a training package and develop an experimental
website to test the effectiveness of the web-based decision aid;
4. Test the effectiveness of this aid on novice occupational
therapists’ capacity to make fitness-to-drive decisions;
5. Host open access web-based decision aid designed to promote
optimal occupational therapy assessment for use by the
profession internationally.
Objectives

Randomised Control Design
Case scenario
decisions
Baseline
Case scenario
decisions
Post training
Training
(Intervention)
No training
(Control)
Group

Results:
Bland-Altman plots and Signal Detection Theory were used to explore
alignment between decisions made by novices (pre and post training in control
and experimental conditions) and the experts’ consensus.
The equality graphs below demonstrate the findings

Mean and standard deviation of mean differences as compared to
experts consensus
The effect size is calculated using the mean BA statistics from the
post-training for control (.31, sd=.41) and for intervention (-.02,
sd=.56); this demonstrated a moderate effect (d=.69, r=.32).

Web link:
https://cisbic.bioinformati
cs.ic.ac.uk/fitness_to_driv
e_decision_aid/
(About to be launched!)
This tool is a training aid
only. The developers are
not liable for practice
based decision making in
the workplace.
Host open access
web-based
decision aid
designed to
promote optimal
occupational
therapy
assessment for
use by the
profession
internationally.

Share expert capacity to optimise decision making
Can increase workforce capacity among novices in enhancing
skilled fitness-to-drive recommendations
Can lead to a reduction in the number of
unsafe drivers
Can lead to maintenance quality of life
for those drivers who are fit-to-drive
Conclusion &
Contribution to practice

Publication:
Unsworth, CU. , Harries, PA. & Davies, M. (2015) 'Using Social
Judgment Theory method to examine how experienced
occupational therapy driver assessors use information to
make fitness-to-drive'. British Journal of Occupational
Therapy, 2 pp. 71 - 72.
doi: 10.1177/0308022614562396
Presentations:
WFOT- 2014
COT- 2015
Brunel Symposium - 2015
Dissemination

Brunel University London 23.6.15
‘Assessing fitness-to-drive after stroke: implementing the
National Clinical Guidelines for Stroke’
Kate Radford PhD
University of Nottingham

Background
• There is currently no universal, standardised way to assess fitness to
drive (Devos et al., 2012; Korner Bitensky et al., 2006).
• The most ecologically valid method is on road assessment but the
numbers of patients involved and resource issues (capacity and who
pays??) mean this is not viable.
• Therefore, we need screening methods that allow us to identify
who needs a more thorough on road assessment (Devos et al, 2011).
• The National Clinical Guidelines for Stroke recommend two
subtests of the Stroke Drivers Screening Assessment (SDSA) plus the
TMT- B (ICWPS, 2012).

Research behind the recommendations…
‘Screening for fitness to drive after stroke: A
systematic review and metanalysis’
Aim: To determine the percentage of safe drivers
To identify the best in-clinic screening tools
Methods:
• - Systematic review of literature
• - Meta-analysis of in-clinic tests
• - Outcome: pass – fail decision on on-road test
Devos et al, Neurology, 2011

Results
• 30 studies in review, 27 in meta-analysis
• 1,728 participants, 938 (54%) passed the on-road
evaluation.
• Best determinants
– Road Sign Recognition (Cut Off 8.5 points)
– Compass - (Cut Off 25 points)
– Trail Making Test B (Cut Off 90 seconds)
– Classified unsafe drivers with accuracies of 84%, 85%,
and 80%, respectively
– Three out of 4 studies found no increased risk of
accident involvement in persons cleared to resume
driving after stroke.

Conclusion
• The Road Sign Recognition, Compass, and TMT
B are clinically administrable office-based tests
that can be used to identify persons with
stroke at risk of failing an on-road assessment.

National Clinical Guidelines for Stroke
Road sign recognition and Compass card tests
from the stroke drivers screening Assessment
and Trail Making B should be used to identify
which patients should be referred for on road
screening and evaluation
2012, Driving (6.27)

Ivory Tower
Clinical practice
Gap between evidence and
Clinical practice

Purpose
• To clarify the regulations governing fitness to
drive following stroke
• To discuss the procedure for the assessment of
fitness to drive following stroke
– How to administer and score the recommended
cognitive tests.

Motor
Impairment
Sensory
Impairment
Cognitive
Impairment
Motor
Function
Stroke effects
Sensory
Function
Cognitive
Function
Driving requires

What impact on the person?
DRIVING CESSATION
Legh-Smith et al, J R Soc Med, 1996
Ragland et al, J Geront Med Sci, 2005
Stroke
Motor
Sensory
Cognitive
Quality of life
Depression
Social isolation
BODY FUNCTIONS ACTIVITY PARTICIPATION
International Classification of Function

Vehicle hand controls

Access

What is the process of returning to driving after a stroke?
STEP 1: Patient completes a Medical Questionnaire
• (download from www.direct.gov.uk)
– Send to DVLA
STEP 2: DVLA either
• make a decision using info provided (15 days)
• Contact patient’s GP or Consultant for more info
• Arrange for medical examination
• Request a Driving Assessment/ Eye test
STEP 3: DVLA Decision made (90 days)

Outcomes of DVLA process
• Retain licence
• Fixed period licence
• Licence restricted to driving with adapted
controls
• Licence revoked (with a reason and sometimes
option to reapply or appeal)

A Before leaving hospital (or specialist outpatient clinic),
every person who has had a stroke or TIA should be
asked whether they drive or wish to drive.
B The person/team responsible for any patient who wishes
to drive should:
• ask about & identify any absolute bars to driving
• consider the patient’s capacity to drive safely
• discuss driving and advise the patient
• document findings and conclusions, inform the GP and
give the patient a written record.
(6.27.1)

UKSF 2014 Driving after Stroke
C The person or team responsible for any patient who
wishes to drive should consult current guidance from
the Driver and Vehicle Licensing Agency (DVLA)
regulations
www.dft.gov.uk/dvla/medical/ataglance.aspx
2012, Driving
(6.27)

DVLA - Medical Rules
STROKE:
Must not drive for 1 month. May resume driving if the clinical
recovery is satisfactory. There is no need to notify DVLA
unless there is residual neurological deficit 1 month after the
episode in particular, visual field defects, cognitive defects and
impaired limb function.
http://www.dft.gov.uk/dvla/medical/aag/S/Stroke%20-%20TIA.aspx

DVLA - Medical Rules
STROKE:
Group 2 vocational – lorries, buses
Licence refused or revoked for 1 year following a stroke or
TIA. Can be considered for licensing after this provided there
is no debarring residual impairment likely to affect safe driving
and no other significant risk factors. Licensing may be subject
to satisfactory medical reports including exercise ECG testing.
http://www.dft.gov.uk/dvla/medical/aag/S/Stroke%20-%20TIA.aspx

You are required to notify the DVLA if you
have any disability which affects, or may
in future affect your fitness as a driver, if
you expect it to last more than 3 months.
Notification

Evaluation of fitness to drive
• 2 stage process
– Driver screening (all)
– On Road Assessment (some)

Driver Screening - 2 tier process
Do you have a car? Do you have a valid licence?
Do you drive? Do you wish to drive?
YES NO
Level 1: Before leaving hospital
Screen for problems that preclude or
impact safe driving
• Medical e.g. Epilepsy
• Visual field defects, reduced visual acuity
• Cognitive impairment
• Motor problems
• Driving history & behaviours
Discuss alternative
transport methods

When should the patient inform the DVLA?
• Multiple TIAs over short period of time
• Condition worsens at any time
• Experience any form of epileptic seizure, other than within the first 24
hours of stroke
• Stroke treatment included brain surgery
• More than one stroke in the past three months
• Doctor/other HCP expresses concern about fitness to drive
• Hold a LGV or PCV licence
• Any on-going effects of stroke after one month e.g. visual field loss,
cognitive impairment, memory problems,
• Persistent limb weakness if it restricts the ability to drive certain
vehicles and or adaptations are needed (licence will need to be coded
to reflect changes)

Level 1: Before leaving hospital
No significant
impairments
? Driving Abilities
Significant
impairments
Safe to drive Cognitive
Screening
Specialist Driving Assessment
Mazer et al, 2004

Level 2: Specialist Driving Assessment
Medical/ ‘In- House’ Assessment
• Medical History, functional abilities, Cognitive Assessment
• Visual/Perceptual Assessment, Behavioural assessment
In/Out Evaluation - Are adaptations needed?
Static rig or simulator assessment
• Brake reaction times, brake pressure and steering strength
• Access to controls
ON-ROAD ASSESSMENT
Off-road Evaluation – trial adaptations
Safe Not Yet Safe Unsafe

Criticisms of current system
• Decisions by doctors subjective and not
based on any standard scale
• Licence renewal should be based on a
criteria related to driving competence
• Road assessments for everybody are
expensive and time consuming, therefore
an objective screening test would be
useful

What happens in practice?
• Stroke survivors unaware of responsibility to
inform the DVLA
• Rehabilitation professionals fail to advise them
King et al 1992, Johnston et al 1994, Goodyear et
al 2003
•Many stroke survivors resume driving without
assessment or advice
Ebrahim et al 1988, Pidikiti & Novack 1991, Fisk et al.
1997, Hawley, 2001, Johnston et al. 2004, Mazer et al.
2004

Cognitive screening for fitness to drive
Purpose of screening
– To identify which drivers are unsafe and require
further assessment at a specialist driving assessment
centre
– To introduce some form of cognitive screening into
procedures where currently none exists
– So that;
– Safe drivers enjoy the privileges of driving a car
– Unsafe drivers are identified prior to accidents

Development of the
Stroke Drivers Screening Assessment
+
Nouri & Lincoln Clin Rehabil 1992; 6: 275-281
79 Stroke Patients
Cognitive Assessment BSM
Road Test

The Stroke Drivers Screening Assessment

Dot cancellation

SDSA -Square Matrices- Directions

Road Sign Recognition

General Instructions before testing
“Some people have problems with concentration, reasoning and
their interpretation of the things they see after a stroke. These may
affect their ability to drive a car. Some of the tasks will be easy and
some more difficult. We wish to identify whether you have any
problems as a result of your stroke, which affect your ability to
drive a car.”
For each test standard instructions are provided. These may be
repeated once if the client seems not to understand or has difficulty
remembering what he/she is required to do. No additional
information may be given. If the client asks for further instructions
a phrase such as “I am not able to give you any more information”
or “Do what you think is right” should be used.

Remember…..
• The SDSA is a screening assessment - to be used in conjunction
with clinical judgment.
• Not intended to provide a decision on safety - but to provide a
recommendation for further action.
• Pass the information on to a GP or stroke physician to inform
their recommendation to DVLA.
• The validation of the SDSA is far more rigorous than for most
other assessment methods used in clinical practice to
determine safety to drive.

Screen for inattention and include training measures
• People with visual inattention excluded from studies in
the review, therefore
• Screen for inattention before completing the other
tests – (SDSA dot cancellation does this).
• SDSA Compass Cards requires training using Square
Matrices Directions– so you might as well complete the
entire SDSA.
• Similarly complete TMT A in preparation for TMT B

What to do
• Screen using SDSA
– Dot cancellation – For inattention
– Complete Square matrices – Directions
– Followed by Compass cards (Cut off 25/32)
– Road Sign Recognition (Cut off 8.5/12)
– TMT – B (Cut off 90 seconds)
– Refer for specialist driving assessment if scoring
below ANY cut off

When should patients be screened?
• Between 1 and 3 months after stroke when
the person is feeling better or later when
contemplating driving again

Use of SDSA alone
Screening procedure to decide who needs referral for
‘on road’ assessment
• Pass
– May need physical adaptations
• Fail
– if early wait and retest (Lincoln & Fanthome 1994)
– If late not fit to drive – can still refer for on road assessment
for ecological reasons

Screening for Fitness to Drive after Stroke
STROKE
Cognitive Screening for Fitness to drive SDSA plus TMT ‘A’ and ‘B’
FAIL on equation or
score below cut offs
PASS on equation or
score above cut offs
Safe to Drive
Advise GP
Unsafe to drive
Advise GP, refer for
road test and tell
patient to inform
DVLA
Repeat Assessment
After 3-4 months
FAIL on equation or
score below cut offs
More detailed assessment (psychological/ medical / visual) and
/or On-Road Assessment at
SPECIALIST DRIVING ASSESSMENT Centre

Commonly asked questions
• If people score below cut offs can they be re-tested
later?
• Can you use either the SDSA with its original equation or
the recommended cut offs identified in the National
Clinical Guidelines?
• Can you use just one or two of the tests?
• Is sensitivity improved by using all three?
• Why the SDSA? Can’t we use the Rookwood battery?
• What about visual screening?
• Won’t a quick MOCA or and ACE-R do?

Responses
• If people score below cut offs can they be re-tested later?
• If tested early after stroke, it is reasonable to expect some recovery, then re-
test after 3-4 months.
• If testing late after stroke, refer for on road assessment.
For test re-test reliability data for the SDSA see the manual
(http://www.nottingham.ac.uk/medicine/documents/publishedassessments/sdsa-manual-2012-uk.pdf )
Ref Lincoln and Fanthome, 2004
For TMT see http://strokengine.ca/assess/module_tmt_psycho-en.html
• Can you use either the SDSA with its original equation or the recommended
cut offs identified in the National Clinical Guidelines?
• YES, BUT if someone had object based neglect it would be missed using square
matrices and Road sign recognition, so there is a risk in missing out dot
cancellation.

• Won’t a quick MOCA or and ACE-R do?
Likely to miss too many people with cognitive problems. Chan et al (2014) showed 78% of those who obtained full marks on the
MoCA had cognitive problems. ACE-R and MoCA mainly assess attention and memory and miss visuospatial and executive
deficits, so not good at detecting the things we need to check for safe driving.
• What about visual screening?
Yes definitely needed, especially visual fields
• Why the SDSA? Can’t we use the Rookwood battery?
Rookwood developed on people referred to a specialist driving assessment centre, so may not be representative of stroke
patients screened in the community. In the validation the instructor un-blinded to the results of the cognitive test, so biased
towards agreement.
The sensitivity to fails in R hemisphere stroke is 42% and in left hemisphere stroke 39%. So if they fail the Rookwood they are
likely to be unsafe on the road PPV 83% and 78% , but it will miss a lot of unsafe drivers (58% and 61% missed).
• Can you use just one or two of the tests?
The cut-off values that were calculated were for each of the three tests. The tests can therefore be administered separately.
However, recommend to administer all three of them since they are evaluating different cognitive functions. And importantly
visual screening first
• Is sensitivity improved by using all three?
This is a question for future research!

Summary
• Ask the driving question
• Identify absolute bars to driving, e.g. epilepsy, visual
field loss, hemianopia, poor visual acuity
• Screen for cognitive impairments – 1-3 months post
stroke
• Refer for more detailed assessments e.g. vision,
cognition and/or on road assessment at a specialist
driving assessment centre where appropriate
• Remind the patient of their responsibility to inform the
DVLA if their stroke is likely to affect their ability to drive
safely.

UKSF 2014 Driving after Stroke
Where to obtain the tests
Stroke Drivers Screening Assessment
• The UK version of the assessment is priced at £100, and the US version is available for
£150.
• Email: Professor Nadina Lincoln nadina.lincoln@nottingham.ac.uk
REVISED MANUAL: http://www.nottingham.ac.uk/medicine/documents/publishedassessments/sdsa-
manual-2012-uk.pdf
Trail Making Test
• Delis-Kaplan Executive Function System™ (D-KEFS™)
• University of IOWA
• http://www.healthcare.uiowa.edu/igec/tools/cognitive/trailMaking.pdf
• http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Trail-Making.html
• Different versions – Caution!
Finding out more about cognitive tests for use in stroke:
• http://strokengine.ca/assess/module_tmt_psycho-en.html

Useful resources
• www. stroke.org.uk ‘Driving after stroke’
• Confidentiality and a Service User’s Fitness to Drive, BAOT/COT
Briefings
• At a Glance Guide to the Medical aspects of fitness to drive
• www.dft.gov.uk/dvla/medical/ataglance.aspx
• Car or motorcycle drivers who have had a stroke or transient
ischaemic attack (TIA). INF188/3, DVLA, www.direct.gov.uk for
DVLA
• Forum of Regional Mobility Centres
http://www.mobility-centres.org.uk/find_a_centre/

Insert the title of your
presentation here
Presented by Name Here
Job Title - Date
Self-assessment tools for the
older driver
Presented by Britta Lang
Head of Safety Science – 23/06/2015

Page 196
Agenda
Background & update
The role of self-regulation for older driver safety
Age-related declines in driving capabilities
Self-assessment tools
1
2
3
4
5
Aims of the review
Summary, conclusions & recommendations6

Page 197
Aims of the review
1. Localise the potential of self-assessment tools in the
current policy/ licensing context
2. Identify driving capabilities that lend themselves for
inclusion in self-assessment tools, review evidence on
age-related changes & association with collision
involvement
3. Review existing self-assessment tools & evidence on their
objectivity, validity, reliability & user acceptance/ utility
4. Summarise current state of self-assessment for older road
users & make recommendations for policy, research &
development

Page 198
Information search & terminology
Search & review of published scientific literature, including:
TRID, Science direct, British Standards, PubMed, SORT, TRKC, Cochrane
Library, Scirus
Consultation of 63 experts & practitioners in the field of older
driver safety, covering:
-Europe (19 provided materials)
-Australia (5 provided materials)
-USA/Canada (5 provided materials)
No agreed criterion of when someone turns into an “older”
driver
Self-assessment, self-screening, self-evaluation
interchangeably used in Europe; differentiation in US
(DoT/NHTSA):
-less formal self-screening (educational)
-self-assessment (evaluation of key functions by health professional)

Prolonging safe driving for as long as possible
Changes in population age-structure as well
as social, economic and environmental
transformations (ONS, 2005)
Changes in lifestyle, increased mobility
expectations; increased dependency on cars
& decrease in walking (Warnes, 1992;
O’Fallon & Sullivan, 2009)
Proportion of women holding a driving
licence on the increase (Mitchell, 2011) &
existing gender differences narrowing (TRIP,
2012; Le Vine & Jones, 2012)
Driving is the safest & easiest form of
transport; it avoids the difficulties/risks of
other forms of transport, particularly
walking (Whelan, Langford, Oxley, Koppel &
Charlton, 2006; Siren & Meng, 2012)
Mobility as a pre-requisite for wellbeing &
autonomy (Whelan, Langford, Oxley, Koppel &
Charlton, 2006; Gagliardi et al., 2010 )
0
20
40
60
80
100
Males Females
Percentageoflicence-holders
1975
2010
Source: DfT, 2010

Older driver road safety forecast
Source: Mitchell, 2011
forecast

Quo vadis UK?
 Liberal driving licence system
 Families carry main responsibility for driving
cessation decisions
 No special training for GPs
 No specific support for older drivers
 Avoid heavy regulation
 Start driving cessation discussion in a positive way as
early as possible
 Develop effective, evaluated trainings for older drivers
 Develop the role of the GP in assisting driving decision
 Develop self-assessments as a potential ice-breaker
for the discussion with the family
Today
Tomorrow?

Page 202
Self-regulation
Crash statistics indicate safe
performance of older drivers up to the
age of approx.75 years; this is
frequently attributed to older drivers’
ability to self-regulate
Self-regulation describes the voluntary
adaptation of driving to age-related
changes in cognition, perception &
physical capacities (Charlton & Molnar,
2011)
Several studies have demonstrated an
association between reported
avoidance of certain driving situations
& measures of fitness to drive, health
& confidence

Page 203
Self-regulation
Driving cessation as the end point of self-
regulation continuum (Dellinger, Sehgal, Sleet &
Barrett-Connor, 2001)
Correct timing of cessation is crucially
important for the safe mobility of older
drivers; study with 2510 older drivers shows
that 72% report to cease driving for health-
related reasons, because of accidents or
because of licence revocations; a third report
stopping too early, 9% report stopping too
late (Stutts et al. 2001)
Oxley, Charlton, Scully & Koppel (2010)
present similar findings: 34% stop too early &
2% too late
But: how does this self-report relate to actual
safety performance?

Page 204
Improving self-regulation
Successful self-regulation depends on correct perception &
matching of capabilities with task demands

Page 205
The Task Capability Model (Fuller, 2000)
Page 205
Capability Task demand
Control
Collision
D > C
C > D
Task difficulty

Page 206
The perception – reality divide (Fuller, 2000)
Perceived capability
Motivation for speed
Effort motivation
Range of
acceptable task
difficulty
Comparator
Decision &
response
Effects on vehicle speed and
position and on other road
users
Objective task
difficulty
Perceived task
difficulty
Objective
capacity

Page 207
Improving self-regulation
Successful self-regulation therefore depends on correct
perception & matching of capabilities with task demands
Calibration (Kuiken & Twisk, 2001): “The ability of a driver to
recognise the relationship between the demands of the driving
task and their own abilities, including error recovery. At any
moment in time, a driver needs to be actively engaged in
assessing what the driving task requires in terms of actions or
the avoidance of actions, and the potential difficulties involved.”
Reducing the gap between subjectively perceived & objectively
measured for vision & hearing in 54 older drivers facilitates
change & is accepted (Holland & Rabbit, 1992)

Page 208
Limitations of self-regulation
Improved self-regulation also a
matter of motivation
Fildes (2008, p. 389) “whilst older
drivers will prefer self-regulation
when it comes to mitigating driving
risk, it is not a sufficient process
alone to ensure their safety”
Moták, Huet, Bougeant & Gabaude
(2012): Possible stereotype threat
may result in an actual impairment of
performance: increased effort focused
on contradicting stereotype

Page 209
Self-regulation in the current policy context
In GB: Self-declaration of fitness to
drive from 70 years onwards; in-depth
assessment only if fitness to drive is in
question
No benefit of age-related controls, but
potential shift in older people towards
less safe forms of transport
Development of multi-tiered assessment
programmes in USA & Australasia: at-
risk older drivers undergo cost-effective
screening before more specialised
assessment

Page 210
Self-regulation in the current policy context
Currently no international agreement on
standardised battery of easy-to-use & cost-
effective diagnostic tools with good
reliability & predictive value
Self-assessment of capabilities can
enhance self-regulation & decisions that
older drivers make about when, where &
how they drive

Page 211
Age-related changes in driving capability
Age-related deteriorations documented for perceptual,
motor & cognitive capabilities
Chronic medical conditions & associated medication
increase with age
Marked inter-individual variability & rate of decline of a
particular ability not necessarily accompanied by similar
declines in others.
Chronological age, or a particular medical diagnosis, is a
poor predictor of sensory, motor & cognitive functioning &
does not of itself determine an individual’s specific fitness
to drive (Folkerts, 1993)
Assessment procedures in this context explore upper
performance limits & link results to road safety outcomes
(Janke, 1994; Carter, 2008, NHTSA, 2008, Langford et al. 2009)

Page 212
Current test procedures
Motor ability:
- Rapid Walk Test & Alternating Foot
Tap Test
Visual attention:
- Useful Field of View Test:
- Subtest 1: processing speed:
identification of target in central
location (A)
- Subtest 2: processing speed for
divided attention: simultaneous
identification of central & peripheral
target (B)
- Subtest 3: processing speed for
selective attention (C)
A
B
C

Page 213
Current test procedures cont.
Decision making:
- Trail Making Test:
- Subtest A: visual search capability: draw lines to
sequentially connect numbered circles (A)
- Subtest B: working memory & task switching
ability: connect encircled numbers & letters (1–
A–2–B–3) (B)
- Subtraction TMT (A-B): executive control
abilities
Cognitive ability:
- Mini Mental State Examination: attention,
orientation, recall, language & visuo-spatial
perception (score 24/30 indicates cognitive
impairment)
- Clock Drawing Test: visuo-spatial &
executive function
A
B

Page 214
Clock Drawing Test

Page 215
Candidates for self-assessment
Visual performance – static & dynamic acuity,
contrast sensitivity
Executive function – trail making or maze following
Cognition – UFOV
Hazard perception & change blindness (further
development & validation required)
Driving style – through questionnaire
Driving problems – through questionnaire
Range of motion – through questionnaire

Page 216
Self-assessment tools
Targeted at older drivers who are motivated to take a test because they
feel unsafe in traffic or have concerns regarding their driving abilities
(Heikkinen et al., 2010)
Educational in purpose: Aim to alert drivers to the presence of age-related
impairments, risks or health concerns that may put them at a greater risk
of collision if adequate compensatory action is not taken (Charlton & Molnar,
2011)
Expectation is that driver will make appropriate adjustments;
compensatory actions cover a range of measures
Not appropriate for older drivers with cognitive impairment (Staplin et al.,
1999; Eby et al., 2003; Molnar et al., 2007)
Web-based solutions provide opportunity for tailoring of complex
assessment & feedback; internet use for older people on the increase
(ONS, 2011)

Page 217
Benefits & limitations
Pros
- Easy to distribute, reach a large number of
respondents
- Unthreatening, completed in private
- Can facilitate early detection of problems
- Can stimulate conversation with family members
Cons
- May not be completed by drivers with concerns over
fitness to drive
- Can be susceptible to self-report/self-enhancement
bias
- May cause stereotype threat & associated impairment

Page 218
Types of self-assessment tools
1. Tools that aim to increase self-awareness, typically by
requiring the respondent to reflect on & self-report problems
experienced & concerns related to safe driving
Examples include: Driving Decisions Workbook (p&p), Enhanced Driving
Decisions Workbook (wb), Devon Driving Decisions Workbook (p&p), Driving Safely
While Aging Gracefully (p&p), RACQ’s Older Drivers’Self-Assessment Questionnaire
(wb), Suffolk’s Older Driver Risk Index (wb), AAA’s Drivers 65 plus: Check your
performance (wb)
2. Tools that measure the driver’s maximum performance on
a test (or tests), to screen for functional impairment of
abilities relevant to driving
Examples include: Driving Health Inventory, AAA Roadwise Review
3. Information brochures including elements of self-
assessment
Examples include: Retiring from Driving

Page
BIC Example 1: Driving Decisions Workbook (1998)
Aim:
1. Provide feedback to facilitate good driving decisions by
increasing self-awareness & general knowledge
2. Increase general awareness of age-related declines in driving
abilities, facilitate discussion with family members & social
network
Development process:
- Literature review of driving capabilities, health factors,
education & skill enhancement
- Focus groups with older drivers & family members
- Expert workshop on assessment components
- Piloting in structured interviews with target group

Page 220
Self-assessment framework

Page 222
Example 1 continued: Evaluation & validation
Evaluation & validation: n=99 older drivers
- Self-reported increases in self-awareness, general knowledge; perceived usefulness of the
instrument
- MMSE & GRIMPS
- Standardised driving course (7 miles), 28 manoeuvres at specific locations &17
performance tasks
94% find tool at least somewhat useful; 14% discover changes they were not
aware of before & intend to make adjustments; females more positive
Sg. correlation between workbook score & on-road performance (r=.30); sg.
correlations also for sub-domains driving abilities & attitudes/experience, but not
for health
Further differentiation by age indicates sg. correlations only for drivers aged 65-
74, but not 75+
No evidence of the impact Workbook’s impact on self-regulation

Page 223
Example 1 updated: The Enhanced DDW

Page 224
BIC Example 2: AAA Roadwise Review
Outcomes for each performance
area: no impairment, mild
impairment or serious impairment
Advice on safe driving strategies &
options for further information &
testing
Older drivers may be referred to a
health professional or fitness-to-
drive assessment specialist
If no impairment is detected,
driver is asked to use assessment
outcomes as a comparison
baseline for future assessments &
is advised that the absence of
impairment should not lead to
diminished vigilance.

Page 225
Example 2: Evaluation & validation
Evaluation study with n=51 older drivers (Bédard et al., 2011),
correlating Roadwise with clinical assessment & on-road test (40
mins):
- Sg. correlations found for Roadwise elements & clinical counterparts:
(r=.61) for TMT A & Visual Search in Roadwise & ( r=.46) for TMT B &
Visual Search
- Correlations between Roadwise & on-road test not consistent

Page 226
Summary & conclusions
Several self-assessment tools available & marketed through
automobile clubs, local authorities, universities, older people
representative groups, usually as an older driver
programme component
Most tools developed in US; development effort varies with
AAA Roadwise & Michigan’s Driving Decisions Workbook as
best in class examples
Only few validation studies to date & more effort is needed
Impacts of self-assessment tools on calibration & self-
regulatory change are understudied
Further development work to include higher-order abilities,
ie situational awareness, change blindness & resistance to
distraction

Page 227
Summary & conclusions cont.
Self-assessment tools are subject to bias; this threatens
provision of accurate feedback with implication for road
safety
Self-assessment tools are no definite measure of driving
competence & cannot replace fitness to drive assessments
However, when appropriately advertised they can make a
valuable contribution & complement older driver
programmes
Web-based presentation of tools has advantages & internet
access & use will increase in future
Government should encourage research into the potential
contribution & predictive validity of self-assessments

Page 228
Recommendations
Aging societies & increasing mobility needs
are a reality; despite their relative safety,
older drivers are an increasingly important
road users group & require attention from
policy makers
Self-assessment tools hold significant
promise as cost-effective & enabling tools
for this policy target group
However, to date the evidence base is still
thin & US dominated; there is no single tool
to date that has demonstrably positively
impacted self-regulation of older drivers
We recommend that British government
should invest in R&D on improving older
driver self-regulation

Page 229
Self-assessment tools for the older
driver
Symposium “Assessing Clinical
Fitness to Drive”
Presented by Britta Lang
Head of Safety Science – 23 June 2015
Tel: +44 (0) 1344 770014
Email: blang@trl.co.uk

Closing remarks
Dr Elizabeth White
Interim Head of Education and Research
College of Occupational Therapists on behalf
of UKOTRF

Assessing clinical fitness to-drive symposium, all slides

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