Fitness-to-drive agreements after stroke: medical versus practical recommendations

Fitness-to-drive recommendations in post-stroke patients: a retrospective study

BACKGROUND

Stroke sequelae can have an impact on daily life activities such as driving. French legislation stipulates that post-stroke patients should undergo a multi-professional fitness-to-drive assessment before being allowed to drive again. This retrospective study aims to explore the determinants of multi-professional fitness-to-drive recommendations.

METHODS

Sixty-six post-stroke patients assessed for fitness to drive in the Kerpape Center, France in 2019 were included. Favorable or unfavorable driving recommendations were attributed to patients following a joint decision by a multi-professional team. Individual characteristics obtained from medical records were compared.

RESULTS

Findings showed that 64% of stroke patients received a favorable fitness-to-drive recommendation. Across all demographic, clinical, and driving characteristics, the time interval between stroke and assessment was significantly longer for patients designated as unfit to drive than for those designated as fit to drive (P = .004). Furthermore, the proportion of instrumental sequelae was higher in patients designated as unfit to drive than in those designated as fit to drive (P = .022). Stepwise logistic regression showed that the presence of instrumental sequelae, mainly aphasia, was the best predictor of fitness-to-drive recommendations.

CONCLUSIONS

The post-stroke time interval and the presence of instrumental sequelae explained the difference between patients recommended as fit-to-drive and unfit-to-drive. Furthermore, aphasia was found be the best predictor of a fitness-to-drive recommendation. It is possible that aphasia impacts the understanding of instructions during on-road testing. These findings emphasize the need for a standardized multi-professional fitness-to-drive assessment, since the determinants of fitness-to-drive recommendation differ between studies.

Driving and Alzheimer's dementia or mild cognitive impairment: a systematic review of the existing guidelines emphasizing on the neurologist's role

BACKGROUND

Driving is a complex task requiring the integrity and the cooperation of cognition, motor, and somatosensory skills, all of which are impacted by neurological diseases.

OBJECTIVE

Identification of neurologist's role when assessing fitness to drive of cognitively impaired individuals.

METHODS

We performed a systematic review of the guidelines/recommendations (G/Rs) regarding the evaluation of driving fitness of patients with mild cognitive impairment (MCI) and/or dementia. Emphasis was put on the neurological and neuropsychological aspects of the evaluation.

RESULTS

Eighteen G/Rs were included in the review (9 national guidelines, 5 recommendation papers, 3 consensus statements, and 1 position paper). All G/Rs referred to drivers with dementia and 9/18 referred to drivers with MCI. A common approach among G/Rs is the initial trichotomization of patients in safe to drive, unsafe to drive, and undetermined cases, which are referred to a second-line evaluator. First-line evaluators are general practitioners in 10/18 G/Rs; second-line evaluators are neurologists in 7/18 G/Rs. Specific neuropsychological tests are proposed in 11/18 G/Rs and relative cut-off values in 7/18. The most commonly used tests are the MMSE, TMT, and CDT. A thorough neurological examination is proposed in only 1/18 G/R.

CONCLUSION

Although extensive multi-disciplinary research has provided useful information for driving behavior of cognitively impaired individuals, we are still far from a widely accepted approach of driving ability evaluation in this increasing population. A comprehensive assessment from a multi-disciplinary team in which the neurologist plays a critical role seems to be required, although this has not yet been implemented in any G/Rs.

The determinants of motorized mobility scooter driving ability after a stroke

Purpose: To investigate the determinants related to the ability to drive a motorized mobility scooter after a stroke.Method: The study was a cross-sectional study. The ability to drive a motorized mobility scooter was measured with the Power Mobility Clinical Driving Assessment. The independent variables included cognitive functions measured by the Color Trails Test and reaction time test, visual functions measured by a visual acuity test and visual field test, and motor functions measured with a dynamometer, the Box and Block Test, and the Functional Independence Measure.Results: The correlation analyses revealed that the Power Mobility Clinical Driving Assessment scores had significant correlations with reaction time (ρ = -.65, p < 0.01), binocular visual field (r = .64, p < 0.01), binocular visual acuity (r = .40, p = 0.03), and the grip strength of the unaffected hand (r = .47, p = 0.01). The multiple regression analysis indicated that reaction time, binocular visual field, and the grip strength of the unaffected hand were the most significant determinants of the ability to drive a motorized mobility scooter (R² = .76).Conclusions: The reaction time, binocular visual field, and grip strength of the unaffected hand were the most significant determinants related to the ability to drive a motorized mobility scooter after a stroke. IMPLICATIONS FOR REHABILITATIONMotorized mobility scooter driving ability for stroke patients is correlated with demographics (age, mobility scooter driving experience, time since last drive) and cognitive, visual and motor functions (reaction time, binocular visual field, visual acuity, and the grip strength of unaffected hand).Primary determinants of motorized mobility scooter driving ability for stroke patients include reaction time, binocular visual field, and grip strength of the unaffected hand.Comprehensive assessments incorporating cognitive, visual and motor functions are needed to evaluate the ability to drive a motorized mobility scooter after a stroke.

Mandatory Physician Reporting of At-Risk Drivers: The Older Driver Example

Purpose of the Study

In a number of states, physicians are mandated by state law to report at-risk drivers to licensing authorities. Often these patients are older adult drivers who may exhibit unsafe driving behaviors, have functional/cognitive impairments, or are diagnosed with conditions such as Alzheimer's disease and/or seizure disorders. The hypothesis that mandatory physician reporting laws reduce the rate of crash-related hospitalizations among older adult drivers was tested.

Design and Methods

Using retrospective data (2004-2009), this study identified 176,066 older driver crash-related hospitalizations, from the State Inpatient Databases. Three age-specific negative binomial generalized estimating equation models were used to estimate the effect of physician reporting laws on state's incidence rate of crash-related hospitalizations among older drivers.

Results

No evidence was found for an independent association between mandatory physician reporting laws and a lower crash hospitalization rate among any of the age groups examined. The main predictor of interest, mandatory physician reporting, failed to explain any significant variation in crash hospitalization rates, when adjusting for other state-specific laws and characteristics. Vision testing at in-person license renewal was a significant predictor of lower crash hospitalization rate, ranging from incidence rate ratio of 0.77 (95% confidence interval 0.62-0.94) among 60- to 64-year olds to 0.83 (95% confidence interval 0.67-0.97) among 80- to 84-year olds.

Implications

Physician reporting laws and age-based licensing requirements are often at odds with older driver's need to maintain independence. This study examines this balance and finds no evidence of the benefits of mandatory physician reporting requirements on driver crash hospitalizations, suggesting that physician mandates do not yet yield significant older driver safety benefits, possibly to the detriment of older driver's well-being and independence.

The Impact of Advanced Age on Driving Safety in Adults with Medical Conditions

BACKGROUND

Adults aged 85 and older, often referred to as the oldest-old, are the fastest-growing segment of the population. The rapidly increasing number of older adults with chronic and multiple medical conditions poses challenges regarding their driving safety.

OBJECTIVE

To investigate the effect of advanced age on driving safety in drivers with medical conditions.

METHODS

We categorized 3,425 drivers with preexisting medical conditions into four age groups: middle-aged (55-64 years, n = 1,386), young-old (65-74 years, n = 1,013), old-old (75-84 years, n = 803), or oldest-old (85 years and older, n = 223). All underwent a formal driving evaluation. The outcome measures included fitness to drive recommendation by the referring physician, comprehensive fitness to drive decision from an official driving evaluation center, history of motor vehicle crashes (MVCs), and history of traffic violations.

RESULTS

The oldest-old reported more cardiopulmonary and visual conditions, but less neurological conditions than the old-old. Compared to the middle-aged, the oldest-old were more likely to be considered unfit to drive by the referring physicians (odds ratio [OR] = 4.47, 95% confidence interval [CI] 2.20-9.10) and by the official driving evaluation center (OR = 2.74, 95% CI 1.87-4.03). The oldest-old reported more MVCs (OR = 2.79, 95% CI 1.88-4.12) compared to the middle-aged.

CONCLUSION

Advanced age adversely affected driving safety outcomes. The oldest-old are a unique age group with medical conditions known to interfere with safe driving. Driving safety strategies should particularly target the oldest-old since they are the fastest-growing group and their increased frailty is associated with severe or fatal injuries due to MVCs.

A Case-Control Study Investigating Simulated Driving Errors in Ischemic Stroke and Subarachnoid Hemorrhage

Background

Stroke can affect a variety of cognitive, perceptual, and motor abilities that are important for safe driving. Results of studies assessing post-stroke driving ability are quite variable in the areas and degree of driving impairment among patients. This highlights the need to consider clinical characteristics, including stroke subtype, when assessing driving performance.

Methods

We compared the simulated driving performance of 30 chronic stroke patients (>3 months), including 15 patients with ischemic stroke (IS) and 15 patients with subarachnoid hemorrhage (SAH), and 20 age-matched controls. A preliminary analysis was performed, subdividing IS patients into right (n = 8) and left (n = 6) hemispheric lesions and SAH patients into middle cerebral artery (MCA, n = 5) and anterior communicating artery (n = 6) territory. A secondary analysis was conducted to investigate the cognitive correlates of driving.

Results

Nine patients (30%) exhibited impaired simulated driving performance, including four patients with IS (26.7%) and five patients with SAH (33.3%). Both patients with IS (2.3 vs. 0.3, U = 76, p < 0.05) and SAH (1.5 vs. 0.3, U = 45, p < 0.001) exhibited difficulty with lane maintenance (% distance out of lane) compared to controls. In addition, patients with IS exhibited difficulty with speed maintenance (% distance over speed limit; 8.9 vs. 4.1, U = 81, p < 0.05), whereas SAH patients exhibited difficulty with turning performance (total turning errors; 5.4 vs. 1.6, U = 39.5, p < 0.001). The Trail Making Test (TMT) and Useful Field of View test were significantly associated with lane maintenance among patients with IS (r_s > 0.6, p < 0.05). No cognitive tests showed utility among patients with SAH.

Conclusion

Both IS and SAH exhibited difficulty with lane maintenance. Patients with IS additionally exhibited difficulty with speed maintenance, whereas SAH patients exhibited difficulty with turning performance. Current results support the importance of differentiating between stroke subtypes and considering other important clinical characteristics (e.g., side of lesion, vascular territory) when assessing driving performance and reinforce the importance of physicians discussing driving safety with patients after stroke.

Comparison of Unsafe Driving Across Medical Conditions

OBJECTIVE

To compare risks of unsafe driving in patients with medical conditions.

METHODS

This large population-based study included all patients who were referred for a fitness-to-drive evaluation at an official driving evaluation center in 2013 and 2014. Risks of unsafe driving included physician's fitness-to-drive recommendation, comprehensive fitness-to-drive decision, motor vehicle crash history, and traffic violation history.

RESULTS

A total of 6584 patients were included in the study. Risks of unsafe driving were significantly different across medical conditions (P<.001 for all outcome measures). Patients with neurological conditions comprised the majority of the database (4837; 74%), but were not at the highest risk for unsafe driving. Patients with psychiatric conditions or substance abuse did worse on most driving safety outcomes, despite their low representation in the total sample (359 [6%] and 46 [1%], respectively).

CONCLUSION

The risk of unsafe driving varied greatly across medical conditions. Sensitization campaigns, education, and medical guidelines for physicians and driver licensing authorities are warranted to identify patients at risk, especially for those with psychiatric conditions and substance abuse problems.