Assessment Group: Discussion and Unresolved Issues

An assessment flowWhy?: Identify drivers with functional changes that may

compromise personal or public health or safety

Why?: Identify individuals who may

benefit from prevention, education, remediation

Who?: Many different sources of screening and referral (self, family, law enforcement, DMV, other agencies, health care professionals,

driver rehabilitation specialists, driver educators, community-based agencies and groups, etc, etc)

What?: Tier One: Brief screening of cognitive, motor, sensory and

health/medication functions. The form of Tier 1, and its next steps, are contingent

on who does the assessment.

An assessment flow

What?: Tier One: Brief screening of cognitive, motor, sensory and

health/medication functions. The form of Tier 1, and its next steps, are contingent

on who does the assessment.

What?: Tier Two: In-depth assessment of cognitive, motor, sensory and health/medication functions,

personality/motivation/awareness. The next steps, are contingent on who does the

assessment. Often done with Tier 3.

What?: Tier Three: Behind the wheel assessment

At each tier, there should be appropriate referrals

Candidate measuresThe domains that follow in red come from the NHTSA/AAMVA

recommendations

A goal is that a battery should be evidence-based (with regard to its predictiveness of driving performance, which could include crashes, on-the-road driving errors, or other performance measures).

There are alternative pathways. 1. One approach focuses less on specific domains, but tries to include a

battery which—in combination—maximizes predictive salience. 2. A second approach tries to represent multiple domains. This will be more

useful for making rehabilitation recommendations and identifying the sources of problems.

The two approaches are not mutually exclusive.

Tier 2 Candidates: Cognition

Domain Candidate measures Notes

Mental Status • Mini-Mental Status Examination• Telephone Interview for Cognitive Status

Does it make sense to separately predict driving for demented and non-demented elders? Where does MCI fit in?TICS has wonderful advantages, including phone plus better memory than MMSE.

Divided Attention • Trails A & B• Useful Field of View

Trails is widely used, and AMA recommended; UFOV is predictive and trainable, but equipment intensive.

Tier 2 Candidates: Cognition

Domain Candidate measures Notes

Perceptual Speed/Visual Search

• Letter Cancellation Task• Digit Symbol Substitution Task•Trails

Does this add anything beyond the speeded Divided Attention Tasks?

Reaction Time • Complex Reaction Time (e.g., Doron

There is no shortage of CRT tasks. Again, these generally require a computer; Doron is driving stimulus-specific.Is a simulator (not portable) a better choice?

Tier 2 Candidates: CognitionDomain Candidate measures Notes

Judgment/ Decision Making

• RoadSmart Judgment Test•Driver risk inventory

We have not seen this measure, but it is referenced, and raises the intriguing prospect of domain-specific reasoning.Is there room for basic reasoning measures here, like Inductive Reasoning?

Episodic Memory • Hopkins Verbal Learning Test• Telephone Interview for Cognitive Status

TICS phone-admin., but picks up memory well; is this really a screen for impairment?

Tier 2 Candidates: CognitionDomain Candidate measures Notes

Working Memory • Digit Span Task•(consider also Delayed Memory)

Again, does this add anything meaningful beyond divided attention tasks? Are better working memory tasks to be used?

Driving Knowledge • Rules of the Road Test• Traffic Signs Test

Cognitive science tells us that in expert domains, the best predictor of performance is domain-specific knowledge; this is also an assumption of state-level licensing programs

Tier 2 Candidates: Cognition

Domain Candidate measures Notes

Spatial ability Block DesignMVPT (horizontal)

Is this too domain-general? Is a specific map-reading task more meaningful?

Visualization of missing information

Visual closure subtest of MVPT

Taps into ability to generate expectancies about impending visual threats?

Complexity/situa-tion awareness (not a domain. . belongs in the flow elsewhere)

DriveABLE

CA/

MD(Grimps+UFOV2) Model

Are these the Tier 1 measures?

Tier 2 Candidates: Sensory

Domain Candidate measures Notes

Proprioception • Foot tap time• Simulator?•Brake reaction time

Face validity with moving foot from gas to break pedal

Cutaneous sensation (pressure on sole of foot)

• Semmes Weinstein?•Pressure and localization sensation test?

Evidence?

Pain • Jette• McGill• VAS

Association with back pain and vehicle crashesDisability specific pain (Arthritis)

Tier 2 Candidates: Sensory – VisionDomain Candidate measures Notes

Oculomotor Control

• Manual assessment SubjectiveTypically an issue in neurologically involved drivers, not older adults

Visual Fields • Perimetry testing with Humphrey or Goldmann;•Confrontational field testing may be sufficient

Identifies blind spots and other visual field disturbances but does not indicate an impact on driving or if driver compensates

Visual Acuity • Wall charts•Automated testing machines

Identifies ability to visually decipher the environmentDetermines if driver meets state vision guidelinesPredictability of crashes?Dynamic visual acuity not measured

Tier 2 Candidates: Sensory – VisionDomain Candidate

measuresNotes

Depth / Stereopsis (For the newly monocular)

• Optec• Keystone•Porto Clinic• Stereo Fly

Stereopsis is a binocular skill; can’t measure monocular driversIn most vision testing machinesConnection to crashes?

Color Recognition • Optec• Keystone• Porto Clinic

Included in most vision testing machinesConnection to crashes?

Contrast Sensitivity • F.A.C.T.• Pelli – Robson Chart• Regan Low Contrast •Letter Acuity Chart• Vision batteries

Linked to driving performance and crashes

Tier 2 Candidates: Sensory – Visual Motor

Domain Candidate measures Notes

Visual Motor • Test of Visual Motor Skills (TVMS-R)

• Bender Visual-MotorGestalt Test

• Rey-Osterrieth Complex Figure Test

Evidence linking assessment performance to driving performance?

Tier 2 Candidates: MotorDomain Candidate measures Notes

Range of motion • Knee flexion• Cervical rotation, flexion, extension, lateral bend (head-neck flexibility)• Trunk rotation• dorsiflexion• Upper extremity

Limited L knee flexion associated with adverse events.Limited evidence of correlation with driving performance for cervical, UE and trunk ROM.Older impaired drivers > risk at T-intersections

Strength (Leg strength especially)

• Grip• Pinch?• Manual muscle testing

Functional grasp association with crash involvement. Which muscle groups?

Tier 2 Candidates: Motor

Domain Candidate measures Notes

Gross Mobility • Rapid Pace Walk• Get up and go test• Number of blocks walked• Foot abnormalities•Fall history

Association with falls and vehicles crashes; Adverse driving events and distance walkedRedundancy with balance and proprioception assessment?

Tier 2 Candidates: SensorimotorDomain Candidate measures Notes

Balance (dizziness)

• Romberg• Berg Balance Scale• Tandem Stand• Side-to-side stand• Single leg stand• Smart Equitest•Sitting balance

Complete Romberg or segments?Association with weighted error score for tandem stand.History of falls associated with vehicle crashesNeurocom Equitest assessment (Quantify/train or cost prohibitive)?

Reaction Time • Foot reaction time (brake) - Doron?

Association with increase vehicle crashes among women

• Behavior, Personality, Beliefs: Driver Risk Assessment (risk taking), impulsivity, empathy, aggression, cautiousness

• Depression

• Mania

Unresolved issue: The Criterion Problem

• By which criteria should we evaluate the predictive salience of our battery?– Accidents?– Simulator? – Field driving tests?– Standardized driving courses?– Subjective driving evaluations?

• Is the more sensible goal the multidimensional assessment of different aspects of driving?

Unresolved issue: Measurement selection

• There is a wide variety of studies• Few multidimensional studies in which measures

evaluated simultaneously• Great variation in dependent variables used across

studies• It seems important to first identify demented

individuals; different prediction equations likely for non-demented elders; more likely to predict subtle driving errors

Unresolved issues: Cognition• Should we do a gross check for dementia, and triage

such individuals out of further assessment? Or do we need tests like Clock Drawing (special Freud scoring), Cognitive-Linguistic Quick Test, Boston Naming, Wechsler Memory Scale, WAIS Picture Completion

• Some commonly used tests seem redundant with what we have shown (Stroop, Minnesota Rate of Manipulation, AARP Reaction Time)

• Interesting dimensions not commonly studied, including Motor-Free Visual Perception Test, Unilateral Neglect

Unresolved issues: Sensory• Is there a better proprioception test for the lower

extremity?• What amount of pressure is needed for

breaking?• Should pain assessment be used and if so,

which pain assessment is the most appropriate?

Unresolved issues: Motor• Should all ROM measurements be functional

rather than exact?• Should upper extremity ROM be tested?• Should MMT be done on lower extremity muscle

groups (such as knee extension) and if so, should it be quantified with hand-held dynamometry?

• If we were to choose one gross mobility test only, which is the best?

Unresolved issues: Sensorimotor• Should a balance (dizziness) test be used?

Unresolved issues• Who is screened? (everyone? just at risk

drivers? just older drivers?)• Who screens? (what kind of training is needed?)• Who pays? (what is the estimated cost, and

what are some possible sources of funding?)• What are the legal implications? (what

supportive policy/legislation is needed?)