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SafeDrivingforIndividualswithLowVisionandBrainInjuryJ A SONVICE , M. S. , OTR/ L

UA BCENTERF ORLOWVI SIONREHABI LI TAT ION

ObjectivesDefinetheclinicaltermlowvision.

Identifycommondiagnosesthatlimitdrivingperformanceforindividualswithlowvision.Describehowdrivingperformanceisimpactedbyvisualdeficits.

Describetheroleofthegeneralpractitionerinsafereturntodriving.

Describetheroleofthelowvisionspecialistinsafereturntodriving.

Understandtheuseofbioptictelescopesfordriving.

RoadwayStatisticsOver102,000milesofpublicroads inAlabama

ØRanked18th innation• 75%Ruralroads

• 26%Urbanroads

67,000milesdriven,~2%busmileage

2015U.S.Department ofTransportation

RoadwayStatisticsAverage#orcarsperhousehold:Alabama

Orange:Alabama Gray:U.S.Average

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RoadwayStatisticsAverageCommuteTime:23.8minutes

RoadwayStatistics

85.5%DroveAlone8.98%Carpooled3.17%WorkatHome

RoadwaySummaryØOnaverage, Alabamians haveanapproximate 25-minutecommute towork/school.

ØNearly 90%ofAlabamians drivealone

ØMajorityofAlabamians donothave reliableaccesstopublictransportation.

CrashRatebyAge

AAAFoundation.org

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TotalMilesTravelled

0

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12000

14000

16000

18000

16-19 20-34 35-54 55-64 65-69 70-79 80-84 85+

Miles ofTravel

Miles Driven

AgingandDrivingØWhile thesenumbersdonotaccountforindividualvariables (suchasdisabilities),wedoseea trendindrivingperformance andage.ØDrivers18andbelowmostlikelytobeinvolvedinacrash.

ØRiskbeginstoincreaseagainafterage70

ØSome, butnotallolderdriversexperiencechanges thateffecttheir ability todrive.

RiskFactorsforOlderAdultsØVision-related changes• Cataract,AMD,Glaucoma

ØCognitivechanges• Depression,dementia

ØPhysicalcondition• Increasedincidenceofdiabetes,stroke,heartdisease,arthritis,

ØMedications• Antidepressants,bloodpressure,benzodiazepines

VisionandDrivingEstimated that90%ofinputadriver receives isvisual1

ØVisual inputisusedtoguidecognitiveandmotorresponsesØSafedrivingdependsonaperson’sability tosensetheenvironment, analyzeand respondtosensorystimuli inatimely manner.

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VisionandDrivingVisiontesting isrequired toobtain,andinmanycases,renew adriver’s license.

ØAll stateshavevisualacuityrequirements fordriving

ØVisionrequirements differ foreachstate.

StateRequirementsVision•Visualacuity– Bestcorrectedacuityofatleast20/60

•Visualfield- 110degrees(horizontal)

Physical•Seizures•Neurologicalconditions

VisionTermsVisualAcuity– clarity orsharpnessofvisionØEnablesustoseethingsclearlywhendriving

• See andreaddirectionalsignage

• Seeandrespondtotrafficandbrakelights• Readmetersondash

• Clearlyseeobjectsontheroad

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VisionTermsVisualField– whatyouseeoftheworldwhenlooking inafixeddirectionØEnablesustobeawareofobjectsbothcentrallyandperipherallywhendriving

•Seeandrespondtomergingcars

•Locateandmakelanechanges•Awarenessofpedestrianscrossing

VisionTermsContrastSensitivity – ability todistinguishlowcontrastitemsØEnablesustorecognizeobjectsfromtheirbackground

•Enhances abilitytodriveinlowlightsituations

•Recognizesidewalksandcurbsfromstreet

•Identifyobjects/potholes instreet

VisionandCrashResearchVisualAcuity - early research focusedonacuityandcrash risk.ØCorrelationsfoundbetweendecreasedacuityandcompromised binocular vision(1976,1994)

ØDatasincehasbeenveryambiguouswithweakassociations.

ØMildacuitylossdoesnotappeartoelevatecrashrisk.

VisionandCrashResearchVisual Field – research from the mid-2000’sand onissomewhat ambiguous

ØLikelyduetodifferentmethodologies

ØStrongestevidencefromSalisburyEyeEvaluationStudy

• Fieldlosspredictiveofcrashinvolvement,particularlylossintheinferiorperipheralfield

Rubinetal. ,2007

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VisionandCrashResearchContrastSensitivity – appears tobeabetterpredictorofdrivingperformance thanacuity.ØMostcommon cause– senilecataract

•2.5xmorelikelytohaveacrashhistory(Owsley,2007)•CorrectablewithsurgeryØCanalsobeassociatedwitheyepathology(e.g.Age-relatedmaculardegeneration)

SimulatedCataract

SafetyConclusionsØStatedriving requirements donotalwaysaccurately assessaperson’sability todrivesafely.

ØSome individualsmaybedenied theprivilege ofdriving,when theymightpossiblydrivesafely.

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LowVisionLowvisionisavisionlosssosevere,thatitcannotbefullycorrectedbyglassesorsurgery.ØVisualacuityis20/70orpoorerinthebetterseeing eye

•Means aperson with 20/70 vision who is20 feet fromeyechartcannotseewhataperson with unimpaired (20/20)vision cansee from70 feetaway

LowVision- FunctionallyLowvisionisuncorrectablevision lossthatinterferes witheveryday activities.

“Notenoughvisiontodowhatyouneed todo”• Varies fromperson toperson

LowVisionvs.LegalBlindness”LegalBlindness”– definitionestablishedbythegovernment asacutofftodetermine disabilitybenefits.

ØArbitrarynumber(20/200orlessinbetterseeingeyeoravisualfieldof20degreesorless)

CommonConditionsCausingLowVisioninOlderAdults

•Age-related macular degeneration (AMD)•Glaucoma•Diabetic Retinopathy•Stroke

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AMDProblemwith the retina

•Macula isdamaged

•Losecentral vision,butperipheral visionremainsintact

•2types:

Dryandwet (DAMD,WAMD)

GlaucomaProblemwith theopticnerve•Usuallywhen fluidbuildsupinfrontoftheeye. Putspressureonopticnerve.•Loseperipheral vision,butcanprogress tocentral

•“Silent thief”oftengoesunnoticed

DiabeticRetinopathyProblemwithbloodvesselsofretina, associatedwithdiabetes•Highbloodsugarcausesdamage tobloodvessels,causingthem toleak, closeorgrowabnormally.•Canstealvisioncompletely

StrokeProblemwithvisualpathways inthebrain

•Symptomsdependonwhichpartofthebrainwasaffected.• Doublevision• Lightsensitivity• Hemianopsia

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HomonymousHemianopsiaVisual information fromthe leftandright fieldsareprocessedbytheoppositesideofthevisual cortex.

•Left sidestroke= rightvisual fieldloss

•Right sidestroke=leftvisual fieldloss

HomonymousHemianopsia

RightHomonymousHemianopsia

CommonConditionsCausingLowVisioninYoungAdults

•Albinism•PediatricGlaucoma

•Nystagmus

•Retinal/Optic Nerve Abnormalities

AlbinismProblemcausedbylackofpigment melanin

•Resultsinlight sensitivity

•Underdeveloped fovea (20/40– 20/200VA)

•Usually stabilizesinmid-teens

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Retinal/OpticNerveConeDystrophy- Degradationofconecells ineye• Resultsindifficultyseeingthingsthatarestill• Detailsindaylight• Objectsincolor

Rod-ConeDystrophy– Degradationofrodandconecells• Graduallossofnightvision• Loss ofperipheralvision

OccupationalTherapyDriving isaninstrumental activityofdaily living(IADL)ØOTPracticeFramework: DomainandProcess3rd

ØDrivingandcommunitymobility:“Planningandmovingaroundinthecommunityandusingpublicorprivatetransportation,suchasdriving,walking,bicycling,oraccessingandridinginbuses,taxicabs,orothertransportationsystems.”

OTRolesØGeneralist Role

ØDriver’s Rehabilitation SpecialistRole

ØLowVisionSpecialistRole

OTGeneralistØAllOTsshouldaddressdrivingandcommunity mobility

ØOT-DRIVE (E.Davis)• Evaluatesub-skillsanddevelopinterventionplan

Ø“…alloccupational therapypractitionerswhoareaddressingthesafety riskofreturninghomeshouldincludedrivingandcommunitymobility.”

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OTGeneralistØRefer toother team members asnecessaryØHaveknowledge ofanddevelop relationshipswithdriver rehabilitation specialists inthecommunityØKnowwhen torefer foracomprehensiveassessment

ØCounselondrivingcessationandtrainonalternative transportation

OTGeneralistEvaluationofSub-SkillsShouldbecompleted aspartofoccupationalperformanceassessment• Drivinghistory• Accidentsornearmisses• Whatkindofcardotheydrive• Useofalternativetransportation• Self-restriction• Wheredoyoudrive?

OTGeneralistEvaluationofSub-SkillsAdditionalassessmentshouldbecompleted dependingondiagnosisorcomplaints•Vision-related dxordecrease infunctionalperformance thatcouldbevisionrelated LeaNumbersLowContrastTest

OTGeneralistIntervention Planning•Client-centered goals that address drivingsub-skills

•Consider alternative transportation•Consider referral tolow vision specialist, ifappropriate•Consider driving cessation

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DrivingCessation•Typicallya lastresort•Knowstate rules regarding reporting• Alabamamayactiftheyperceivethepersonisunsafe(denyinglicenseorrestricting)• Alicenseddoctorrequestthedriverberetestedorhavelicenserevoked.

•Beready toassistinfindingalternativetransportation.The inability todrivecanlimitoccupationalperformance.

DriverRehabilitationSpecialistHasspecialized trainingbeyondOTschool,includingcertification (CDRS).ØDetermineifapersonisatriskorcancontinuetodrivesafely

ØCompletesacomprehensive drivingevaluation• Step1:Verifypersonmeetsstaterequirements• Step2:Clinicalevaluation• Step3:On-roadevaluation

DriverRehabilitationSpecialistClinicEvaluation•Priortoon-roadevaluation

•Gathermedical/socialhistory•Determinelevelofpre-requisiteskills•Determineneedforadaptiveequipment

•Lookforredflags• Sensory/cognitive function

•Gatherinformationfromfamily

DriverRehabilitationSpecialistOn-RoadEvaluation•Completedininstructor’svehicle

•Essentialtodeterminefunctionalimpactof visiondeficitsandabilitytouseadaptiveequipmentoradaptivestrategies

•Applicationofcognitivestrategiesbehindthewheel:• Decisionmaking• Routeplanning• Judgment

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LowVisionSpecialistOccupationalTherapist workswithclientbyreferral(typicallyophthalmologistoroptometrist) todevelopaplanofcare thataddressesclientgoals.

ØOftenassessmentofperformance skillsfordriving

ØTraining intheuseofadaptive equipment

Mayormaynothavespecialty certification (SCLV)

LowVisionSpecialistClinicalevaluation typically includes:•Medical/social history•Motorskills• Cognitive function• Sensory function• Acuity,fields,contrast,color(ifnotprovidedbyreferringphysician)

• Functionalmobility status

LowVisionSpecialistDynavision•Simulates visualfield

•Allowsobjects tobedisplayedinperiphery toassessreactiontime.

•Canincludedistractorstosimulatedividedattentiontasks.

•Usedtoteach visualscanning

LowVisionSpecialistUsefulFieldofView (UFOV)•Computer-basedassessmentofprocessingspeedandattention

•Considerable research tosupportscoresbelowanidentified threshold increasescrashrisk.

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LowVisionSpecialistTrails MakingTestA&B

•Neuropsychological testofvisualattentionandtaskswitching.

•Providesinfoonvisual searchspeed, scanning,andexecutivefunction

LowVisionSpecialistSaintLouisUniversityMentalStatus(SLUMS)•Brieforal/written screening tool•Fordetecting mildcognitiveimpairment anddementia

•Memory-lossoftenfirstpresentswithdecreased way-finding.

LowVisionSpecialist LowVisionSpecialistBiopticsØSystemtoview objectsatadistance

ØCarrier lensand telescope

ØConsiderations• focusing•monocularvsbinocular• fieldofview•mountinglocation

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1. Interstatesignagetonormalviewer

2. ViewthroughGalileanbioptic(simulated)

3. ViewthroughKeplerianbioptic(simulated)

Bioptics StepsforBiopticDriving1. Individualisdeterminedbyanophthalmologistor

optometrist tomeet visionrequirements ofstate• Alabama this mustbeat least20/60 orbetterusing bioptic• 110degree field ofview

2. Individualisfittedforpreferred/appropriate device• Precise eyemeasurements takenbyoptometrist

3. Device isorderedandadjustedforproper fitwhen dispensed

4. Trainingbyanoccupationaltherapist toensure accuratetechniquesandspeed forspottingwithdevice

5. Around30hoursofon-roadtrainingwithCDRSbeforetakingdrivingexam

LowVisionSpecialistØProvidessoundclinical judgement onphysical,sensoryandcognitiveappropriateness forreturn todriving.

ØALWAYS refer toadriving rehabspecialist toassesstheclient functionallybehind thewheel!

WhentoRefer•Clienthasaknowndiagnosis thatcouldimpactdriving•Client ishaving repeated accidentswhile drivingorperforming functionalmobility•Counselclientnottodriveuntil referred forevaluation (visiondoctor)

•Pre-driver screen, suchasOT-DRIVE orOT-DORA

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HowtoRefer•Bestpractice istoreferdirectly to lowvisiondoctor(ophthalmologist/optometrist)

•Canaskphysiciantoreferdirectly tolowvisionOTwithcertaindefinitive diagnoses• Example- homonymous hemianopsia

•Clientcannotbe receiving other formsofOTconcurrently foroutpatient services

LocationsUABCenterforLowVision

Rehabilitation

•Birmingham,AL

•LowvisionoptometristandOT

•DawnDeCarlo,OD–ClinicDirector

•(205)488-0736

•(205)488-0746(fax)

CommunityServicesforVisionRehabilitation

•Mobile,AL

•MD,optometrist,OT

•JoeFontenot,MD–MedicalDirector

•(251)476-4744

•(251)476-4741

Questions