Op Med: Expert Perspectives on Drivers' Evaluations and Rights
To help us understand the thorny issues surrounding mature drivers, confidentiality and consent, cognitive testing, driving safety and DMV reporting, we sought insight and perspective from a variety of subject matter experts: neurologists, driving program evaluators and geriatric specialists. Not all of the panelists chose to respond to every question.
Our Panel of Experts:
Daniel Cohen, M.D.
Sentara Neurology Specialists
Chair of Neurology, Eastern Virginia Medical School
Sarah K. Lageman, Ph.D., ABPP-CN
Virginia Commonwealth University
Department of Neurology
Parkinson's & Movement Disorders Center at Neuroscience, Orthopaedic and Wellness Center
Dr. Lageman focuses her research on developing neurocognitive and behavioral interventions to improve cognition, emotional functioning and quality of life in individuals with neurodegenerative disorders.
Hamid R. Okhravi, MD
Professor of Geriatrics
Eastern Virginia Medical School
Director of the Memory Consultation Clinic at Eastern Virginia Medical School and Director of the Driving Simulator Evaluation Clinic
Scott W. Sautter, Ph.D., FACPN
Board Certified Neuropsychologist
Fellow, National Academy of Neuropsychology
Hampton Roads Neuropsychology, Inc. Virginia Beach
When conducting an examination or assessment, do you feel it is necessary to give any type test, cognitive or otherwise, without informing the patient of what the test is and what it is for? Some studies suggest that a family member be present.
D.C. In our clinic, cognitive testing is not done exclusively to consider driving safety but to understand overall neurological health and consider a variety of safety issues such as management of finances, medications, etc. Therefore, I don't mention driving specifically before doing any kind of cognitive testing. We discuss the implications of their performance afterward.
S.L. In a neuropsychological evaluation, I typically explain the purpose and nature of the evaluation in general to the patient and family members if they are present, but I do not explicitly review the purpose of each test. No one likes to be tested, but if possible, I ask that a family member be present. I like to prepare the patient by putting them at ease, and I try to alleviate any stress or anxiety that might impact the results.
S.S. In my profession as a licensed clinical psychologist and board certified neuropsychologist it is not only inappropriate but unethical to conduct an assessment without informing the patient beforehand about the purpose, nature, consequences and the risk and benefits of the examination. When I conduct evaluations regarding cognitive capacity I will invite family members to attend the interview process and mental status examination, as it is important at the end to evaluate whether there is a discrepancy between the patient and the family’s perception of this individual’s capacity to meet daily demands in different functional realms.
The APA ethics code, section 9.03 states that consent should include: a) an explanation of the nature and purpose of the assessment, b) fees, c) involvement of third parties, and d) limits of confidentiality. The patient/client should also be provided with sufficient opportunity to ask questions and receive answers. Although not explicitly required by the revised Ethics Code, there may be good practical and ethical reasons to provide information concerning the referral source; foreseeable risks, discomforts and benefits; and time commitment, as such elements may well be intrinsic to consent that really is adequately informed. Where mandatory reporting requirements exist (Section 4.05), such as those associated with the motor vehicle administration in some states, the limits of confidentiality and involvement of these agencies should be anticipated in neurological populations and discussed with patients as a possible limitation of confidentiality at the outset of an evaluation. The National Academy of Neuropsychology, in line with the revised APA Ethical Principles and Code of Conduct, strongly encourages neuropsychologists to provide informed consent to patients seeking services and views its conveyance as a basic professional and ethical responsibility.
Do you think the three-word recall portion of the mini-cog (sans clock drawing), as an evaluation, should be used as a reason to immediately suspend a senior’s driving license, or would you tend to recommend a full medical evaluation by a geriatric specialist, and/or, have the driver participate in a driving evaluation prior to recommending suspension?
D.C. I am not aware of any strong association between poor word recall alone and driving crash risk. In our clinic, cognitive testing is done to understand overall neurological health and consider a variety of safety issues such as management of finances, medications, etc. Keep in mind that tests of visual fields, neck mobility and motor function/coordination are other aspects of neurological health that need to be considered when assessing driving safety. The two cognitive tests most validated for crash risk include clock drawing and a test of executive function called the Trail Making Test. When the results of these tests raise a red flag, we then recommend a formal driving safety evaluation rather than reporting to the DMV.
S.L. I would not recommend using the three-word recall portion of the mini-cog as a stand-alone evaluation. It was designed as a brief screener of basic cognitive functions. While a full medical evaluation by a geriatric specialist may be helpful in determining driving safety, the accuracy of that evaluation would depend upon the specialist’s training and knowledge of how clinical interview information or tests they administer correlate with driving safety. Having a patient complete a driving safety evaluation would generally be the best way to evaluate their driving safety.
H.O. From my standpoint, a road examination is the gold standard of driving ability. The driving simulator at EVMS is one tool we use to help determine a patient’s executive function. Oddly enough, not all types of what we would call dementia actually impair driving. Also, the clock drawing and trail making test part B or a combination of all these assessment tools are better predictors than a short, three-word recall exam. But don’t expect every primary care physician to know all of these screening tools in an in-depth way; that’s not their area of specialization, and they don’t do this on a daily basis. Also, a general practice setting is much different from a clinical setting where the patient comes to me specifically for memory-related concerns. The mini-cog is not really a good predictor of driving ability—tests that measure special and executive functions are better.
S.S. The mini-cog with and without the clock drawing is insufficient to immediately suspend a senior’s driver’s license, but rather ought to be considered a screening rather than a diagnostic tool. Screening instruments rule in problems, identifying the problem as a red flag or a concern, and diagnostic tests such as neuropsychological assessment rules out problems and provides a differential diagnosis. A comprehensive neuropsychological assessment should be requested following the identification of a red flag or a concern.
If there is an identification of concern for driving capacity based on the outcome of the neuropsychological assessment, a functional driving evaluation should be made, and the best approach to do this would be a driving simulator. This can be followed by behind-the-wheel driving examination should the individual pass the driving simulator. In this manner, a very thorough evidenced-based approach can be made to ensure due process in the evaluation of someone suspected of an incapacity to drive.
Have you ever felt it was necessary to directly notify the DMV to have them immediately suspend a senior’s driving license? If so, did you discuss with patient and family beforehand so they could set up a transportation plan? Feel free to give example.
D.C. When testing performance is grossly abnormal, we counsel patients that we do not think they are safe to drive and indicate we are documenting this in their medical record. If they continue to drive against our advice, particularly if they lack the insight to understand the concerns, we then report. We discuss with the family that access to a vehicle is an important factor since many individuals will attempt to drive despite a revoked license.
S.L. In my clinical practice, I only comment on driving safety if I feel the test results raise concerns. In that case, I note that neuropsychological tests do not directly assess driving safety, but the attention, processing speed, visuospatial or executive deficits observed on testing raise concerns. I then recommend that the patient complete a driving safety evaluation through an occupational therapist or the DMV.
If there are concerns about driving safety, I think it is always best to have a discussion with the patient and their family about those concerns. Many patients are agreeable to driving less or completely stopping after a conversation. I often ask them how they will know they are not safe to drive and then explain that having an accident and potentially hurting themselves or others is what we all want to avoid. In my clinical impression, many patients with more mild problems are safe to drive locally, and I encourage them to avoid nighttime, highway and high-traffic volume times. They may then gradually drive less and less and eventually stop. In other situations, the cognitive deficits are much more concerning, and so I encourage them to get a driving evaluation if they do not want to stop driving on their own.
H.O. Most of the time, family members are a part of the discussion about whether the patient should continue to drive. It is a very personal situation, and each situation is different. However, if after a complete assessment, the patient clearly proves to be too impaired to drive or requires a restricted license, we talk with the family. If we don’t get a sense that the driver will agree to stop on their own or will agree to a limited license, it may be necessary to alert the DMV. After that point, it is up to the DMV to make certain that their own protocols/steps are being followed. It’s a difficult thing, but we must consider the patient’s safety and the safety of other drivers.
S.S. Yes, I have directly notified the DMV by a letter faxed to them immediately following an examination that clearly demonstrated the individual did not have the cognitive capacity to drive as well as notifying the family and patient. Here is an example of an individual who had a suspected incapacity to drive and was referred for a comprehensive neuropsychological assessment. This gentleman had gone to the airport to pick up his wife traveling back from a trip. Reportedly he arrived on the wrong day and then could not find his car parked at the airport and had to call a cab to come home. The following day his wife called and said that she is at the airport and needs to be picked up, so he drove the family’s second car to the airport to meet his wife but then could not figure out where his car was parked and had to enlist the police to help find both cars. When he completed his assessment in our office it was clear that this gentleman had senile dementia of the Alzheimer’s type, and secondary to a dense amnestic profile, impaired judgment, with limited awareness of the extent of his cognitive difficulties. In this case it was very clear he should not be driving.
Do you feel that sharing the outcome of a dementia screening tool directly to the DMV suggesting a driving license suspension without the patient’s knowledge to be a violation of a patient’s privacy rights? Why, or why not?
S.L. Though I have some concerns about anonymous reporting of drivers to the DMV, I am hesitant to say we should eliminate the practice altogether. In my experience, there have been times where the family dynamic wasn’t optimal, and communication between family members was poor. As much as I endeavor to take a comprehensive approach and bring appropriate family members into the discussion, on occasion, I can see where a medical practitioner might feel compelled to report a driver if their safety or the safety of others is clearly at stake. However, it’s important to note that a short assessment by a GP doesn’t really tell the entire story.
S.S. It is inappropriate to use a dementia screening tool for the diagnostic purpose of identifying cognitive incapacity for the purpose of suspending an individual’s driving license, but rather the intention is simply to identify there is a concern and have it more formally evaluated. I would suggest that the physician in that circumstance who believes that the individual is in fact incapacitated work with the family and the patient to have a more formal evaluation to include neuropsychological assessment prior to returning to driving to ensure safety, health and wellbeing of the individual, family members and others in the community.