April, 2008

By Kent Milton and Patti Y. Horsley 

SACRAMENTO--The toughest decision faced by an older Californian may be surrendering the car keys. Some seniors say that the loss of driving privileges can be virtually as devastating as the death of a spouse. Any remedy that offers the possibility of extending the safe driving years promises to be a valuable (and highly valued) service.

One emerging answer is third-party assessment—thorough, objective and reliable. When coupled with the opportunity for rehabilitation, assessment also seems far less threatening. One such agent of change is the occupational therapist (OT), whose examination process includes clinical evaluation, recipes for rehabilitation if required, and a training cycle to improve deficient driving skills. Twenty-nine California OT programs offer this service, and 17 of these provide the added capability of in-vehicle evaluations resulting in the appropriate adaptive and/or rehabilitative actions that may keep the individual driving safely.

Typical of these programs is unit managed by Duane Cintron, an OT and a certified driving rehabilitation specialist, who operates in the broader Sacramento community. Cintron says that driving problems often start with vision changes, echoing the nation’s motor vehicle departments, which observe that vision problems are the most common functional stumbling block to renewing the driver’s license.

Cintron notes that 20-20 eyesight is a measure of visual acuity, but not of the ability to process what is seen. “Useful vision is a learned skill,” he says, meaning that people acquire the interpretative capability with practice during their early years. For example, when a ball suddenly appears in the street, a child may be close behind. Sometimes older people lose the capacity to make rapid situational judgments because of eye ailments or a stroke, which may diminish cognition and perception. The therapist’s role is to recapture these abilities so life--and driving--can resume. If the identified vision problem (e.g.. cataracts) can be solved medically, that often resolves any driving issues. Other eye ailments may require analysis and retraining by a vision specialist (Cintron works closely with one).

Comprehending what one sees is so important to driving that Cintron checks a range of visual skills including useful field of view (what the eyes see and how the individual puts that information to use), motor-free visual perception (a recognition test measured with symbols on flip cards), and coulometer (eye muscle) skills critical for smooth yet rapid environmental scans. He also looks at depth perception and contrast sensitivity—the ability to pick out objects blending into a gray or dark background.

After this exhaustive study of vision, Cintron runs through a battery of clinical tests used to measure functional losses, which in turn have an impact on driving ability. First he checks strength, balance, range of motion and sensory loss--inability to feel the feet, legs or arms. Then follows cognitive evaluation, determined by thought-process tests such as spelling a word backward, following written or verbal directions, or counting backward by sevens. The ability to sustain attention is measured by asking subjects to complete the tedious task of eliminating a given letter of the alphabet from a printed paragraph in a distracting environment.

Clinical evaluation may define (or preclude) the need for a drive test, which begins with a closed course sequence set up on a parking lot, followed by street driving-’--residential, business, rural roads and freeways. Cintron works with all ages, and he estimates that 90 percent of his clientele continue to drive, including those who work their way back to safe status through rehabilitation. Currently about one patient in five is a senior.

He, like other occupational therapists who evaluate drivers, hopes to expand that ratio as more people become aware of the possibilities. His comment to seniors: “Don’t be afraid of assessment, it can help you remain on the road. And isn’t that what you want?” He also notes that OTs can be a valuable resource for doctors seeking the best answers for their patients. Families often rely on his counsel as well when making decisions about the driving future of a senior.

About 80 percent of Ciniron’s patients seek help after a traumatic event such as stroke, heart attack or a crash. His older patients usually come through referrals from family or doctors. Cintron believes more seniors would self-refer if they understood the benefits. Many forms of trauma can be dealt with, although rehabilitation may be stretched over a considerable period, lie describes a syndrome known as visual-spatial neglect, where the brain no longer recognizes a part of the body, a limb or even an entire side of the environment. Asked to draw a clock face, a person with this problem will squeeze all 12 numbers onto one side of the clock. Driving is impossible for this person, and rehabilitation represents a challenge to both patient and therapist because so much time and patience are required.

As the senior population soars (today there are approximately four million Californians over 65. by 2030 the number will be nine million), California’s 29 occupational therapists equipped to conduct driving-fitness evaluations appears to be too few. Elin Schold Davis., older driver project coordinator for the American Occupational Therapy Association, agrees.

“One of our national objectives has been the development of educational resources for therapists. building awareness and encouraging expansion of occupational therapy driving rehabilitation programs. Awareness and demand drive program development and expansion. We are preparing resources to respond as the medical community and seniors gain knowledge that occupational therapy assessments and rehabilitation can be a path to added driving years,” she said.

In California, the Center for Injury Prevention, Policy and Practice and the State and Local Injury Control Section of the California Department of Public Health have joined to train more O’[s. even those classified as “generalists” who have not previously focused on driving. The training effort, funded by a California Office of Traffic Safety grant, will guide OT generalists to ask patients “do you drive?’ And if not, “is regaining the ability to drive one goal of your rehabilitation”

To reinforce their interaction with patients, generalists will be trained in the basic skills of assessing how functional problems arising from health issues affect driving. They also will be provided information on how to secure advanced training in driver evaluation and rehabilitation.

California Highway Patrol Commissioner Joe Farrow, who chairs the Older Californian Traffic Safety (OCTS) Task Force, says expanding OT availability “coincides with our task force objective to emphasize the positive impact of professional assessment. We need more evaluators, and we need to make it clear that professional. third-party assessment can be a powerful tool in helping seniors recognize their limitations and—more importantly—provide a method to deal with these impediments to safe driving.”

 
(Information about OT driver evaluation and rehabilitation  programs can he found at http://www.eldersafety.org/resources/occupational_therapist_locator.html or http://www1.aota.org/driver_search/index.aspx .)

About the authors: Kent Milton is a retired annuitant with the California Highway Patrol and is Chairman of the Public Information Section of the Older Californian Traffic Safety Task Force.  Patti Y. Horsley holds and MPG and is with the Center for Injury Prevention Policy and Practice at San Diego State University.  She presently serves as a consultant to the EPIC Branch, California Department of Public Health.