assessment group: discussion and unresolved issues
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Assessment Group: Discussion and Unresolved Issues. An assessment flow. Why?: Identify drivers with functional changes that may compromise personal or public health or safety. Why?: Identify individuals who may benefit from prevention, education, remediation. - PowerPoint PPT PresentationTRANSCRIPT
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?)