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I.C. DEVELOP TOOLS NEEDED TO IMPLEMENT MODEL PROGRAMS
I.C.2. Test Procedures
(a) First-Tier Functional Screening
(b) Second-Tier Functional Screening
(c) Design and Methodology For On-Road Evaluations of Driving Competence
IC2(a)i. Gross Impairments Screening (GRIMPS)
Battery of General Physical and Mental Abilities
Objective: To screen for gross impairments (GRIMPS) in
physical and perceptual-cognitive functions important for safe driving, using
a brief (~ 15 min) procedure that can be administered by DMV line personnel, or
by other professionals or volunteers in diverse community settings, with limited
training (less than 1 day), modest test materials costs, and without specialized
test equipment. Outcomes of GRIMPS include self-awareness and awareness by friends
and family of serious functional deficits that may, in turn, lead to diagnostic
testing, remediation activities, mobility counseling, and/or limitations to driving.
The rationale and justification for selection of tests presently included in GRIMPS
is provided in section IA2 describing driving and functional assessment outcomes.
Alternative procedures and/or upgraded protocols may be defined through pilot
studies which evaluate current tests (Maryland Pilot Study).
Equipment and Materials: Furniture (desk or table,
and two chairs, including at least one straight-backed chair); 10-ft long tape
measure (for rapid-pace walk); colored duct tape (to mark 10-foot path if space
is dedicated for GRIMPS); stop watch (for timed tests); cardboard clock face
with high contrast between the numerals, the clock hands, and their background
(to be used in head/neck flexibility test); lap seat belts (for use in head/neck
flexibility test); laminated 55-inch by 8.5-inch chart to be hand-held or wall-mounted
(for measuring abnormalities in visual scanning patterns); pencil; and data
forms (for Trail-Making tests, Motor-Free Visual Perception test, and data recording
forms). If GRIMPS is performed in a public space, including office environments,
senior centers, etc., movable partitions should be used to provide a private
testing area, approximately 11-ft long x 8-in wide. A "GRIMPS Kit" including
all materials except furniture and partitions has been developed, and is available
for distribution to test administrators. The "Kit" comes in a 3-ring binder;
the binder itself serves as test equipment for the alternating foot-tap measure.
The cost of all materials included in the "GRIMPS Kit" is $40.00.
Data Recording and Test Scoring: Driver's performance
on GRIMPS is typically recorded on the prepared data form (1 page) at the time
of testing, retained as a (single page) hard copy record, and transferred to
an electronic file after the protocol is completed. An example data form is
presented on the following page. Alternately, performance data can be entered
on a PC at the time of testing. When GRIMPS is administered in an agency setting
as per a given jurisdiction's policy, absolute and/or normalized measures
of performance may be provided to drivers with an explanation of resulting licensing
or referral action (if any). Similarly, performance norms with (preliminary)
cutoff scores will support recommendations for follow up actions (e.g., referral)
by GRIMPS administrators in an Area Agency on Aging, health care facility, social
service facility, or other private or community setting. Norms developed through
field tests will be provided to States/Provinces and other interested parties,
and will be updated on a regular basis as more data become available.
Test Procedures: A private testing environment must
be established, by using a separate office or partitioning a suitable space
in a larger room. An enclosed area approximately 11' long by 8' wide is recommended.
An opening should be provided at one end of the testing area (door optional)
and a table and two chairs should be situated near the opposite end of the testing
area. (Note: It is anticipated that space requirements for GRIMPS tests can
be met in a driver's own home).
The test protocol begins when the examiner greets the driver and positions
him/her just outside the opening to the testing area to deliver instructions.
[ Maryland GRIMPS score sheet
]
Rapid-Pace Walk
This is the first test, which is a measure of lower limb mobility. The measuring
tape is laid on the floor, pulled out to its full 10-ft length, and locked open
at this length. The subject walks next to the measuring tape, turns at the end,
and walks back to the start position. The total walking distance is 20 ft. Alternatively,
the adhesive tape can be pre-applied on the floor to mark the 10-foot path,
in settings where dedicated space is allocated for conducting GRIMPS. The examiner
will say, "I want you to walk along side of this tape measure (tape line)
to the end, turn around, and walk back here as quickly as you can."
(Demonstrate) "If you use a cane or walker, you may use it if you feel more
comfortable. I am going to time you. Go as fast as you feel safe and comfortable."
"Ready, begin."
Start timing when the subject picks up his or her first foot. Stop timing when
the last foot crosses the finish line. Record the total time to traverse the
10-ft path up and back with the stop watch.
Norms: Marottoli, Cooney, Wagner, Doucette, and Tinetti (1994)
| Statistic |
Entire cohort of persons age 72+ living
in the New Haven Community |
Subset of active drivers |
| n |
1007 |
348 |
| mean (in seconds) |
9.635 |
7.97 |
| standard deviation |
5.11 |
3.43 |
Guralnik, Simonick, Ferrucci, et al. (1994):
mean for all subjects age 71+ (n=5097): 5.0 seconds
mean for all men age 71+ (n=1785): 4.4 seconds
mean for all women age 71+ (n=3312): 5.3 seconds
Subjects who took longer than 7 seconds to complete the rapid-pace walk were
twice as likely to experience adverse traffic events (traffic crash, violation,
stopped by police) in the year following testing as subjects who completed the
walk in 7 seconds or less [relative risk, 2.0, CI 1.0-3.8]) (Marottoli et al.,
1994). The Guralnik study found that those taking longer to complete a battery
of three lower extremity tests (rapid-pace walk, chair stands, and standing
balance) were 4.2 to 4.9 times as likely to have disability at four years than
those with the best scores; tests were also predictive of nursing home admissions
and mortality rates.
Cued Recall (Mini Mental Status Examination [MMSE] Test Item #3)
This is a test of immediate memory. Direct the driver to sit in the straight-backed
chair at the table. When driver is seated, the examiner sits across the table
and delivers the instruction, "I'm going to say three, short words now as
a memory test. Please repeat them back to me in the same order." The examiner
verbally announces three short, common but unrelated words, which serve as a
memory set (BED, APPLE, SHOE), then again asks the driver to repeat them back.
The examiner records the number of memory set elements accurately repeated.
If the driver cannot repeat all three elements in the set, the examiner should
announce it again, up to a maximum of six times. The examiner also records the
number of times the memory set was announced. After this is
completed, The examiner delivers the instruction, "I will ask you again
later to remember these same three words and say them to me."
Alternating Foot-Tap Test
This is an alternative measure of lower limb mobility, as required of a driver
to move his or her right foot from the gas pedal to the brake pedal. The driver
sits in a chair for this test. The test administrator opens the 3-ring binder
and places it on the floor with the 3 rings oriented crosswise in front of the
participant, and located at a distance of 16 to 24 inches from the front edge
of the chair. This should provide a separation between foot tap locations of
approximately 12 inches. Following instructions, the driver will touch his or
her right foot to the floor 5 times alternately on each side of the opened
binder, moving from one side to the other on every tap. The total number
of taps will be 10. The driver must make sure to lift the foot sufficiently
high to clear the rings of the binder.
Instruct the driver, "Please place your right foot on the floor, next to
the right side of this binder. Now move your left foot back out of
the way, and move your right foot back and forth over the binder rings, alternately
tapping each side of the floor next to the binder. Move your foot back and forth
across the binder rings for a total of 10 taps, beginning when I tell you. I
will time how quickly you can do this. [Test administrator demonstrates
foot tap motion]. Ready? Go."
The examiner records the time to complete the foot tapping task with a stop
watch.
Norms (right foot-tap time): Marottoli, Cooney, Wagner, Doucette,
and Tinetti (1994):
| Statistic |
Entire Cohort
Age 72+ |
Drivers Only
Age 72+ |
| Right Foot Tap |
Right Foot Tap |
| n |
1055 |
352 |
| mean |
5.61 s |
4.80 s |
| sd |
2.48 |
1.56 |
Motor Free Visual Perception Test (MVPT) - Visual Closure Subtest
The MVPT is an individually administered, multiple-choice test of visual perception.
The only response required from the subject is that he or she point
to whichever one of four alternatives is correct. The subject is not allowed
to trace any figures. The examiner should encourage the subject to look at all
four alternatives before making a final decision. The MVPT is not a timed test,
and the subject should be given a reasonable amount of time (15 seconds) to
make a selection. The examiner scores the subject's response by marking the
appropriate space on the accompanying scoring sheet. The visual closure subtest
measures the ability to identify incomplete figures when only fragments are
presented (see example on following page). This subtest should take no more
than 3 minutes to administer.
Instructions for practice items for visual closure subtest: Point to the four
alternative figures, saying, "If we finished drawing these figures, which
one would look just like this one?" Now point to the stimulus figure. After
the subject responds, point to the correct alternative saying, "Yes (No),
if we connected these lines, this one would look just like this." Point
to the stimulus figure.
Instructions for items 22-32: Point to the four alternative figures, saying,
"If we finished drawing these figures, which one would look just like this
one?" Now point to the stimulus figure. No confirmation or explanation
is given.
For GRIMPS application, the examiner records number of incorrect responses.
The cut-point for passing vs failing will be established after pilot study data
(from the Maryland MVA) are analyzed.
Arm Reach
This is a test of upper limb mobility. The driver does this test while sitting
in the chair.
Examiner asks the driver,"Please raise your right arm as high as you can
over your head. You may put your arm down... Now please raise your left arm
as high as you can over your head."
The examiner records whether or not driver could lift each arm above shoulder
height. Drivers who can not reach above the height of their shoulders will "fail"
this test.
Head/Neck and Upper Torso Rotation
The driver does this test while seated in the chair. It is a measure of the
ability of a driver to turn and look over his/her shoulder to see to the sides
and rear of the vehicle when changing lanes or merging. The examiner should
ask the driver to buckle the seat belt that has been attached to the chair,
and to tighten it. The examiner should prompt the driver to check again to make
sure the belt is as tight as it can be without discomfort. This part of the
procedure is to ensure that the driver remains positioned in the chair, with
his or her lower back pressed against the seat back, in the same posture that
he or she would assume when sitting in the driver's seat of a car. The examiner
stands 10 feet behind the driver at a pre-marked location,
and sets the clock hands to either 3:00 or 9:00 while the examinee is facing
the opposite direction.
The examiner delivers the instruction, "Just as you would turn your head
and upper body to look behind you to back your car or change lanes, please turn
and read the time on the clock face that I am holding behind you."
The examiner records whether the driver can read the requested information.
If the examinee can not turn far enough in one direction to read the clock,
he or she should be asked to try turning the other way. The test is scored as
pass (the driver can turn his or her head to read the clock) or fail
(the driver does not have enough flexibility/mobility to perform this motion).
[ Motor-Free Visual Perception Test:
Visual Closure Subtest (Example Item (The answer is A)) ]
Scanning Task
The scanning test is presented on a 55-in by 8.5-in laminated sheet that displays
10 common symbols. The symbols are arranged in 2 rows of 5 columns, as shown
below.
The driver is seated 3 to 5 feet from the stimulus sheet, only after the following
instructions have been delivered. The examiner states, "without moving your
head, scan the poster and report to me the symbols you see. If you do not know
what a particular symbol is called, describe what it looks like." The examiner
notes the order in which the driver reports the symbols.
A normal scan pattern of a cognitively-intact individual may be any of three:
(1) rectilinear (left to right/top to bottom); (2) clockwise; or (3) counterclockwise.
Subjects with impaired visual scanning capabilities demonstrate disorganized,
random, and/or abbreviated or truncated strategies (frequently missing items
on one side of the board). Those with hemi-neglect often show an asymmetrical
pattern, initiating visual search from the right side rather than the left and
confining all search efforts to the right side. Also, whereas subjects with
normal visual attention never overlook or repeat a stimulus on the test, those
with inattention may commit both of these errors. Scan patterns for GRIMPS will
be scored as one of three categories:
1. Normal: Clockwise, counter-clockwise, by rows, by columns.
2. Erratic: All symbols identified, but in haphazard order.
3. Neglect: Two or more shapes not identified at all.
Trail-Making Test: Part A (abbreviated) and Part B
This is a paper-and-pencil test of general cognitive function. Specific functional
capabilities targeted by this assessment tool include: visual search and sequencing
(Part A); and information speed and attention switching (Part B). Both parts
require effective psychomotor coordination. Part A involves connecting, in order,
25 encircled numbers randomly arranged on a page. (For this application, an
abbreviated Trails A test is used, containing only 8 numbers, to reduce the
amount of time allotted for GRIMPS). Part B includes both numbers (1-13) and
letters (A-L), and requires connecting the two in alternating order (1 to A,
to 2, to B, etc.). The score on either test is the overall time (seconds) to
complete the connections. The last item completed at each 30-second interval
is also recorded by the examiner. Mistakes are pointed out by the test administrator
and are corrected as they occur; their effect is to increase the overall time
required.
The instruction delivered by the examiner is, "Now I will give you paper
and pencil. On the paper are the numbers 1 through 8, scattered across the page.
Starting with 1, draw lines to connect each number to the next higher number.
I will time how fast you can do this. Ready? Go." The examiner records
time-to-complete.
The examiner then states, "On this sheet of paper the numbers 1 through
13 and the letters A through L are mixed up in the same way. This time, start
with 1, then draw a line to A, then draw a line to 2, then to B, then 3-C, 4-D,
and so on, alternating back and forth between numbers and letters until you
finish with the number 13. Again, I will time how fast you can do this. Ready?
Go." The examiner records the last item completed at each 30-second interval,
plus total time-to-complete. The Trails B test sheet is shown on the following
page.
Norms for Trails B
Stutts, Stewart, and Martell (1998): The means by age group for time to completion
(in seconds) for Trails B from the study were 78.8, 85.8, 93.7, and 106 seconds,
for age groups 65-69, 70-74, 75-79, and 80+ respectively. Stutts et al. (1998)
state that average completion times for the two Trail-Making Tests were below
(i.e., better than) published age norms of Heaton et al., 1991 and Davies, 1968,
and suggest a relatively healthy and/or well educated sample.
Richardson and Marottoli (1996): Age and education-specific normative data
were provided for 101 independently living active drivers, free from neurologic
and psychiatric disease. Mean time to complete (and standard deviations) were
as follows:
age 76-80/education<12 years (n=26) = 197.17 seconds (71.03);
age 76-80/education>12 years (n=24) = 119.17 seconds (33.47);
age 81-91/education<12 years (n=18) = 195.47 seconds (69.70);
age 81-91/education > 12 (n=33) = 137 seconds (55.93).
Also in this paper were means and standard deviations interpolated from conversion
tables provided by Heaton, Grant, and Matthews (1991):
age 75-80/6-8 years of education=184.5 (92.5);
age 75-80/9-11 years of education = 157.5 (78.5);
age 75-80/education > 12 years of education = 122.5 (55.5).
Davies (1968):
Age 60-69 (n=90)
90th percentile = 64
75th percentile = 89
50th percentile=119
25th percentile=172
10th percentile = 282
Age 70-79 (n=90)
90th percentile =79
75th percentile =132
50th percentile=196
25th percentile=292
10th percentile = 450
[ Trail-Making Test, Part B
]
Delayed Recall (MMSE Test Item # 5)
This is a test of working memory. The examiner asks, "Please tell me again
the three words you repeated earlier." Examiner records the number of words
recalled correctly, and announces that the test is completed.
Vision Tests (Optional)
If GRIMPS is administered in a motor vehicle agency setting, drivers' visual
capability will be tested using the established protocol for the jurisdiction.
Typically, only a static acuity measure and a gross measure of the horizontal
peripheral field size will be obtained.
For other settings, it is recommended that the GRIMPS administrators add measures
of standard and low contrast acuity to the other tests described above. Stimuli
for each test are presented on 5.5 in by 5.5 in test card that serves as a "wall
chart" when viewed from a distance of 5 ft. (Note: the distance has been adjusted
for GRIMPS administration). The chart is printed on folded stock so that it
is also self-standing. The charts are obtained from the AARP (1992) "Older Driver
Skill Assessment and Resource Guide: Creating Mobility Choices." Permission
to use these charts has been granted from AARP.
Place Chart 1 (the high contrast side) on a convenient surface
in a brightly lit location 5 feet from the test participant, at eye level.
The correct letters are printed below. As the person reads each line, circle
only WRONG answers.
Ask the participant: "Please tell me the letters printed on the top line."
Then ask the participant to read each successive line. The smallest line of
letters without any errors is the acuity score. Record both the line number
and the corresponding acuity score.
Now turn the chart around so that Chart 2 (the low contrast
side) is facing the participant (the chart should still be placed at eye level
in a brightly lit location, 5 feet from the test participant).
Tell the participant "This chart measures your ability to see low contrast
objects. Low contrast objects are harder to see than high contrast objects.
You need to be able to see low contrast objects when you drive, like worn or
faded lane lines, curbs, medians, pedestrians, and other vehicles. These things
are harder to see in poor visibility conditions like fog, or at dusk and dawn."
Ask the participant: "Please tell me the letters printed on the top line."
The correct letters are printed below. As the person reads each line, circle
only WRONG answers. Then ask the participant to read each successive line, and
record the participant's responses. The smallest line of letters without any
errors is the acuity score. Record both the line number and the corresponding
acuity score. Also record the difference between the line number obtained on
Chart 1 and Chart 2.
NOTE: Scores for the low contrast chart will probably be 1 or 2 points lower
than for the high contrast chart. The greater the difference between the two
scores, the greater is the caution the participant must take when driving in
low light conditions. A participant may be advised to limit night driving, and
should see his or her eye care specialist to rule out eye diseases such as cataracts.
| Chart 1: High Contrast |
Chart 2: Low Contrast |
| Line |
Acuity |
Letters |
Line |
Acuity |
Letters |
| 1 |
20/100 |
O R S |
1 |
20/100 |
R H K |
| 2 |
20/80 |
Z H N |
2 |
20/80 |
H N V |
| 3 |
20/60 |
H S R |
3 |
20/60 |
N K S |
| 4 |
20/50 |
S Z K |
4 |
20/50 |
Z R H |
| 5 |
20/40 |
V R N |
5 |
20/40 |
K V S |
| 6 |
20/30 |
Z S H |
6 |
20/30 |
R Z N |
[ High contrast acuity chart (top)
and low contrast acuity chart (bottom). ]
(Reprinted with permission from AARP's Older Driver Skill Assessment and
Resource Guide: Creating Mobility Choices)
IC2(a)ii. Vision Screens
(commercially available (1))
Static Contrast Sensitivity
Wall Charts/Cards:
Pelli-Robson Test of Static Contrast Sensitivity
Clement Clarke, Inc., 3128 East 17th Avenue, Columbus, OH 43219, (800) 848-8923.
Chart measures 25 x 34 in, and comes with scoring pad (100 sheets) and instructions
for use.
Pelli, Robson, and Wilkins (1988) designed a 48-letter test of contrast sensitivity
at one spatial frequency. The contrast between letters and background decreases
as one moves down and toward the right of wall-mounted chart, viewed at distance
of 1 meter (about 40 inches) under normal room illumination (white area approximately
85 cd/m2). The letters from left to right and from top to bottom
progressively fade out, as if they must be read in thicker and thicker fog.
Letters (in groups of 3) range from 90 percent contrast (upper left) to 0.5
percent contrast (lower right). Drivers should be made to guess, even when they
believe that the letters are invisible. The examiner should allow several seconds
for the faintest letters to appear, but don't let the driver give up until he
or she has guessed incorrectly 2 of the 3 letters in a triplet, as the reliability
of the results depends on this. The driver's sensitivity is indicated by the
faintest triplet for which 2 of the 3 letters are named correctly. The log contrast
sensitivity for this triplet is given by the number on the scoring pad nearest
to the triplet. The instructions indicate that three measurements should be
taken: left eye, right, eye, and both eyes together. If all three measures are
taken, test time is approximately 8 minutes. Binocular log contrast sensitivity
is normally 0.15 higher than monocular.
Vistech Consultants Vision Contrast Test System (VCTS 6500)
Vistech Consultants, Inc., 4162 Little York Road, Dayton, OH 45414-2566, (937)
454-1399.
[Note: First Generation of tests is available from Vistech; Second generation/revised
charts (exclusive arrangement with Dr. Ginsburg) are available through Stereo
Optical.]
First Generation: includes chart, instruction manual, evaluation forms, light
meter, laminated instruction sheet and answer key.
VCTS 6500 - Far distance wall chart; measures 27 in x 37 in; 10 ft viewing
distance.
VCTS 6000 - Portable near vision chart; measures 5 in x 7 in; 18 in viewing
distance.
VCTS 6500 Chart contains 5 rows of sine wave gratings (1.5, 3.0, 6.0, 12, and
18 cycles per degree) and 9 columns of "patches" containing bars that vary in
contrast. The bars are either oriented straight up and down, slanted to the
right, or slanted to the left. The driver starts at the first row, and "reads"
across, telling the examiner in which of the three directions the bars are oriented.
The contrast decreases in each row from left to right. The highest numbered
patch that can be correctly seen in each row of the chart is the observer's
contrast sensitivity for that spatial frequency. Observer views chart from a
10 ft distance, under normal room lighting (30-70 footlamberts).
Smith-Kettlewell Institute Low Luminance (SKILL) Card
The Smith-Kettlewell Eye Research Institute, 2232 Webster Street, San Francisco,
CA 94115, (415) 561-1620.
Available from the Smith-Kettlewell Institute, who requests a donation for
the chart.
This is a test for assessing visual function under the conditions that "stress"
the visual system; the combination of low contrast and low light level. It is
designed to measure spatial vision under conditions of reduced contrast and
luminance using normal office lighting. Its developers state that it is sensitive
to alterations in visual function due to optic neuritis, glaucoma, and age-related
maculopathy, and that it is closely correlated with reading performance in patients
with early age related maculopathy and with driving performance in the elderly.
This letter chart is viewed at a distance of 40 cm (16 in). From the top of
the chart to the bottom, each line of letters is smaller than the line preceding
it. One of the SKILL Card charts shows black letters on a white background (high-contrast
letters); the other card shows black letters on a dark gray background (low
contrast letters on a low-luminance background). Guessing is encouraged. Instructions
for use and scoring are included, as well as score sheets and age norms. The
SKILL score is the acuity loss (number of letters) between the light and dark
sides.
Vision Screening Devices:
Vistech Consultants Multivision Contrast Tester (MCT 8000)
Vistech Consultants, Inc., 4162 Little York Road, Dayton, OH 45414-2566, (937)
454-1399.
Multivision Contrast Tester measures near and far distance contrast sensitivity,
three types of glare (central, peripheral, and radial), near and distance acuity.
The Cataract Functional Disability Test, performed with the MCT 8000 documents
the degree of functional disability a patient is experiencing as a result of
a cataract.
OPTEC 1000 DMV
Stereo Optical Company, 3539 North Kenton Avenue, Chicago, IL 60641 1-800-334-9500,
312-777-2869.
Slide packages vary according to requests from various state DMVs; Optec can
design and develop new tests as the need arises.
Slides may include 4 tests: Snellen letter and number acuity, color perception,
stereo depth perception, traffic sign recognition, muscle balance phoria. A
set of 2 contrast sensitivity slides (Vistech consultants sine wave gratings)
is also available. The Optec 1000 DMV can also accomplish perimeter testing
(nasal and temporal at 55, 70, and 85 degrees) and night vision testing.
Static Acuity
Standard Wall Charts (Snellen Letter Chart and Sloane Letter Chart):
Snellen "E" Charts
(Available from Prevent Blindness America, 500 E. Remington Road, Schaumburg,
IL 60173; 1-800-331-2020).
20-ft. distance: Tumbling "E" symbols on one side, other letters on reverse.
Printed on a durable, tear-resistant latex sheet, with eyelets for easy hanging.
Chart comes with practice "E" card and Guide to Testing Distance Visual
Acuity. Measures 9 in x 23in.
10-ft. distance: Smaller chart for shorter distance. Other specifications same
as above. Measures 9 in x 18 in.
Sloan Low Vision Letter Chart for 6 Meters (20 ft)
(Available from Good-Lite Co. 1540 Havannah Avenue, Forrest Part, IL 60130;
708-366-3860).
Two-sided chart (10 in x 18 in ) where one side contains 4 rows of letters
from 20/200 to 20/100 acuity, and the other side contains 8 rows of letters
from 20/100 to 20/20. Two test charts per set.
ETDRS (Early Treatment Diabetic Retinopathy Study) Chart:
(Available from Prevent Blindness America, 500 E. Remington Road, Schaumburg,
IL 60173 1-800-331-2020).
ETDRS Distance Chart: This durable eye chart utilizes all 10 Sloan letters
(C, D, H, K, N, O, R, S, V and Z) to test vision at 10 feet. Each line consists
of five optotypes, standardizing the number of letters that must be correctly
identified to pass any line (three out of five). Three sets of letters on the
lower lines can help prevent memorization. Made of durable plastic, with hole
for hanging. 18 in x 18 in; folds to 9 in x 18 in. (Shipped directly from the
manufacturer.)
ETDRS Near Chart: This innovative new chart, developed especially for Prevent
Blindness America, includes an occluder on a 16-inch cord for testing near vision.
Printed on both sides for discouraging memorization and screening each eye with
a different but equally difficult test. Five optotypes per line standardizes
passing at three out of five on each line. Made of durable plastic; utilizes
all 10 Sloan letters (C, D, H, K, N, O, R, S, V and Z). Measures
9 in x 7 in.
IC2(a)iii. Road Sign/Knowledge Test
Summary:
According to information presented by Janke and Hersch (1997), only four U.S.
jurisdictions and two Canadian provinces require an age-based knowledge test
for driver license renewal. This includes the District of Columbia, Illinois,
Indiana, New Hampshire, Alberta, and Ontario. Six other jurisdictions require
knowledge tests for all license renewals (regardless of age). This includes
California, Hawaii, Kansas, Louisiana, Michigan, and Utah). Janke and Hersch
(1997) analyzed test results for 1,501 California driver license applicants
ages 65 and older who failed to complete the license renewal process during
their initial visit to the DMV. Some drivers fail the knowledge test several
times, despite having an opportunity to review the material in the Driver Handbook
between tests. While 47.4 percent passed it on the first attempt, the failure
rate for older drivers renewing their licenses is higher than that for the population
as a whole.
In Oregon, if a driver is referred to the DMV for reexamination, he or she
is offered an appointment with a Driver Improvement Counselor, who is "an experienced
former driver examiner who has received special training and whose role is to
advise, recommend, critique, and persuade, rather than to merely test the driver"
(Janke, 1994). One component is an oral knowledge test consisting of seven questions.
Six are prescribed and one may be chosen from the State's regular oral test.
The six prescribed questions are:
(1) You are preparing to make a left turn from a two-way street. Your car should
be in what position?
(2) At an intersection where there are no stop signs or traffic lights to control
traffic, you must yield to the car on which side of you?
(3) You are coming toward an intersection with a two-way street. In which direction
should you look first?
(4) You are in a "left turn only" lane and you want to go straight ahead. What
should you do?
(5) Tell the correct way to change lanes.
(6) Tell what it means when a school bus is stopped and its red lights are flashing.
Several researchers have evaluated the effectiveness of traffic sign knowledge
tests and rules of the road tests in predicting crashes or impaired driving
performance. In a study of 3,238 drivers ages 65 and older who applied for renewal
of North Carolina driver's license, Stutts, Stewart, and Martell (1996) found
that performance on the knowledge test declined significantly as a function
of increasing age (time to complete test increased with increasing age). The
correlation between knowledge test score and number of crashes was significant.
This test required the driver to identify and explain the meaning of 12 traffic
signs based on their color and shape (e.g., yellow diamond with + would be identified
as a warning sign for a crossroad ahead). The signs were displayed six at a
time in the viewing equipment used for vision testing. The test is not normally
timed for license renewal, however, for the research, examiners recorded how
long (in seconds) it took license applicants to complete the test. Applicants
were not told they were being timed; the number of errors remained the only
criteria for passing or failing test. Three or more errors automatically dismisses
a license applicant.
Tarawneh, McCoy, Bishu, and Ballard (1993) found that the driving knowledge
test score was significantly correlated with driving performance (correlation
coefficient =0.27, p=0.0053). Better performance on the knowledge test was associated
with better on-road driving performance. The knowledge test was a 50-question,
multiple choice test designed to determine the driving knowledge pertinent to
the types of crashes in which older drivers in Nebraska were over-involved.
Questions pinpointed contributing circumstances (failure to yield, disregard
signal, improper turn signal, improper turn, following too close, and improper
lane change) and crash type (right angle, rear end, side swipe, head on, left
turn, other turn, right turn, and pedestrian). The percentage of the questions
answered quickly was used as the measure of driving knowledge.
In another study, Cushman (1992) found that the group of subjects who failed
an on-road driving exam had significantly lower mean scores on the written (multiple
choice) knowledge test and the road sign identification test compared to the
group of subjects who passed the on-road driving exam. The road (driving) knowledge
test was a multiple-choice, paper-and-pencil test consisting of 21 questions
assessing knowledge of rules of the road. It additionally required subjects
to identify and describe the meaning of 16 road signs (what the required driver
action was).
Hunt, Morris, Edwards, and Wilson (1993) employed a traffic sign recognition
test that required the identification of the following four standard symbols:
traffic merging, no right turn, no left turn, and no U turn. These symbol signs
were chosen because they are frequently encountered in everyday driving situations.
Subjects were asked to explain the meaning of each symbol. Each item was scored
individually to determine if one type of sign posed greater difficulty than
the others. All five subjects with mild dementia who failed the road test also
performed poorly on the pre-driving traffic sign recognition test. The correlation
between the pass/fail outcome on the road test and performance on the Traffic
Sign Recognition test was significant at the p<.0002 level. The authors noted
that visual form detection may be impaired in mild senile dementia of the Alzheimer
type (SDAT), while visual acuity remains intact; this may contribute to the
difficulty some subjects experienced with sign recognition, since the signs
were symbols (form) rather than letters (acuity).
In a research study of 102 older drivers referred to the DMV for a reexam and
33 paid volunteers, the correlation between knowledge test errors (standard
California renewal knowledge test) and weighted errors on the road test was
significant for the combined referral and volunteer group and for the referral
group only (Janke and Eberhard, 1998; Janke and Hersch, 1997). The Driver's
Examination on California Vehicle Code and Safe Driving Practices contains 18
multiple choice questions, each with 4 choices. A renewal applicant must score
at least 15 (3 errors or less) to pass the test. There are 5 different versions
of the test, with questions developed from information presented in the 1997
California Driver Handbook. One or two questions relate to the meaning
of signs and pavement markings depicted on the test form, others ask about the
legal BAC limit, visual scanning practices, the meaning of signals, what to
do if involved in a crash, etc.
Janke and Eberhard (1998) and Janke and Hersch (1997) also reported on a supplementary
test of traffic sign knowledge and perception. This two-part written traffic-sign
test presented pictures of traffic signs and asked whether it meant that the
driver should perform a certain action (e.g., "watch for hazards"). A second
part presented several traffic sign shapes embedded in complex abstract drawings,
and subjects were to indicate the number of sign shapes of a particular type
hidden in the drawing. Using the sample of subjects mentioned above, sign test
errors correlated significantly with weighted errors on the road test for the
combined referral and volunteer group, but not for the referral group only.
Janke and Hersch employed another traffic sign recognition test in a study
of 101 licensed drivers ages 72 to 90. This was a paper-and-pencil test consisting
of 12 factually oriented questions requiring a subject to check an alternative
corresponding to the meaning of each pictured sign, and one judgmentally oriented
question, where an intersection displays a "no left turn" and two "do not enter"
signs on the through path, and the subject must check the alternative corresponding
to what they could do (turn right). The correlation between traffic sign errors
and weighted error score on the drive test was not significant. Janke and Hersch
(1997) recommend that jurisdictions employ knowledge testing for license renewal.
They stated that an adequate knowledge test given to all renewal applicants
may be sufficient to screen out most cases of cognitive impairment and that
it should be possible to modify present tests to make them not only tests of
crystallized knowledge, but dementia screens. For example, diagrams of traffic
situations could be incorporated in the tests in which drivers would be required
to state what they should do if they were driving Car A, and then what they
should do if they were driving Car B. The switching of attention and point of
view required in such a task might prove to be especially difficult for a person
with cognitive impairment.
A test such as that described above is given in Pennsylvania to drivers who
have been convicted of violations of the PA Vehicle Code resulting in six or
more points. Part of this Special Point Exam tests drivers' judgment about safe
versus unsafe driving decisions, and accounts for two-thirds of the total score.
The crash situations in the study guide and on the test are taken from reports
of real crashes. In each crash situation there are a number of diagrams that
show traffic conditions, vehicle movements, and traffic signs and signals in
the crash area. Examinees are required to integrate all of this information
to respond correctly. A description of what happened is under each diagram.
An example of this kind of test question is shown on the following pages.
Conclusions/Preliminary Recommendations:
Performance on simple tests of traffic sign recognition and rules of the road
has been shown to correlate significantly with poor driving performance and
also with cognitive impairment. More complex test questions requiring drivers
to visualize multiple perspectives, project their own and/or other vehicles'
movements, or integrate a number of traffic situational factors show promise
as protocols tailored to detect cognitive impairment.
References:
Cushman (1992)
Hunt, Morris, Edwards, and Wilson (1993)
Janke and Eberhard (1998)
Janke and Hersch (1997)
PennDOT Special Point Examination Driver's Handbook
Stutts, Stewart, and Martell (1996)
Tarawneh, McCoy, Bishu, and Ballard (1993)
[ PA SPE (1) (2)
]
IC2(a)iv. Supplemental Tests Specialized for Attentional
and Informational Processing Skills
Visual Attention (Selective Attention/Divided Attention)
Visual Attention Analyzer, Model 2000 (Useful Field of View)
Visual Resources, Inc., 333 West Wacker Drive, Suite 700, Chicago, IL 60606;
phone: (773) 248-0883; fax: (773) 248-0885; email: kristi@ufov.com; contact:
Kristi Berg.
A model 2000 Vision Attention Analyzer is used to measure the detection, localization
and identification of suprathreshold targets in complex displays, and has been
shown to be predictive of the performance of daily activities such as driving
a car. The size of the UFOV is determined by manipulating three variables: target
presentation duration, the competing attentional demands of the central and
peripheral task, and the salience of the peripheral target. Three subtests provide
a measure of the percentage reduction of a maximum 35 degree radius field. During
the first subtest (which measures processing speed capability and vigilance),
a test participant is required to identify a centrally located object which
varies in duration, by pressing an icon of a truck or a car (whichever was presented)
on the touch-screen display after the target is presented. The second subtest
(which measures divided attention capabilities) requires the same identification,
in addition to locating a simultaneously presented peripheral target of varying
eccentricity. A third subtest (which measures selective attention capabilities)
requires the same two responses required for subtests 1 and 2; for this subtest,
the peripheral target is embedded in distractors. The composite measure of UFOV
reduction is recorded as a percentage ranging from 0 to 90 percent, and the
basis for the loss can be determined by considering the percentages of loss
on the three subtests.
The Visual Attention Analyzer is currently available in several models and
options. All are fully automated. UFOV testing is also available on disk through
Visual Resources, Inc., and The Psychological Corporation.
Auto-Trails
Frank Schieber, University of South Dakota, 414 E. Clark Street, Psychology
Department, Vermillion, SD 57069. Phone: (605) 677-5295; Fax: (605) 677-6604.
This procedure is a modified and automated version of Reitan's (1958) Trail
Making Test (Part A). It presently runs in DOS mode, although it is being upgraded
for a Windows environment. The software may be obtained for free from Dr. Schieber;
however, the user must supply a touch screen and interface card. In this test,
14 numbers are presented on a computer monitor. They are arranged randomly against
the still (static) background of a traffic scene as observed by the driver through
the windshield. The subject must touch the numbers (touch screen display) in
ascending order as rapidly and accurately as possible, consistent with the clinical
"Trails" protocol. Timing is done by the computer.
Dynamic Trails Test [DynaTrails]
The Scientex Corporation; 1722 Sumneytown Pike, P.O. Box 1367; Kulpsville,
PA 19443
Phone: (215) 412-4912; Fax: (215) 412-4911; e-mail: 75142.515@compuserve.com
Scientex has developed software to present a derivative of the Trails
B procedure using a computer touch screen. A moving driving scene, stored
on the hard drive as an MPEG file, is presented in the background. Test stimuli
(numbers and letters) are overlaid on the driving scene. A data file of the
subject's performance is generated which records the following data: the time
after start at which each number and letter stimulus is pressed (including error
responses); the exact coordinates on the screen where each response was made;
and subject identifying information as entered on a set-up screen by the experimenter/test
administrator. This is a Windows-based application.
This software product may be made available at cost, but with restrictions
on copying or redistributing it, to qualified researchers and motor vehicle
agency officials. For more information contact Scientex at the location
above.
Channel Capacity (Information Processing)
WayPoint
WayPoint Research, Inc., 538 Burlington Road, Suite B, Atlanta, GA 30307, (404)
982-0011.
WayPoint is a brief, paper-and-pencil test, where subjects connect alternating
numbers and letters in sequence. The test was developed to identify high-risk
drivers (truck drivers, bus operators, etc).
Six exercises are presented in pamphlet form. The first 4 exercises contain
8 numbers and 7 letters which are to be connected in alternating number-letter
order by means of a continuous pencil line; the last two exercises contain 5
numbers and 4 letters to be connected in the same way. Some exercises have small
pictures used as irrelevant distractors. Subjects are instructed to keep going
if they make a mistake. Performance on each exercise is timed with a stopwatch.
WayPoint can be administered one-on-one or in a group. It uses a (proprietary)
Windows-based scoring program to assess crash risk (high or low), and a narrative
about the person's strengths and weaknesses. The scoring system calculates channel
capacity or information processing rate, accuracy, focus, vigilance (sustained
attention), and search (the ability to find details in a visually noisy field).
Based on these 5 interacting factors, a driver falls into one of 60 different
categories. Associated with each category is a driving style and collision risk
factor, which is a 5-point scale that expresses the likelihood of both "preventable"
and "non-preventable" collisions.
IC2(b)i. Clinical Assessment of Dementia
Mini-Mental Status Examination
Summary
The MMSE is an 11-item (30 point) screening instrument for dementia (Folstein,
Folstein, and McHugh, 1975) that contains test items in 6 general cognitive
domains: orientation (items 1 and 2); registration, or learning and remembering
new information (item 3), attention/calculation (item 4a: spelling "world" backwards
or item 4b: counting backwards by 7 from 100), recall (item 5), language (items
6-10), and visuospatial perception/praxis (item 11: copying a figure of 2 intersecting
pentagons). It requires approximately 10 minutes to administer. The 11 items
are progressive and are to be asked in the order presented on the following
page.
When given to 69 patients, the test was able to separate the three following
diagnostic groups.
Dementia: n=29, mean age = 80.8, mean MMSE score = 9.6, sd=5.8, range = 0-22
Depression with cognitive impairment: n=10, mean age = 74.5, mean MMSE score
= 19.0, sd = 6.6, range = 9-27
Depression: n=30, mean age = 49.8, mean MMSE score = 25.1, sd= 5.4, range
= 8-30.
For 63 normal elderly persons with an average age of 73.9 years, the mean MMSE
score was 27.6, (sd=1.7, range = 24-30). Standardization of the test by administration
to 63 normal elderly subjects and 137 patients indicated that the score of 20
or less was found essentially only in patients with dementia, delirium, schizophrenia
or affective disorder, and not in normal elderly people or in patients with
a primary diagnosis of neurosis and personality disorder.
The MMSE has been used extensively in older driver research studies, as summarized
below.
In a study of 283 community-dwelling individuals ages 72 to 92 (mean age =
77.8), Marottoli, Cooney, Wagner, Doucette, and Tinetti (1994) found that persons
with borderline cognitive impairment (MMSE score of 23-25) were more likely
to have adverse events (traffic crash, violation, or stopped by police) in the
year following examination than those with higher or lower scores (relative
risk = 2.0, 95% CI = 1.1-3.7). The authors examined the components of the MMSE
individually and by cognitive domain (orientation, memory, attention, language,
and visuospatial ability), and found that the item most closely associated with
adverse events was impaired design copying [24% of persons who could not correctly
copy the intersecting pentagons had events compared with 8% of those who could
(relative risk = 3.0, CI = 1.6-5.6)].
Johansson (1997) conducted a matched-pair, case-control study, with close (1
year) age matching in Sweden. The case subjects included 37 drivers age 65 and
older (mean age = 75.5) with temporarily-suspended licenses due to crashes (23
drivers) or other moving violations (14 drivers). The control subjects included
37 drivers age 65 and older with no license suspensions. The case subjects (suspensions
+ crashes) had significantly lower MMSE scores (p=.019), lower immediate memory
task performance (p=.010), and poorer performance on the cube copying task (p=.010)
compared to matched controls.
[ Mini-Mental Status Exam ]
In a study of 101 licensed drivers (39 females and 62 males) ages 72 to 90
(mean age = 78.3), MMSE correct responses were not significantly correlated
with road test weighted errors. However, MMSE correct responses did significantly
correlate with concentration errors on the road test (r=0.09, p=0.359). MMSE
"error areas," the number of cognitive domains represented on the MMSE on which
at least one error was made, correlated 0.27 (p=0.006) with road test weighted
errors and 0.29 (p=0.003) with concentration errors (Janke and Hersch, 1997).
In a study of 30 licensed drivers ages 61 to 89 (mean = 72.2), the correlation
between MMSE score and in-traffic score was 0.72, and was significant at the
p<.01 level (Odenheimer, Beaudet, Jette, Albert, Grande, and Minaker, 1994).
Subjects were recruited by word-of-mouth from studies of normal aging (n=17),
medical and dementia clinics (n=9), and from the community (n=4). Adjusting
for age resulted in no change in the correlation. Although there was a strong
correlation between the MMSE and driving performance, the MMSE alone was deemed
inadequate to predict driving performance. The MMSE scores of the four subjects
who failed the road test were 4, 16, 21, and 24. Of the subjects who passed
the road test, the lowest MMSE score was 14.
Tarawneh, McCoy, Bishu, and Ballard (1993) studied 105 drivers licensed in
Nebraska, who were between the ages of 65 and 88 (mean age = 71.4). In this
study, the MMSE showed a significant correlation to performance on an on-road
driving test (correlation = 0.24, p<0.01).
A consensus statement was generated by 22 researchers who met in Borlange Sweden,
aimed at providing advice to primary care physicians concerning the assessment
of cognitive status in relation to driving (Lundberg, Johansson, Ball, Bjerre,
Blomqvist, Braekhus, Brouwer, Blysma, Carr, Englund, Friedland, Hakamies-Blomqvist,
Klemetz, O'Neill, Odenheimer, Rizzo, Schelin, Seideman, Tallman, Viitanen, Waller,
and Winblad, 1997). Although consensus could not be reached concerning the issue
of a cut-off score on the MMSE, it was determined by the majority (with some
reservation) that some cut-off levels can be cautiously proposed in the context
of decisions concerning future driving.
Cut-off scores must be considered as being relative, forming a small part
of the basis of making decisions about driving, and secondary to a clinical
evaluation.
MMSE scores 10, accompanied by a diagnosis of dementia, indicates a sufficiently
low level of cognitive functioning to justify recommending immediate cessation
of driving.
MMSE scores of 11-17, accompanied by a diagnosis of dementia, suggests severe
cognitive impairment; the patient should be referred for specialized assessment
unless the clinician feels that it is unnecessary.
MMSE scores of 18-23 indicates mild impairment; decisions concerning possible
assessment should be based on the functional level of the patient. If the functional
level is stable, then a periodic follow-up is recommended. If functional deterioration
is present, then specialized assessment is recommended.
For patients without diagnosis of dementia, scores of 17 or less and scores
of 18-23 with accompanying signs of functional deterioration should be indications
for specialized assessment.
Some participants could not accept this suggested use for the following reasons:
Risk of designating false positives; low scores are related to illiteracy,
aphasia, depression, and resistive behavior; may not correctly assess mental
status of patient.
MMSE does not assess poor judgment and impulse control; persons with scores
above the cut-off may be inappropriately viewed as safe drivers.
Use may be wasteful adding nothing more to evaluation of competence than
clinical observation of general cognitive functioning.
References:
Folstein, Folstein, and McHugh (1975)
Lundberg, Johansson, Ball, Bjerre, Blomqvist, Braekhus, Brouwer, Blysma,
Carr, Englund, Friedland, Hakamies-Blomqvist, Klemetz, O'Neill, Odenheimer,
Rizzo, Schelin, Seideman, Tallman, Viitanen, Waller, and Winblad (1997)
Marottoli, Cooney, Wagner, Doucette, and Tinetti (1994)
Johansson (1997)
Janke and Hersch (1997)
Odenheimer, Beaudet, Jette, Albert, Grande, and Minaker (1994)
Tarawneh, McCoy, Bishu, and Ballard (1993)
Drachman and Swearer (1995)
Mattis Organic Mental Syndrome Screening Examination
(MOMSSE)
Summary:
The MOMSSE is a brief mental status examination (Mattis, 1976) consisting of
items testing:
General fund of information (e.g., How many weeks are in a year?).
Verbal Abstraction (e.g., How are a poem and statue alike?).
Attention (forward and backward digit span).
Memory (orientation, verbal memory, reproduction of design from memory).
Language (e.g., test for objects, body parts, double and triple commands,
reading silently and aloud).
Construction (draw a clock, cube copying).
It is comprised of a sample of several WAIS subtests, a Benton geometric figure,
and some items from the Eisenson Test of Aphasia. It requires 15 to 20 minutes
to administer.
Owsley, Ball, Sloane, Roenker, and Bruni (1991) employed the MOMSSE in a study
of 53 drivers ages 57 to 83 (mean age = 70). Each of the 14 subtests was scored
from 0 (normal) to 2 (impaired), and an overall composite score was calculated
by adding subtest scores. Composite scores ranged from 0 to 28 (0 = excellent
mental status; 28 = severe dementia). Individuals with high MOMSSE scores (n=8)
experienced 3.8 times more crashes on average than those with MOMSSE scores
less than 10 (n=45). For intersection crashes only, subjects with MOMSSE scores
greater than 10 (n=8) had a total of 9 intersection crashes, and those with
scores less than 10 (n=39) had only 7 intersection crashes between them. On
the basis of the number of subjects in each group, individuals with higher MOMSSE
scores had 6.3 times more intersection crashes than those with lower scores.
Mental Status (score on MOMSSE) was found to be significantly related to number
of crashes (r=.36). When crashes were categorized by type, most were found to
be intersection problems. MOMSSE scores were found to be better predictors of
intersection crashes than crashes in general (r=.41). MOMSSE and UFOV together
predicted 29 percent of the variance in intersection crashes, and 20 percent
of the variance in crashes in general.
In a study of 294 subjects ages 56 to 90 (mean age = 71 years), Ball, Owsley,
Sloane, Roenker, and Bruni (1993) found a significant correlation between MOMSSE
score and crash frequency (r=.34, p<.01). Data were tested with the LISREL
VII structural modeling program to evaluate independent variables in terms of
whether they directly influence the dependent variable (crashes), or if they
operate indirectly through other variables. In this study, UFOV and mental status
were the only variables that had a direct effect on the crash-frequency variance.
Mental status was found to have a small, but significant direct effect on crash
frequency, and a larger indirect effect on crash frequency through UFOV. Together,
UFOV and mental status (MOMSSE) account for 28 percent of the variance in crash
frequency. Mental status had sensitivity (.61) and specificity (.62) values
that were "markedly" less than those for UFOV (.89) and (.81), respectively.
References:
Ball, Owsley, Sloane, Roenker, and Bruni (1993)
Mattis (1976)
Owsley, Ball, Sloane, Roenker, and Bruni (1991)
Short Blessed Test (6-item version of the Blessed
Information-Memory-Concentration Mental Status Test)
Summary:
Originally a 26-item test (Orientation-Memory-Concentration) of cognitive impairment,
it was shortened to a 6-item test, and has been shown to reliably discriminate
among mild, moderate, and severe cognitive deficits. It is also easily administered
by a nonphysician. The 6-item test predicted the scores on the 26-item validated
mental status questionnaire in two patient groups in a skilled nursing home
(n=322), patients in a health-related facility (n=42 and n=170), and in a senior
citizen center (n=52). There was a positive correlation between scores on the
6-item test and plaque counts obtained from the cerebral cortex of 38 subjects
at autopsy (Katzman, Brown, Fuld, Peck, Schechter, and Schimmel, 1983).
This test requires identification of current year and month, identifying time
within one hour, counting backwards from 20 to 1, saying months in reverse order,
and repeating a name and address that the test administrator has told the subject
just before asking the current time. Weighted scores on the test range from
0 (no errors) to 28 (maximum errors). Scores of 0-8 indicate normal or minimal
cognitive impairment; 9-19 moderate impairment; and 20 and above severe impairment.
Item Max Error Score Weight Weighted Score
1 What year is it now? 1 _____ x 4 _____
2 What month is it now? 1 _____ x 3 _____
Memory phrase:
Repeat this phrase after me: John Brown,
42 Market Street, Chicago
3 About what time is it? 1 _____ x 3 _____
(within 1 hour)
4 Count backwards 20 to 1 2 _____ x 2 _____
5 Say the months in reverse order 2 _____ x 2 _____
6 Repeat the memory phrase 5 _____ x 2 _____
In a study of 13 healthy elderly control subjects (mean age = 73.5), 12 subjects
with very mild dementia (mean age = 72.5); and 12 subjects with mild dementia
(mean age = 73.4), the correlation between the pass/fail outcome on an on-road
driving evaluation and performance on the Short Blessed Test was significant
at the p<.001 level (Hunt, Morris, Edwards, and Wilson, 1993).
The Short Blessed Cognitive Test was also employed in a study of 3,238 drivers
ages 65 and older, who applied for renewal of their North Carolina driver's
license (Stutts, Stewart, and Martell, 1996, 1997). Results of single variable
models for the association of each cognitive test measure with recent prior
crash involvement using continuous test scores (Chi Square Tests) showed that
the Short Blessed test was not significant. Multivariate Poisson Regression
Models were employed to control for effects of age, race, driving exposure,
etc, and included Trails A, Trails B, and Short Blessed test. All three models
fit the data adequately, although the Short Blessed was the least significant
of the variables with an associated p-value of 0.48 (odds ratio= 1.10, 95% confidence
interval= 1.01-1.19 for association of cognitive test with recent prior crash
involvement). The researchers stated that the Short Blessed test was less sensitive
to reduced cognitive function than the two Trails tests employed in this research,
even though it is supposed to be relatively sensitive to milder levels of impairment.
The short answer format may make it less appropriate for driver's license settings,
compared to the more performance-based Trail Making and AARP Reaction Time Tests.
References:
Hunt, Morris, Edwards, and Wilson (1993)
Katzman, Brown, Fuld, Peck, Schechter, and Schimmel (1983)
Stutts, Stewart, and Martell (1996, 1997)
Cognitive Assessment Screening Test (CAST)
Summary:
The CAST is a paper-and-pencil self-administered cognitive test, designed for
use in general physicians' offices to screen geriatric patients for dementia
(Drachman and Swearer, 1995). CAST was designed to require little (or no) examiner
time, little examiner training, and sensitivity and specificity that are comparable
to the best existing screening tests. Elderly patients with some high school
education (a static representative of over 70 percent of the adult population)
can complete the test in approximately 15 minutes without supervision in a physician's
waiting room. The test is shown on the following 3 pages
The test has three one-page sections (Parts A, B, and C). Part A consists of
10 questions with 28 scored responses; Part B consists of 5 more-demanding questions,
with 12 scored responses; and Part C has 13 self-report questions that assess
the examinee's perception of a decline in memory and competence. The combined
score of Parts A and B is used to determine whether performance falls within
the normal range, or below the threshold for dementia. The subjective report
of Part C identifies individuals who are concerned about age-related cognitive
decline.
When tested in a "real world" population of elderly unscreened individuals
followed in a medical geriatric clinic, a cut-off score of 36 had a sensitivity
of 88 percent and a specificity of 100 percent. The test is viewed as an initial
sort into 2 groups: elderly patients with probable dementia, and patients whose
cognitive function is probably normal. The authors advise that patients who
fall below the cut-off should be further evaluated with more extensive psychometric
testing.
References:
Drachman and Swearer (1995)
[ Cognitive Assessment Screening Test
Part A | Part B
| Part C ]
7 Minute Screening Test for Alzheimer's Disease
Summary:
The 7 Minute Screen is a simple paper-and-pencil test designed to assist health
care professionals in the identification of patients who should be further evaluated
for Alzheimer's Disease. The test was developed by Dr. Paul Solomon, Professor
of Psychology at Williams College and Co-Director of the Memory Clinic at Southwestern
Vermont Medical Center, and his colleagues to address the under diagnosis of
Alzheimer's Disease that can occur in a brief office visit, particularly in
the early-to-moderate stages of AD. The goal was to create a unique testing
battery that could be rapidly administered by office personnel following a brief
training session (about 1 hour), be scored objectively, and not be sensitive
to education level. The screen is the first in a two-step process, where the
second step would be a full diagnostic evaluation for those "flagged" by the
screen.
This test was recently applied to 120 people, and was found to be 90 percent
accurate in the identification of individuals with Alzheimer's Disease. It identified
13 of 13 people known to have early Alzheimers, in the study where examiners
were blind to diagnosis (Solomon, Hirschoff, Kelly, Relin, Brush, DeVeaux, and
Pendlebury, 1998).
The subjects were sixty successive referrals to the Memory Disorders Clinic
at Southwestern Vermont Medical Center, Bennington, who were diagnosed as having
probable AD (mean age = 77.6, range = 66-89) and 60 community-dwelling volunteers
of comparable age (mean age = 77.5, range = 67-91), sex distribution, and education.
The main outcome measure was comparison of the probability of dementia on the
7 Minute Screen with the criterion standard of clinical diagnosis established
by examination and laboratory studies. The secondary outcome measures were test-retest
and interrater reliability (correlation coefficients), and time for administration.
The mean time of administration was 7 minutes 42 seconds. Mean scores for patients
with AD and control subjects on all four individual tests were significantly
different (for each, P<.001). When the four tests were combined in a logistic
regression, the battery had a sensitivity of 100 percent and a specificity of
100 percent. A series of 1,000 repeated random samples of 30 patients with AD
and 30 control subjects taken from the overall sample of 60 patients with AD
and 60 control subjects had a mean sensitivity of 92 percent and a mean specificity
of 96 percent. The battery was equally sensitive to patients with mild AD, as
demonstrated by correctly classifying all 13 patients with AD using Mini-Mental
State Examination scores of 24 or higher. Neither age nor education was a statistically
significant factor when added as a covariate. Test-retest reliabilities for
individual tests ranged from 0.83 to 0.93. Test-retest reliability for the entire
battery was 0.91. Interrater reliability for the entire battery was 0.92.
Several large scale studies (up to 2,000 patients) are underway in primary
care practices across the U.S. Information obtained from Janssen Pharmaceutica
Research Foundation (the screening kit distributor) states that some primary
care physicians have incorporated the 7 Minute Screen as a part of their annual
physical for patients over the age of 65.
The test includes 4 quizzes that probe a patient's ability to recall words
and images seen moments before, along with finding a solution to a simple clock
problem. Reminder words are provided if needed. According to Dr. Solomon, few
people can recall all of the categories, but a normal person will benefit from
the reminder words. A person with Alzheimer's Disease will not find the reminder
words helpful (The Morning Call, March 13, 1998).
The test battery:
Step 1. Patient is asked to state the correct year, month, date, day of week,
and time. Perfect score is zero; maximum score is 113. Points are added for
errors (e.g., 5 points are added for each month off, 1 point for each date off,
10 points for each year off, 1 point for each day off, 1 point for each 30 minutes
off).
Step 2. Pictures of objects in 1 of 16 categories are presented to the patient,
4 at a time. The patient must respond with the name of the object when the examiner
supplies the category. For example, the examiner says, "There is a piece of
fruit on this page. What is it?" The patient would look at the page, and reply
"Grapes." After the patient names each of the four objects, the examiner removes
the four pictures and asks the patient to respond with the name of each of the
four objects when the examiner supplies the category name. If the patient recalls
all four items correctly, the examiner moves on to the next four items. If the
patient makes a mistake on one or more items, the page of four items is shown
again, with the cued recall and then the delayed recall. After all 16 items
are displayed and recalled the examiner asks the patient to recite the months
in reverse order, but the task is not scored. Then, the patient is asked to
recall as many of the objects as possible. Reminder words such as "article of
clothing" for the "shoe" object are provided by the examiner. Perfect score
is 16.
Step 3. Patient is asked to draw a clock face, with numbers and to place the
clock hands to read 20 minutes to 4:00. A point is given for correct numbers,
their position, and for placement and length of clock hands. Perfect score is
7.
Step 4. Patient is asked to name, within 60 seconds, as many objects as possible
within a single category, such as "vegetables." Scoring is one point for each
correct response. Most people easily name 12 or more objects. The maximum score
is 45 (for calculation purposes).
The screening kit contains a scoring calculator; the examiner enters the score
for each test. The calculator performs a complex logarithmic process, and provides
immediate output to assess a patient as normal or at low or high probability
of Alzheimer's Disease.
The 7 Minute Screen Kit consists of a training video, testing materials, a
scoring calculator, and score sheets (for recording performance for placement
in a patient's record). Also included is a sheet that lists recommended laboratory
and radiologic studies if a patient tests positive and a reprint of the Archives
of Neurology article (Solomon, Hirschoff, Kelly, Relin, Brush, DeVeaux,
and Pendlebury, 1998) that describes the validation of the Screen. The Screening
kit is free of charge and is available to qualified health-care professionals.
Distribution of the materials needed to administer and score the 7 Minute Screen
is supported by Janssen Pharmaceutica Research Foundation. Two website addresses
are provided with the materials: www.7minutescreen.com and http://phin.org.
References:
Newspaper article: Alzheimer's Screening Test Developed, The Morning Call,
March 13, 1998
Solomon, Hirschoff, Kelly, Relin, Brush, DeVeaux, and Pendlebury (1998).
7 Minute Screening Kit
Janssen Pharmaceutica Research Foundation, Janssen at Washington Crossing,
1125 Trenton-Harbourton Road, P.O. Box 200, Titusville, NJ 08560-0200.
IC2(b)ii. Psychophysical Test Batteries
Automated Psychophysical Test (APT)
Summary:
This program is in the public domain and is available without cost from: A.
James McKnight and A. Scott McKnight, National Public Services Research Institute,
8201 Corporate Drive, Suite 220, Landover, MD 20785, (301) 731-9891 ext.101.
It requires a 486 or better IBM-PC platform.
The APT is a computerized test of 22 visual, attentional, perceptual, cognitive
and psychomotor abilities:
Sensory
Static Visual Acuity: to differentiate stimuli in high contrast images
Low Contrast Acuity: to differentiate stimuli in low contrast images
Dynamic Visual Acuity: to differentiate stimuli in moving images
Attentional
Range of Attention: to respond to presentation of parafoveal images (similar
to "Useful Field of View")
Simple response: single response to the presence of images
Choice response: alternative responses to the form of images
Simple image
Complex image
Selective Attention: to shift attention from one characteristic of an image
to another
Divided Attention: to share attention between images presented simultaneously
Perceptual
Perceptual Speed: to identify quickly a target image within an image field
Motion Detection: to detect direction of motion near the motion threshold
Field Dependence: to discern a figure within cluttered background ("embedded
figures")
Cognitive
Information Processing: to perform mental operations with information
Digit matching: to identify number series matching target series
Figure matching: to identify figure matching target figure
Missing pattern: to identify the pattern missing from an otherwise complete
series
Short Term Memory: to recall information immediately after presentation
Digit matching: to identify number series matching previous target series
Figure matching: to identify figure matching previous target figure
Delayed Short Term Memory: to recall information after intervening tasks
Digit matching: to identify number series matching previous target series
after performing intervening tasks
Psychomotor
Simple Reaction Time: to respond quickly to appearance of a stimulus
Abstract image: to respond to appearance of a square
Meaningful image: to respond to appearance of brake lights
Choice Reaction Time: to respond quickly to the nature of a stimulus
Abstract image: to respond directionally to the direction of arrows
Meaningful image: to respond directionally to the pattern of brake lights
Visual Tracking: to track a laterally moving image in order to stop it at
a designated point
Design features intended to facilitate its use by the elderly include the
use of sound to give instructions, thereby permitting subjects to respond
to visual stimuli as instructions are given rather than presenting instructions
and test stimuli in sequence; use of a joy stick response system in
which all responses correspond to directions on the screen, eliminating the
need to learn response codes and minimizing response errors; and a sequencing
system that allows subjects to repeat instructions as desired, as well
as automatically repeating them after obvious errors or long delays. Familiarity
with computers is not a factor in performance, as asymptotes are reached in
a few trials of any exercise. To test the full range of abilities listed requires
30 to 60 minutes.
The individual exercises making up each APT measure are scored in terms of
time and error. The time score on any exercise is the mean time on
the individual exercises where the responses are correct. No times are recorded
for incorrect responses. Those failing to respond within the time limit are
assigned a score equal to the longest time of those correctly completing the
exercise in order to prevent time scores from being unduly influenced by long
latencies. For most exercises, error is a dichotomous measure to be
scored correct or incorrect, and score on the measure is the proportion of responses
that were incorrect. Two exceptions are visual acuity, where the correctness
measure is the level of acuity and the visual tracking where it is the distance
error averaged across exercises. Since visual tracking is also a component of
the attention-sharing measure, results for that measure include both incorrect
responses and distance error.
The APT was used in a study of 360 drivers age 62 and older who were currently
licensed and driving (McKnight and McKnight, 1998). The subjects were divided
into 2 groups:
"Incident-Involved." 249 drivers referred to licensing agencies for
reexam by police, family, courts, physicians, and licensing personnel. The mean
age was 80.6 years. Sixty percent of the group was male. Subjects with physical
problems such as stroke, severe arthritis, or loss of consciousness were excluded.
"Incident-Free."111 drivers not previously referred for reexamination,
obtained by solicitations through senior citizens groups. The mean age was 75.2
years. Sixty percent of the group was male.
The dependent variable was the presence or absence of a deficiency in driving
performance, operationalized as observed incidents of deficient driving resulting
in referrals to State licensing authority for reexamination. The correlations
between unsafe driving incidents and performance on the APT is shown below.
All correlations are positive, meaning that time and error were positively related
to driving performance deficiency. All correlations given are significant at
the .05 level while those in excess of .23 are significant at the .01 level
(2-tail in both cases).
Correlation of Ability Measures with Unsafe Driving
Incidents
| Ability |
Time |
Error |
Sensory
Static Visual Acuity
Low Contrast Acuity
Dynamic Visual Acuity
|
.28
.21
.19
|
.18
.17
.19
|
| |
| Attentional |
|
|
Range of Attention
|
|
|
Simple response
|
.20 |
|
Choice response
|
|
|
Simple image
Complex image
|
.30
.33 |
.28
.23 |
Selective Attention
|
.29 |
.33 |
Divided Attention
|
.15 |
.33/.36d |
| |
|
Perceptual
|
|
|
| Perceptual Speed |
.28 |
.22 |
Motion Detection
|
.24 |
.35 |
| Field dependence |
.12 |
.23 |
| |
| Cognitive |
|
|
Information Processing
|
|
|
Digit matching
|
.17 |
.40 |
Figure matching
|
.21 |
.30 |
Missing pattern
|
NS |
.38 |
| Short Term Memory |
|
|
Digit matching
|
.31 |
.28 |
Figure matching
|
NS |
.20 |
| Delayed Short Term Memory |
|
|
Digit matching
|
.28 |
.32 |
| |
| Psychomotor |
|
|
|
Simple Reaction Time
|
|
|
Abstract image
|
.24 |
|
Meaningful image
|
.30 |
|
| Choice Reaction Time |
|
|
Abstract image
|
.33 |
.23 |
Meaningful image
|
.30 |
.37 |
| Visual Tracking |
|
.31d
|
d = distance measure
Scores were aggregated across measures to obtain a measure of overall ability
to compare with driving performance. In doing so, scores for all measures, both
time and error, were standardized so that all would be equally weighted. With
the composite measure, it was possible to establish a "passing" score such that
80 percent of the incident-involved drivers fell below it and 80 percent
of the incident-free drivers exceeded it. A less demanding passing score found
one-third of the incident-involved drivers failing but none of the incident-free
drivers.
The authors describe two forms of implementation for the screening process.
First, in its full form it could be administered to all individuals whose driving
performance or general behavior give due cause to suspect age-related declines
in ability that could pose a threat to themselves and the motoring public. In
addition to the license referral process involved in the present study, the
test might be administered by physicians, occupational therapists, and others
working with elderly populations. Based upon the data that have been, and are
still being gathered, it will be possible to reduce the number of exercises
that must be administered to obtain acceptably reliable measures of the various
abilities making up the test, allowing it to be completed in between 20 and
40 minutes, depending upon the ability of the individual.
The second form of administration might be as part of the regular license renewal
process. Its integration into license renewal would permit detection of many
deficient drivers who are not identified through the reexamination referral
process or through private medical specialists without requiring special, age-based
license testing. To be practical, the current APT would need to be modified
to reduce testing time (~5 minutes in length) for the bulk of drivers. This
could be accomplished through development of an adaptive testing method by which
the great majority of license renewals, having no serious deficiencies, could
be quickly identified and screened out of further testing. More complete testing
would be confined to those with an elevated probability of serious deficiency.
References:
McKnight and McKnight (1998)
Cognitive Behavioral Driver's Inventory (CBDI)
Summary:
The CBDI is a test battery that includes computerized and standardized psychometric
tests (Engum, Pendergrass, Cron, Lambert, and Hulse, 1988). The standardized,
nonautomated tests include the following: WAIS-R Picture Completion Test; WAIS-R
Digit Symbol Test; and Trail-Making Test Parts A and B.
The computerized items are presented on an Atari 800 computer. Test software
is adapted from Bracy's (1982, 1985) Cognitive Rehabilitation Programs (BCRP)
for brain-injured and stroke patients, marketed through Psychological Software
Service, Inc. (PSS). Computerized tests include:
Visual Reaction Differential Response - The computer screen is bisected
by a vertical line; a small dark square appears in random locations with random
inter-trial interval. A subject pushes the joystick toward the side of the screen
on which the square appears. Dependent variables are response time, variance,
errors, and latencies in each visual quadrant. This test measures attention,
concentration, reaction time.
Visual Reaction Differential Response Reversed - Same as above, but
a subject must push the joystick in the opposite direction. Measures attention,
concentration, reaction time, dynamic cognitive processing, simple decision
making. A radio, placed in a backroom provides auditory distractors.
Visual Discrimination Differential Response II - Three squares are
presented on the screen. The subject fixates on the center square and moves
the joystick toward the square that turns the same color as the center square.
Measures rapid decision-making and stimulus discrimination/response differentiation.
Visual Scanning III - Two columns of alpha characters are shown, one
on each side of the screen. Starting in the left column, a character group is
highlighted, and the subject must find the matching character group in the right
column and move the cursor to it. This procedure repeats for 20 trials using
alternative sides for the initial stimulus. Measures ability to shift attention
from one stimulus set to another and back.
Vision is also measured in the research using the Keystone Driver Vision
Tester (far visual acuity, color vision) and the Keystone Perimeter Field
of Vision (measures up to 90 degrees on each side of fixation point).
The 10 tasks yield 27 response measures. A score termed "General Driving Index"
(or "GDI27") was defined as the mean standard score of all 27 items.
A road test is given to assess basic vehicle control operations, attitudinal
variables (subjectively evaluated), reactions under pressure or stress, and
cognitive variables such as ability to follow directions, safety awareness,
ability to find one's way around a designated circuit, and problem solving.
The CBDI was employed in a study of 92 brain- or spinal-cord injured patients
from the Center for Outpatient Rehabilitation in Knoxville, TN: 61 percent had
suffered a stroke, 21 percent had suffered traumatic brain injury, and 6 percent
had suffered spinal cord injury (Engum, Pendergrass, Cron, Lambert, and Hulse,
1988). The internal consistency reliability of the CBDI was 0.95 (Cronbach's
alpha). The correlation between performance on the CBDI (GDI27) and road test
performance was significant (2=86, Cramer's V=0.97, p<.0001).
Of the 44 patients who passed the CBDI, 42 passed the road test (95.5%). Of
the 48 patients who failed the CBDI, only 6 were allowed to take the road test.
All 6 patients "convincingly" failed the road test.
In another study of 121 brain-injured patients (cerebral vascular accident
and traumatic head injury victims) at Fort Sanders Regional Medical Center in
Knoxville, TN, two scores were calculated for each patient: (1) the overall
General Driver's Index (GDI27) defined as the mean standard score of all 27
variables; and (2) the short form Abbreviated Driver's Index (ADI10), defined
as the mean standard score of those 10 items with the highest corrected part-whole
correlations. The 10 best items with corrected part-whole correlations (which
measure how closely a given item correlates with all other items excluding itself)
were:
Trails B Time
WAIS Digit Symbol (N correct)
Visual Reaction Differential Response: joy stick to square (ave. time, Q1
time, and Q3 time)
Visual Reaction Differential Response Reverse: joy stick away (ave time,
Q1 time, Q3 time, and Q4 time)
Left Visual Scanning III (time)
Both the GDI27 and ADI10 have a mean of 50 and a standard deviation of 10,
with scores above 50 indicating greater levels of disability (Engum, Lambert,
Womac, and Pendergrass, 1988). Patients were given the CBDI and then an on-road
driving test. Results are as follows. The short form ADI10 scores and long form
GDI27 scores were very closely related [r(GDI27, ADI10)=0.97 (p<.001)]. Above
average scores on the CBDI (>50 indicates more deficit) were more likely
to occur in patients who failed the road test, while below average scores (<
50 indicates less deficit) were more likely to occur in patients who passed
the road test. Sixty-three of 121 patients passed the on-road exam. Patients
who passed had average GDI27 and ADI10 standard scores of 45. Patients who failed
the on-road exam had average standard scores of 55.
An indeterminate region with standard scores ranging from 47-52 has an overlap
of passing and failing distributions. A patient with a standard score in this
"zone of uncertainty" is almost equally likely to have passed or failed in the
examiner's opinion. Patients who obtained a standard GDI27 score of 47 or below
passed the on-road test 100 percent of the time. Patients who obtained a standard
GDI27 score of 53 or above failed the on-road test 100 percent of the time.
The following decision-making criteria are suggested: standard scores of 46
or less are clearly passing; standard scores of 47-52 are borderline; and standard
scores of 53 or greater are clearly failing. Borderline test scores on the CBDI
are not definitive and an examiner should judge these cases with information
independent of the CBDI, such as a road test, behavioral observations, or other
neuropsychological tests.
In a double-blind validation study using 175 brain-injured patients (Engum,
Lambert, Scott, Pendergrass, and Womac, 1989), the relationship between CBDI
performance (pass, borderline, fail) and the on-road evaluation outcome (pass,
fail) was significant (r=0.81, p<.0001). Of the 42 patients who received
a favorable "pass" decision based on CBDI performance, 40 passed the on-road
exam. Only 7 of the 39 patients who received an unfavorable "fail" rating on
the CBDI passed the on-road test. Patients who passed the road test passed significantly
more CBDI items (mean = 17.1) than those who failed the road test (mean = 6.3).
Patients who failed the road test failed significantly more CBDI items (mean
= 11.7) than those who passed the road test (mean = 1.7). Patients who passed
the road test produced much less scatter or within-subject variability (mean
= 16.76) in their responses than those who failed the road test (mean = 82.33).
The researchers conducted another study to determine whether the CBDI would
discriminate between 3 discrete groups: (1) those brain-injured persons whose
residual cognitive impairments preclude them from driving; (2) those brain-injured
individuals who have recovered sufficient cognitive function that they should
be allowed to resume driving; and (3) normal control subjects without brain
damage (Engum and Lambert, 1990). Subjects underwent examination on the CBDI
and were then are assessed on the road. The 215 rehabilitation patients had
a mean age of 47.8 years; the 41 control subjects had a mean age of 31.15 years.
Five summary scores were calculated from the CBDI:
(1) GDI27 - the average of the patient's 27 CBDI item scores; (2) within subject
variance; (3) number of items passed; (4) number of items borderline; and (5)
number of items failed. All 5 summary scores, plus 25 of the 27 item scores
significantly discriminated the 215 brain-injured patients from the 41 normal
controls (p<.05). The 109 patients who passed the road test performed significantly
better on all 27 items of the CBDI, and 4 of the 5 summary scores than the 54
patients who failed the road test (p<.01). The sole exception was for the
number of borderline items, which was unrelated to road test performance. After
removing the confounding effects of age, 20 of 27 item scores and 4 of 5 summary
scores continued to differentiate patients from controls. Five of the seven
that failed to differentiate pertained to number of errors (various Visual Reaction
and Scanning tests). Average GDI27 performance for controls (42.09) was superior
to that of patients passing road test (45.75), which was, in turn, superior
to patients who failed road test (54.23).
References:
Engum, Pendergrass, Cron, Lambert, and Hulse (1988)
Engum, Lambert, Womac, and Pendergrass (1988)
Engum, Lambert, Scott, Pendergrass, and Womac (1989)
Engum, Lambert, and Scott (1990)
DrivAble Testing
Summary:
The (cognitive) competence screen is presented on a touch screen computer,
and takes 20-30 minutes to administer (DrivAble Testing, Ltd., 1997). Tasks
require multiple mental abilities and integration and shifting among these abilities.
Tests include:
a selective attention task;
an assessment of judgment/decision making using a Gap Task (designed by research
team);
visual attention, using a version of UFOV (Ball et al., 1994);
a spatial working memory task;
a simple and choice reaction time test; and
Weaver's Driving Video (selected and revised driving scenarios).
Two competence scores are generated: The high cut-off score identifies the
performance level necessary to accurately predict that the driver would pass
the road test; the low cut-off score identifies the performance level below
which accurate predictions of failing road-test performance can be achieved.
The road test would only need to be administered to those who score in the mid
range on the competence screen (and, depending on the jurisdiction, for those
who fail the competence screen but want a road test as due process).
A road test was administered by 2 experienced driving instructors from the
Canadian Automobile Association. Testing was conducted in a mid-sized American
car equipped with dual brakes. Definition and scoring of errors was as follows:
Hazardous or potentially catastrophic driving errors: errors committed
by drivers who are no longer competent to drive (e.g., wrong-way on a freeway,
stop at green light), and would result in a crash if examiner did not intervene
or traffic did not adjust.
Discriminating driving errors: potentially dangerous errors that signal
declining driving skill (e.g., poor positioning on turns and straight aways,
observational errors).
Non-discriminating driving errors: errors made equally often by good
and bad drivers, reflecting bad habits as opposed to declining ability (e.g.,
rolled stops and speed errors). Drivers are not penalized for non-discriminating
errors. Discriminating errors are documented and scored in terms of their severity
(5, 10, or 51 points). Hazardous errors were renamed as Criterion errors and
the commission results in an automatic fail. A combined criterion of one or
more criterion errors and/or discriminating point total exceeding criterion,
results in a failure on the road test.
In the test development research 279 drivers were assessed across three groups:
176 patients who were referred to a clinic with suspected decline in mental
abilities (the majority were diagnosed with Alzheimer's) with a mean age of
72 years; 70 mature healthy drivers who volunteered for the research, with a
mean age of 69 years; and 33 young healthy controls who also volunteered, ranging
in age from 30 to 40 years, with a mean age of 36 years. Subjects in the development
research were used to develop road test procedures and scoring. The majority
of the drivers who failed the road test received low scores (poor performance)
on the cognitive screen; the majority of the drivers who passed the road test
received high scores (good performance) on the cognitive screen.
Validation research included 431 drivers. The cut-off scores identified in
the original research for the competence screen were 94 percent accurate in
predicting actual pass/fail performance on the road test. Only 33 percent of
those tested had Competence Screen scores falling below the high and low cut-off
scores. Analysis of the road test errors revealed the same categories of errors
and verified the effectiveness of the road test for revealing the errors among
unsafe drivers. Using the joint criterion, all of the young normal drivers passed
the road test, approximately 95 percent of the mature control group drivers
passed the road test, and only 25 percent of the cognitively impaired (patient)
group passed the road test.
The Competency Screen resulted in a 5 percent error in predicted road test
performance: it predicted a pass for 29 of the 33 drivers who passed the road
test, and predicted a fail for 33 of the 34 drivers who failed the drive test.
The screen reduced the number of drivers who needed to be tested by 67 percent.
Only 33 percent of the drivers in the sample received an indeterminate score
on the competence screen: 54 percent of the indeterminate drivers passed the
road test and 45 percent failed the road test.
References:
DrivAble Testing Ltd (1997)., Suite 200, 18208 102 Avenue, Edmonton, Alberta,
Canada, T5S 1S7. Phone: (403) 413-1909; fax: (403) 413-8916
Dobbs (1997)
The Neurocognitive Driving Test (NDT)
Summary:
The NDT is a new computerized task designed to provide an ecologically valid
measure of driving ability based on Michon's Hierarchical Model of Driving Behavior.
It has recently been administered at Moss Rehab Driving School, a branch of
the Moss Rehab Hospital Philadelphia, Pennsylvania (Schultheis and Chute, 1998).
The NDT is divided into five sections as follows, with a total performance score
calculated using variables from each section:
I. Self Evaluation: Includes 5 questions involving self-rating of driving
skills.
II. Pre-Driving Questions: Includes 12 multiple choice and open-ended
questions, with both linguistic and graphic stimuli designed to target an individual's
ability to correctly identify important information needed prior to engaging
in driving (i.e., check gas in car, have correct paperwork).
III. Reaction Time Task: Includes a total of 24 counter-balanced trials,
12 measuring simple reaction time (6 left-foot trials and 6 right-foot trials)
and 12 measuring choice reaction time.
IV. Driving Scenario Task: Includes the presentation of 4 driving scenarios,
which the subject "drives" through with the use of an attached steering wheel
and foot pedals. They include: (1) Following Signs; (2) Emergency Situation;
(3) Following Verbal Directions; and (4) Following Written Directions.
V. Visual Task: Includes a visual task, designed to assess an individual's
left and right visual fields for gross field cuts or visual inattention. The
subject is asked to stare at a small black box in the center of a blank screen.
When the task begins, a small dot flashes at various locations on the computer
screen. If the subject sees the dot, he/she is required to respond by stepping
on the right (green) foot pedal.
All participants were between 18 and 60 years of age, with a minimum of one
year of driving experience and no prior medical or psychiatric history. The
subjects included 15 brain-injured (BI) adults and 26 healthy adults. The BI
adults were 10 men and 5 women with a mean age of 38.6 years (range= 21-59 years)
and mean education level of 14.3 years. Their mean number of years of driving
experience prior to their injury was 21.0, and at the time of testing only four
individuals had not returned to driving. The 26 healthy adults included 18 males
and 8 females, with a mean age of 27.7 years (range= 18-45 years) and a mean
education level of 14.5 years. All subjects had a valid driver's licenses at
the time of testing. The mean number of years of driving was 10.7.
All brain-injured subjects were administered both a hospital-based driving
evaluation and the NDT.
The hospital-based evaluation included performance of various off-road and
behind-the-wheel evaluations. Subjects were then separately rank ordered based
on their overall performance rating in the hospital evaluation and on their
NDT Total Performance score. A comparison of the rank ordering was conducted
using a Spearman Rank Order Correlation. Healthy subjects received only the
NDT. Mean and standard deviation of healthy-subject performance was calculated
for comparison with performance by BI subjects.
A positive correlation (p = 0.743), was found between the rank order generated
by the hospital-based evaluation and the rank order generated by the NDT for
BI subjects. Of the 15 BI subjects, the NDT accurately predicted 10/11 subjects
who passed the hospital-based evaluation and placed the four individuals who
failed the hospital evaluation at the lower end of the rank order. The subject
ranked lowest by the NDT was the lowest ranked passing subject by the hospital
evaluation.
A comparison of NDT total performance between BI and healthy subjects was calculated
by a simple factorial ANOVA covarying for age, and revealed a significant difference
between BI subjects who passed the hospital evaluation and normal subjects (p=
.034). Additionally, it was observed that BI subjects who failed the hospital
evaluation exhibited poorer NDT performance then both normal subjects and BI
subjects who had passed.
This first concurrent validity study involved 15 BI subjects, who were administered
the NDT and a comprehensive hospital-based evaluation. The results demonstrate
a significant correlation between the rank order of driving ability generated
by the hospital driving evaluation and the rank order of driving ability generated
by the NDT Total score. This comparison demonstrates the ability of the NDT
to determine the rank order of driving ability, as determined by a presently
accepted measure of driving ability (e.g. hospital-based evaluation). The correlation
of the two rank orders suggests that both programs are targeting similar skills,
which at present serve as the criterion to whether an individual is able to
return to driving after a brain injury.
References:
Schultheis and Chute (1998).
IC2(b)iii. Ophthalmological/Optometric Examination
Definitions
An optometrist is a health care professional trained and state licensed
to provide primary eye care services. These services include comprehensive eye
health and vision exams; diagnosis and treatment of eye diseases and vision
disorders; the detection of general health problems; the prescribing of glasses,
contact lenses, low vision rehabilitation, vision therapy, and medications;
and the counseling of patients regarding their surgical alternatives and vision
needs as related to their occupations, avocations, and lifestyle. Doctors of
optometry provide 70 percent of primary eye and vision care services in this
country and far outnumber any other eye care practitioners (American Optometric
Association, 1996)
The optometrist has completed pre-professional undergraduate education in a
college of optometry, leading to a doctor of optometry (O.D.) degree. Some optometrists
complete a residency. All States require at least 15 hours of continuing education
each year for license renewal. All 50 States and DC have legislation authorizing
doctors of optometry who have satisfactorily completed specific education courses
and examinations to use pharmaceutical agents in the evaluation and diagnosis
of conditions of the eye and visual system. Also, all 50 States have legislation
authorizing doctors of optometry to use drugs to treat certain eye conditions.
Doctors of optometry work closely with other professionals by consulting with
family practitioners, pediatricians, neurologists, ophthalmologists, dermatologists,
and others when treatment is required outside the scope of their practices.
This consultation process is two-way, and as the health care delivery system
continues to change, this interprofessional consultation and concurrent care
will become more important.
An ophthalmologist is a medical doctor (MD or osteopath) who is educated,
trained, and licensed to provide total care of the eyes (medical, surgical,
and optical), including: performing comprehensive medical eye examinations;
prescribing corrective lenses; diagnosing diseases and disorders of the eye;
and using the appropriate medical and surgical procedures necessary for their
treatment. Retinal specialists are ophthalmologists with extra training and
experience in treating disease affecting the retina such as diabetic retinopathy.
Vision Examinations: Content and Frequency
Because primary care physicians provide only a vision screening (distance acuity,
questions on seeing difficulties, and a check with an ophthalmoscope), people
are advised by the AOA to get a thorough eye exam every year or two from an
optometrist that will include:
A review of family and personal health history, including any problems the
individual is having with vision;
Tests to determine how well the individual can see at near and far distances;
Tests to determine nearsightedness, farsightedness and astigmatism (a refraction)
and if there is a problem, a lens prescription to correct for it;
A check of eye coordination and eye muscle function;
Tests of ability to change focus easily from near to far and vice versa and
to maintain clear focus for reading and other close work;
An eye health examination, involving a number of tests (in some cases, the
eyes may be dilated for this part of the exam).
AOA recommends that people ages 10 to 40 see an optometrist every 2 to 3 years;
people ages 41 to 60 every two years; and people age 61 and older every year
(AOA, 1996). Individuals age 61 and older have an increasing risk for the development
of cataracts, glaucoma, and macular degeneration and other sight threatening
or visually disabling eye conditions as well as systematic health conditions.
Additionally, people age 65 and older who are diagnosed with diabetes or hypertension;
those who have a family history of glaucoma or cataracts; and those taking prescription
or nonprescription drugs with ocular side effects should follow their optometrist's
advise on how often they need professional care.
Eye Diseases
Diabetic Retinopathy. Diabetic retinopathy is a complication of diabetes
mellitus, caused by the deterioration of the blood vessels nourishing the retina
(American Academy of Ophthalmology, 1984). These weakened blood vessels may
leak fluid or blood, develop fragile brush-like branches, and become enlarged
in certain places. The risk of developing diabetic retinopathy is high for patients
who have had diabetes for a long time. Approximately 60 percent of patients
having diabetes for 15 years or more have some blood vessel damage in their
eyes. Diabetic eye disease remains the leading cause of blindness in the U.S.
for adults between the ages of 20 and 74 years. Pregnancy, high blood pressure,
poor control of diabetes, ethnic influences, and smoking may worsen this condition
in diabetic patients.
Though gradual blurring of vision may occur, sight is usually unaffected by
background retinopathy (early stage that does not progress in 80 percent of
diabetic patients), and changes in the eye can go unnoticed unless detected
by a medical eye condition. When bleeding occurs in proliferative retinopathy,
the patient has hazy or complete loss of sight. Though there is no symptom or
pain, this severe form of diabetic retinopathy requires immediate medical attention.
To detect diabetic retinopathy, an ophthalmologist painlessly examines the
interior of the eye using an instrument called an ophthalmoscope. The interior
of the eye may also be photographed to provide further information. If diabetic
retinopathy is noted, a second method of examination may be used to see which
blood vessels are bleeding or leaking fluid. A fluorescent dye is injected into
the patient's arm. It travels through the bloodstream and passes into the blood
vessels of the retina. Photographs are taken rapidly of the dye as it leaks
through the retina's blood vessels. This treatment is called fluorescein angiography.
The most significant treatment is the use of ophthalmologic laser surgery to
seal or photocoagulate the leaking blood vessels. This treatment does not require
an incision and may be performed in an ophthalmologist's office. If diabetic
retinopathy is detected early, photocoagulation by ophthalmologic laser surgery
may stop continued damage. Even in advanced stages of the disease, it can reduce
the chance that a patient will have severe loss. However, photocoagulation cannot
be used in all patients. Depending on the location and extent of diabetic retinopathy,
and if the vitreous is too clouded with blood, a surgical treatment called vitrectomy
can be performed. The blood-filled vitreous is removed from the eye and replaced
with a clear artificial solution. About 70 percent of vitrectomy patients notice
an improvement in sight. Successful treatment depends on early detection with
monitoring and treatment by an ophthalmologist, in addition to the patient following
diet and medication recommendations. Although physical activity presents few
problems with background retinopathy, it can increase bleeding in proliferative
retinopathy. Exercise for patients with proliferative retinopathy should be
moderate, and straining or leaning over with the head down should be avoided.
Macular Degeneration. The retina is the delicate layer of tissue that
lines the inside wall of the back of the eye. The macula is a very small area
in the center of the retina. If the macula is damaged, the central part of the
images are blocked/blurred. The images around the blurred area may be clearly
visible. Macular degeneration does not result in total blindness, but it makes
reading or close work difficult to impossible without special low vision optical
aids. Although macular degeneration most often occurs in older people, aging
alone does not always result in central visual loss. The most common form of
macular degeneration is called involutional macular degeneration; this form
accounts for 70 percent of all cases and is associated with aging (American
Academy of Ophthalmology, 1984).
Many patients do not realize they have a macular problem until blurred vision
becomes obvious. An ophthalmologist can detect macular degeneration in the early
stages by viewing it with an ophthalmoscope, if periodic eye exams are part
of the patient's health care. The examination will also include a grid test
in which the patient looks at a test page similar to graph paper; this checks
for the extent of sight loss spots. A color vision test may be employed, as
color vision dimming is also a symptom of macular degeneration. A fluorescein
angiogram may also be done, as described earlier.
There is no cure for the most common involutional form of macular degeneration.
Low vision optical aids help improve vision. Many types of magnifying devices
are available: spectacles, hand or stand magnifiers, telescopes, and closed
circuit television for viewing objects are some of the available sources. Aids
are either prescribed by an ophthalmologist or by referral to a low vision specialist
or center. People over age 50 and people with a family history of retinal problems
should have periodic eye exams that check for macular degeneration.
Glaucoma. Glaucoma is one of the leading causes of blindness in the
U.S., affecting 2 out of every 100 persons over age 35 (American Academy of
Ophthalmology, 1983). When diagnosed early, blindness from glaucoma is almost
preventable. Glaucoma occurs when the drainage system of the eye gets blocked
and fluid pressure within the inner eye increases, causing damage to the optic
nerve. Most adult glaucoma patients have "chronic open-angle glaucoma" which
is a partial blockage that causes a gradual increase of pressure within the
eye. According to the American Academy of Ophthalmology (1983) it is seldomly
accompanied by symptoms, "stealing vision so quietly that the patient is unaware
of trouble until the optic nerve is badly damaged." Factors increasing the risk
of damage include a family history of glaucoma, and general health problems
such as diabetes, arteriosclerosis, or anemia.
Early diagnosis can be made in the course of a periodic eye examination, by
an ophthalmologist who determines the pressure of the eye during a painless
procedure. The fields of vision will be tested for shrinkage or blind spots,
and an ophthalmoscope will be used to examine the optic nerve.
Glaucoma is usually controlled by eye drops given 2 to 4 times per day or by
pills in various combinations, to decrease pressure either by assisting outflow
of fluid from the eye or by decreasing the amount of fluid entering the eye.
If medications are poorly tolerated or ineffective in controlling pressure in
open-angle glaucoma, surgery can be performed to form a new drainage canal in
the eye.
The American Academy of Ophthalmology recommends that persons over age 35 be
checked for glaucoma every 2 or 3 years.
Cataract. A cataract is a clouding of the normally clear and transparent
lens of the eye, that usually develops gradually over many years (American Academy
of Ophthalmology, 1984). It may cover only a small part of the lens; if sight
is not greatly impaired, there may be no need to remove the cataract. Alternatively,
if a large portion of the lens becomes cloudy, sight can be partially or completely
lost until the cataract is removed. Depending on the size and location of the
cloudy area in a lens, a person may or may not be aware that a cataract is developing.
As cataracts develop, there may be hazy, fuzzy, and blurred vision. Double vision
may also occur when a cataract is beginning to form. The eyes may be more sensitive
to light and glare making night driving difficult.
Most cataracts are caused by a change in the chemical composition of the lens,
resulting in a loss of transparency. These changes can be caused by aging, injuries
to the eye, certain diseases and conditions of the eye and body, and heredity
or birth defects. The normal process of aging may cause the lens to harden and
turn cloudy. These are called senile cataracts and are the most common type,
occurring as early as age 40. The American Academy of Ophthalmology recommends
that persons over age 40 with a family history of cataracts have their eyes
checked periodically to detect signs of eye disorders, including cataracts.
A cataract usually cannot be detected by looking at the outside of the eye;
proper instruments are required. Surgery is the only effective way to remove
the cloudy lens. Once the cloudy natural lens of the eye is removed, the patient
needs a substitute lens to focus the eye. These may include special cataract
glasses, hard or soft contact lenses, or interocular lenses (IOLs) that are
permanent lenses implanted inside the eye by surgery, in place of the natural
lenses.
References:
American Optometric Association (AOA): Definition of Doctor of Optometry
AOA (1996): Vision Screening vs. Vision Examination
American Academy of Ophthalmology (1984): Macular Degeneration
American Academy of Ophthalmology (1984): Diabetic Retinopathy
American Academy of Ophthalmology (1983): Glaucoma
American Academy of Ophthalmology (1984): Cataract
IC2(b)iv. Simulator Measures of Response Effectiveness
Iowa Driving Simulator (IDS)
The IDS is a realistic ground-vehicle simulator that provides 190 degrees in
the forward field of view and 65 degrees in the rear view. Multiple roadway
types, traffic signals, traffic conditions, and vehicles can be displayed. These
vehicles interact with the driver and each other according to a particular set
of rules dictated by the experimental driving scenario. Acceleration speeds
of up to 1.1g produce a majority of the movement cues experienced during normal
driving. The steering wheel, accelerator, brake pedal, and gearshift positions
are read by the host computer to give feedback to the driver and allow him/her
to control the driving simulation.
This simulator was used in a study of 39 licensed drivers (21 with Alzheimer's
Disease and 18 controls without dementia) to determine fitness to drive for
neurological patients (Rizzo, Reinach, McGehee, and Dawson, 1997). The study
had three goals: (1) to test the hypothesis that drivers with AD are more at
risk for crashes than controls of similar ages without dementia; (2) to determine
what specific driver safety errors preceded a crash; and (3) to determine how
such unsafe events are predicted by visual and cognitive factors sensitive to
decline in aging and AD. Each participant "drove" approximately 18 miles on
a simulated 2-lane highway with interactive traffic. Four events associated
with potential crashes were interspersed with uneventful highway segments. In
event 1, the participant drove at 55 mph and encountered a slower moving tractor-trailer
truck traveling uphill at 35 mph. In event 2, the participant suddenly encountered
a lead vehicle stopped at a 4-way intersection waiting to turn left. In event
3, the participant drove at 55 mph and encountered a slower moving lead vehicle
traveling at 35 mph along a flat segment of highway. The participant had to
slow and travel at the leading vehicle's speed for 2 seconds before the lead
vehicle increased its speed to 55 mph. In event 4, the participant encountered
the same lead vehicle slowing down to turn left at a 4-way intersection. Driver
performance errors were classified into 1 of 3 possible categories: unplanned
lane deviations; dangerously close headways (less than 0.6 seconds); and abrupt
braking. Near misses occurred when the driver had to take evasive action to
avoid a collision.
Six participants (29%) with AD experienced simulator crashes versus none of
the 18 controls. Drivers with AD were more than twice as likely to experience
close calls. Plots of critical control factors in the moments preceding a crash
revealed patterns of driver inattention and error. In one type of crash, the
driver was looking directly out the front of the windshield but took no action
(looking without seeing). Other crash types involved participants who reacted
too late or evaded a primary hazard only to experience a second collision. Only
one crash occurred on a straightaway segment; this driver lost control of the
vehicle while distracted. Analysis of the crash circumstances, taking into account
vehicle speed using the General Estimates System, showed that several of the
crashes in the study (15 of 21) would likely have been fatal. Thirty-six drivers
had near misses (14 of the 19 AD participants and 6 of the 17 control participants).
The authors conclude that high-fidelity driving simulation provides a unique
new source of performance parameters to standardize the assessment of driver
fitness. By increasing the exposure of older drivers and drivers with dementia
in high-fidelity simulated collision avoidance scenarios, the experimenters
were able to infer crash risk through direct observation of events that might
have taken months to infer from real-life events. Detailed observations of crashes
and other safety errors provide unbiased evidence to aid in the difficult clinical
decision of whether older or medically impaired individuals should continue
to drive.
Doron Precision Systems
P.O. Box 400; Binghamton, NY 13902-0400; (607) 772-1610.
L-300 Series Driver Analyzer: Cue Recognition Subtasks.
Cue Recognition is a three-part test administered via a noninteractive driver
simulator system (Doron Precision Systems' L-300 Series Driver Analyzer). A
familiarization session allows for RT testing (press the brake in response to
lights flashing in a certain configuration on the console). Cue Recognition
presents car icons generally facing away from the subject and rapidly and suddenly
changing their positions on a wide projection screen. When an "action cue" occurs
(icon faces forward or to the side) the subject is to release the accelerator,
and within 5 seconds, brake or turn the wheel in the appropriate direction.
For Cue 1, the action cue is a car facing toward the subject; the subject must
brake. For Cue 2, the action cue is a car that faces to the left or right; the
subject must turn the steering wheel in that direction. Cue 3 contains a mix
of Cue 1 and Cue 2 trials. Release of the accelerator from stimulus initiation
is timed, and the score is output in distance traveled at 55 mph from stimulus
presentation to accelerator release. Speed of braking or wheel turn is irrelevant.
Cue Recognition was employed in a study of 102 subjects (ages 60 to 91) referred
to CA DMV for reexamination, and 33 paid volunteers ages 56 to 85 (Janke and
Eberhard, 1998; Janke and Hersch, 1997). The purpose of the study was to determine
which of the several psychophysical tests administered were able to predict
the on-road driving performance of the test sample. Results showed that Cue
1, Cue 2, and Cue 3 average distances, total errors, and average RT (Doron orientation
exercise) correlated significantly with a weighted error score on a road test
as follows:
Total Errors: r = .4382, p< .000
Average RT: r = .3297, p<.005
Cue 1 distance: r = .4777, p<.000
Cue 2 distance: r = .4656, p<.000
Cue 3 distance: r = .3584, p<.002
A subset of the referred subjects were cognitively impaired; they performed
significantly more poorly on Cue 2, Cue 3, reaction time, and total errors than
the cognitively nonimpaired referrals.
L-300 R/A (Rehabilitation and Assessment) Simulator. This
system is designed to evaluate a driver's readiness and capability to operate
a motor vehicle safely. The driver analyzer films allow a therapist to evaluate
a person's cognitive skills as well as their physical abilities and limitations.
It may be used to: (1) identify deficiencies that rule out an individual as
a candidate for driving; (2) evaluate if an individual needs adaptive equipment,
and if so, what type; and (3) determine what therapy or training would help
the individual improve his/her operation of a motor vehicle, in cases where
the individual has limitations. The simulator may also be used as a training
and rehabilitation tool, allowing for behind-the-wheel training under non-threatening,
realistic driving situations. A disabled person may be trained using wide angle
sound and motion films, in the necessary perceptual, judgmental, and procedural
skills needed for driving. A printout is used for evaluation of performance.
The simulator has been used in the Driving Program at Spring Hill Rehabilitation
in San Antonio, TX (Doron Brochure, Q and A with Kim Redding, O.T.). At this
facility, patients with neurological problems including head injuries and stroke
are targeted for assessment (those who have cognitive and perceptual deficits)
as are physically impaired clients. The visual aspect of the evaluation is helpful
to clients with visual scanning, visual attention, or visual field impairments,
according to Ms. Redding. The information obtained from the simulator setting
is beneficial in providing insight to clients regarding how their deficits affect
driving. The simulated environment helps OTs evaluate crash avoidance and threat
recognition skills in a safe environment. On the road, therapists have little
idea how clients will respond to stressful, threatening situations. In the simulator,
the amount of visual stimuli a client receives can be controlled: for example,
a client with a head injury may perform well in low stimulus situations, but
in unfamiliar locations where fast decisions are critical, they may not do as
well.
MultiCAD, Scientex Corp.
MultiCAD ia a PC-based tabletop testing system that uses a combination
of video clips of driving scenes and computer-generated images to maintain a
high level of face validity for everyday driving situations. The MultiCAD
protocol displays dynamic, suburban arterial driving scenes on a 27-inch screen
capable of accepting both video (NTSC TV standard) and computer graphics (SVGA)
inputs. A brake and accelerator pedal assembly is used for stop-and-go decisions
and brake reaction measures. The MultiCAD battery contains multimedia
(audio and visual) instructions, presented on-screen through pre-recorded video
of a "talking head." Tests that measure drivers' responses to actual traffic
scenes are described below. Study results were presented in section 1A2h of
this Notebook (see Staplin, Gish, Decina, Lococo, and McKnight, 1998).
Angular Motion Sensitivity. This test uses MultiCAD to measure
drivers' ability to rapidly detect changes in the relative motion of their own
versus other vehicles. A video of suburban driving scenes is used which presents
a driver's eye view of travel along an arterial route with light traffic, following
a lead vehicle (that the subject is told to pay attention to) at varying distances.
Subjects are required to depress the brake in the MultiCAD assembly
whenever the vehicle directly ahead in the same lane applies its brakes or at
any other time it would be advisable to stop or slow down under actual driving
conditions (e.g., an adjacent-lane driver encroaches into the lane of travel).
The lead vehicle brake lights are illuminated when it slows in 12 of the 15
angular motion sensitivity trials. For three other angular motion sensitivity
trials, the lead vehicle's brake lights are disabled during filming of the video,
so that the subject is required to detect the change in headway without the
additional brake light cue. These three trials are intermixed with the trials
in which the brake lights are illuminated.
Measures of effectiveness are: (1) mean brake reaction time
across 12 trials, to slowing/stopping lead vehicle with brake light activation,
for correct responses; (2) percent error for these trials (e.g., percent
of the trials where the vehicle ahead slows and the brake lights are
clearly visible, but the subject did not press the brake pedal); (3)
mean brake reaction time across three trials, to slowing/stopping lead vehicle
with no brake light activation, for correct responses; and (4)
percent error for these three trials.
Useful (Functional) Field of View. This divided attention test uses
MultiCAD to measure drivers' ability to remain vigilant and respond
in a timely and appropriate manner to events that occur directly ahead in the
travel path, while also detecting unexpected events of a safety-critical nature
that occur in the areas of peripheral vision. After angular motion sensitivity
data are obtained, the same driving video continues to use the lead vehicle
target as a "foveal task" (i.e., located centrally along the driver's line of
sight). At predetermined intervals in relation to a (lead vehicle) brake light
stimulus, vehicles and pedestrians are introduced unexpectedly in the periphery
of the driver's forward vision, offset at angles of approximately 15 degrees
and 30 degrees to the left and right sides. The motion of these peripheral targets
brings them into potential conflict with the driver within several seconds'
travel time.
For threats intersecting from the periphery at approximately
a 15-degree angle of eccentricity (2 trials), the
measures of effectiveness are: (1) mean reaction time for correct response to
(a) a vehicle pulling out from behind a building on the right side of the scene
and (b) a vehicle backing out of a parking space from behind a (blocking) U-Haul
van on the left side of the scene; and (2) percent error for these two trials.
For threats intersecting from the periphery at approximately a 30-degree
angle of eccentricity (1 trial), the measures of effectiveness are: (1) mean
reaction time for correct response to a pedestrian stepping off the curb and
entering the driver's path; and (2) percent error.
Easy Driver
Schiff and Oldak (1993) used a computer-video display and recording system
called Easy Driver which runs from a Macintosh microcomputer and a
standard large-screen color TV monitor, with a dual pedal control unit (brake
and accelerator). Drivers view driving scenarios while they operate brake and
accelerator pedals to drive at preferred speeds under various conditions, and
to brake in response to events occurring in the video. The scenarios include
traffic events in which drivers may respond to the onset of brake lights in
a lead vehicle or rapid closures of gaps between vehicles, intrusions of other
vehicles and pedestrians (high and low illumination conditions), stop signs
and traffic signals, and tennis balls (small, high contrast target) or basketballs
(large, low contrast target, used in day and in dusk conditions) rolling into
the road in suburban residential areas (indicating possible incursion of child).
Drivers proceed at their own pace in several scenarios including highway driving
in excellent road conditions in light traffic, wet snow/rain, heavy rain, and
night driving with oncoming headlight glare. A left turn scenario to tap "go/no
go" decisions (gap acceptance) has been filmed but was not used as part of the
research study, because varying the speed of approach affected the speed of
the oncoming vehicles, although this scenario may be useful in a fixed speed
format. A simple RT task is also included in the program. Assessment time is
15 minutes. Study results were presented in section 1A2h of this Notebook.
Of particular interest, as noted by the study authors, is that "many persons
over age 75 and 2 individuals with cataracts failed to see small objects (e.g.,
basketball or tennis ball bouncing across the street) portending a possible
emergency event (child running into the road)." One of the best predictors of
crash risk for older drivers was a dusk scenario in which a basketball (low
contrast target) bounces in front of the driver's car. Responses to the corresponding
daylight event were unrelated to crash risk, specifically denoting the lighting
condition as critical. The authors note that these measures might be used for
diagnostic and counseling purposes in various public and private settings, such
as AAA auto club centers, community centers, AARP programs, motor vehicle bureaus,
hospital rehabilitation centers, and driver training schools or classes. The
original digital video-computer system has been modified to permit use of standard
TV monitors, thus reducing the cost and increasing the resolution. The system
runs on standard Macintosh microcomputers (desktop or laptop).
STISIM (Systems Technology, Inc.) Simulator
13766 Hawthorne Blvd., Hawthorne, CA 90250. Phone: (310) 679-2281; Fax: (310)
644-3887.
STISIM is a PC-based interactive simulator designed to represent a range of
psychomotor, divided attention, and cognitive tasks involved in driving. The
simulation includes vehicle dynamics, visual and auditory displays, and a performance
measurement system. Driving tasks are programmable with Scenario Definition
Language (SDL) that allows the user to specify an arbitrary sequence of tasks,
events, and performance measurement intervals. The visual display scene can
be presented with conventional computer monitors or projectors. The scene includes
a roadway, horizon scene, secondary task displays, intersections, traffic control
devices, and interacting traffic. The events in the SDL allow the user to specify
various driving tasks that permit measurement of psychomotor, divided attention,
situation awareness, and other cognitive behavior. Steering and speed control
behavior can be measured on straight and curved road sections. Subsidiary peripheral
signals can be presented that divide the driver's attention and require a horn
or turn indicator response. The specification of lead and opposing vehicles
requires the driver to make passing decisions while signal light timing can
be specified to require stop/go decisions. Cross traffic and pedestrians can
be specified to intersect the driver's path. Situation awareness can be tested
by including interactive traffic/pedestrians and a side view mirror representation
of an adjacent vehicle that interferes with lane changing. The simulator has
been used in driver behavior research associated with impairment (alcohol, drugs,
and fatigue), visibility, traffic control devices, intersection complexity,
decision making, vehicle control, and IVHS.
University of Illinois/Atari Interactive Driving Simulator
In their research, Szlyk, Brigell, and Seiple (1993) utilized an interactive
driving simulator (developed in collaboration with Atari Corp.), that is composed
of a seat, steering wheel, gas and brake pedals, and an automatic transmission.
The visual display consists of three 24-inch color monitors displaying a total
160 horizontal viewing field and a 35 vertical viewing field of a computer-generated
environment to a driver sitting 22 inches from the center screen. Stimuli are
computer-generated images of a simulated roadway with traffic, signs, and painted
roadway lines. The video scene is updated 20 times per second. Simulator performance
measures of effectiveness in the research included: (1) mean speed (in mph);
(2) average slowing and stopping to traffic signals; (3) number of lane boundary
crossings; (4) mean break pedal pressure; (5) mean gas pedal pressure; (6) number
of simulator crashes; (7) lane position; (8) steering angle; and (9) vehicle
angle to the road. Six staged driving simulator challenges required visuocognitive/motor
skills to avoid a crash; three of these were intersections with cross traffic.
Eye and head movement were recorded for each subject. Self report of crashes
over the previous five years was also collected for each subject.
The test participants in the study by Szlyk et al. (1993) included 6 patients
(2 females and 4 males) with hemianopic visual field deficits, ages 53 to 80
(mean = 71 years); 7 older controls with normal vision (3 females and 4 males)
ages 62 to 83 (mean = 70 years); and 31 younger controls (16 females and 15
males) with normal vision age 21 to 64 (mean = 40 years). Results of the study
included the following: (1) significantly more lane boundary crossings for the
older patient group, but no significant differences between the older and younger
control groups for this performance measure; (2) greater variability in lane
position among the older patient group with no consistent differences in absolute
lane position between the two control groups; (3) greater deviations in steering
angle by both groups of older drivers compared to the younger control group,
but no significant differences between the older patient and older control group
on this measure; (4) no significant differences between the three groups in
their vehicle angle to the road performance measure; (5) longer slowing times
by four older controls and three older patients when compared to the younger
controls, but no differences in mean slowing times between the two older groups,
due to a large variability among individuals; (6) prolonged stopping times by
both older driver groups when compared to the younger control group; (7) slower
average speeds exhibited by both older groups when compared to the younger group,
but no differences in mean speed between the older patients and older control
subjects; (8) lower average pedal pressure and greater variability in accelerator
pedal pressure by both older groups in comparison to the younger group, but
no differences between the two older groups on this measure; (9) no significant
differences between mean brake pedal pressure among the three groups, but greater
variability in brake pedal pressure for both older groups when compared to the
normally sighted younger controls; and (10) simulator crashes occurred only
for two subjects in the older normally-sighted group. Real-world crash reports
were obtained for a 5-year period. Two of the four older subjects who had real-world
crashes also had the longest slowing times, the longest stopping times, and
the most crashes in the driving simulator.
driVR System
Imago Systems, Inc. Virtual Reality Technology; Suite 670; 220 Cambie Street;
Vancouver, B.C., V6B 2M9; Phone: (604) 681-9288; Toll free: 1-888-613-3311;
Fax: (604) 681-8705; email: imagovr@ibm.net
The driVR system provides objective data that can be used by a clinician during
assessment, training or rehabilitation of driving skills. It was developed to
incorporate cognitive and behavioral factors that affect driving performance,
such as attention, visual tracking, tactical decision making, and strategic
planning. It measures operational and tactical performance during "virtual driving
events" such as road sign recognition, lane tracking, speed, obstacle avoidance,
hazard recognition and reaction time. The driVR system incorporates the latest
in virtual reality technology and 3D graphics software. The simulator runs on
a Pentium PC and includes a virtual reality headset and interactive driving
controls. The user operates the vehicle and drives around a realistic 3D environment
using steering and brake/accelerator controls. Upon completion of the course,
objective real-time data is presented in the form of detailed test results (profiles
or ratings of driving skills and risk behavior). When not using the simulator,
the computer can be used for other tasks.
Although the hardware plus single-use full license on the software may be purchased
through Imago Systems, this option is available only to Canadian clients, as
computer warranties do not extend beyond the border. In the U.S., the computer
should be purchased locally to allow for local warranty service. A large well-known
computer manufacturer should be selected. Alternatively, the system may be leased
(2 and 3 year options); rented to own; or set up on a pay-per-use system. On
the pay-per-use system, the user must supply his/her own computer.
The results of a study conducted by Liu and Miyazaki (in press) at
the University of Alberta supports the use of age-specific norms and provides
some evidence for validity. There are components of the driVR test that can
discriminate between normal subjects and head-injured subjects (the Follow Traffic
Route and Performance at Stop Signs). The authors state that DriVR should be
used as an adjunct to current assessment tools, and not as a replacement until
further research is conducted. It is planned that research will continue to
determine the correlation between driVR and on-road driving performance, as
well as further psychometric testing. Clinical validation of driving segments
within the driVR has been achieved through research at the University of Alberta;
however it is not yet published.
Elemental Driving Simulator
Life Sciences Associates, One Fenimore Road, Bayport, NY 11705-2115. Phone:
(516) 472-2111, Fax: (516) 472-8146.
The EDS is a personal computer-based quasi-simulator for use by professionals
in driver rehabilitation with cognitively at-risk persons (e.g., older drivers,
persons returning to driving after a head injury or stroke). The EDS helps address
the issue of whether the individual possesses sufficient information processing
capabilities to drive safely (Gianutsos and Campbell, 1988, 1991). It is comprised
of an IBM-compatible PC, a 10-inch diameter steering wheel controlling a 150K
linear potentiometer with turn signal, and a momentary contact foot pedal. The
software is written in compiled QuickBASIC, and is fully menu driven. Testing
requires about 20 minutes, although 30 minutes should be scheduled to allow
for sufficient practice by the poorest performing segment. The system is elemental
in its technical simplicity and in its simulation of the elements of driving-related
cognitive abilities. The assessment protocol begins with a self-appraisal of
cognitive abilities related to driving: steering control, speed of reaction,
self-control (impulsivity), field of view, consistency, and adjustments to changes
and complexity. Each of these areas is then assessed in increasingly complex
simulated steering tasks. Phase 1 is a preview tracking task which requires
the subject to steer a simulated vehicle which moves at a fixed pace in the
center position of the driving lane. Measures of lateral position are taken
8 times per second. In Phase II, a two-choice RT test is added to the steering
task, where as the road advances, a small, one-character stimulus face appears
unpredictably on either side of the roadway. The subject must turn the signal
lever on the steering column toward the face as soon as possible, while maintaining
a steady position in the center of the road. Reaction times are stored along
with the steering measures. In Phase III, a contingency is introduced into the
reaction time test such that when the face is flashing ("hazard"), the subject
must signal away from it, and when it is steady, the subject must signal toward
the face.
Gianutsos (1994) employed the EDS in a study of 50 control subjects (average
age = 41 years) who were assessed to obtain baseline data to establish population
norms; 1,145 community-residing older drivers (average age = 69 years); and
82 drivers seeking driver rehabilitation related to a central nervous system
(CNS) disorder (average age = 37 years). The rehab sample received a comprehensive
driving evaluation that included medical and driving history, vision screening,
EDS, Doron simulator, and a road test. A pass or fail decision was made about
each individual. The performance of the 50 control group drivers was more consistent
and substantially better than that of 1,145 community-residing older drivers
and the group of 82 drivers seeking driver rehabilitation related to a CNS disorder.
As a group, the older drivers performed almost as poorly in terms of steering
ability, two-choice reaction time, and in complex reaction time as the rehabilitation
patients who failed their driving exam. The failers were always worse than the
passers, however the difference in performance was significant only for steering
unsteadiness.
Case examples have shown also that observations of actual on-road performance
are consistent with conclusions based on the EDS; persons who perform poorly
on the EDS have been observed to exhibit lane drifting, poor steering control,
failure to make head checks, impulsivity, and difficulty in making adjustments
during a 1.5 hour drive.
The EDS was employed in a study of 1,475 ITT Hartford Insurance Co. policyholders
for whom past driving histories were available through insurance records, divided
into two groups based on the presence or absence of recent at-fault crashes
(Brown, Greaney, Mitchel, and Lee, 1993). Driver age ranged between 50 and 80+.
Insurance and motor vehicle department records provided information about the
following variables: at-fault crashes, non-fault crashes, non-crash claims,
violations and convictions, miles driven, age, gender, and marital status. Performance
on the EDS yielded a low but significant correlation with at-fault crashes (r
= -.09, p .05). Sample selection bias (policy holders with poor functional
capabilities may have declined to participate) and testing under noisy conditions
(hotel sites) may have contributed to the low correlations. Additionally, a
higher correlation may have been attained if an important procedure had been
followed in test administration (according to the test developer). The EDS should
be administered as a one-on-one test with a test administrator trained in its
use. Each phase should be preceded by sufficient practice to ensure that the
subject is comfortable with the task. The theory is that driving is a highly
practiced task, and the subjects should be encouraged to continue in the practice
mode until they feel they have reached their best level of performance. Also,
this approach contributes to the clinical acceptance, as people believe they
have been given the fairest possible chance.
Driving Advisement System (DAS)
Life Sciences Associates, One Fenimore Road, Bayport, NY 11705-2115. Phone:
(516) 472-2111, Fax: (516) 472-8146.
The DAS is a more comprehensive protocol that uses the same IBM compatible
system as the EDS. The DAS is a one-hour long protocol designed for advising
persons who seek to resume driving following brain injury, caused by head injury
or stroke. Its procedures address the complexity of information processing,
and breaks responses down into a decision and an execution component. As the
task demands increase in complexity, the choice component of reaction time is
expected to increase, but not the execution component. Momentary contact switches
are activated by three pedals, laid out on a floor plate with a middle gas pedal,
a left brake pedal, and a right horn pedal; the horn and brake pedal are equidistant
from the gas pedal. A steering wheel senses rotation of approximately 270. There
are five parts to the appraisal: self appraisal; a pursuit tracking task ("On
the Road"); a simple reaction time procedure ("Brake"); a choice reaction time
task ("Decide"); and a reversing choice reaction time task ("Inhibit").
In the self-appraisal portion, ratings are obtained for eight parameters:
reaction time, decision speed, movement speed, speed of adaption, consistency,
concentration, field of vision, and impulse control. After each parameter is
explained carefully, the subject uses the steering wheel to move a marker that
represents his/her present status on a display in comparison to "other safe
drivers."
In the pursuit tracking task, the display contains an abstract representation
of a road with a small rectangular block representing the vehicle, which can
only be moved laterally. The road itself changes, creating an illusion of movement.
The subject's task is to hold down the gas pedal to keep the vehicle moving
along the road and to use the steering wheel to maintain the vehicle in the
center of the road. Modifiable parameters include speed of progress, roadway
width, roadway curviness, length of course, and amount of preview of the roadway
above the vehicle.
In the simple reaction time test, the subject holds down the accelerator
until the letter "B" appears either in the right or left signal box. Then, s/he
moves the foot from the gas to the brake as quickly as possible, and replaces
the foot on the gas to resume driving. Resumption time (brake to gas), choice
time (appearance of B to release of gas), and execution time (release of gas
to press of brake) are measured in 100ths of a second. False alarms are also
recorded on trials where the gas pedal is released before the "B" appears. Performance
is compared to comprehensive driving evaluations in driving rehab centers, and
may include an on-road exam.
The choice reaction time test builds on the simple reaction time test
by adding an equal number of "H" (horn) and "B" (brake) stimuli, in an unpredictable
sequence. The object is to be as quick as possible without making errors in
pedal activation.
The reversing choice reaction time test builds on the procedures used
in the choice reaction time segment. On a random half of the trials, a sign
appears in the center of the screen that says, "pedals reversed." When this
happens, the person must press the brake pedal when an "H" appears, and press
the horn pedal when a "B" appears. The program switches unpredictably between
the "ordinary" mode and the "pedals reversed" mode, demanding rapid adjustment.
The DAS was employed in a study of 60 licensed drivers ages 18 to 86, who were
deemed to be safe drivers and free from serious neurological impairment (standardization
sample) and 60 traumatic brain injury and cerebrovascular accident survivors
(Gianutsos, Campbell, Beattie, and Mandroita, 1992). The findings indicate that
execution times of the standardization group in "Brake," Decide," and "Inhibit,"
do not increase with increasing task complexity and substantiates that these
times are reflective of motor functioning and not mental processing. In contrast,
the choice times increased with increasing complexity. The DAS measures correlated
with an on-the-road assessment (pass/fail criterion) in a group of 60 traumatic
brain injury and cerebrovascular accident survivors slightly better than the
Porto Clinic Glare (a device used in predriving assessments typically conducted
in occupational therapy settings, that screens visual acuity, visual fields,
depth, glare recovery, color vision, and reaction time in approximately 20 minutes).
References:
Brown, Greaney, Mitchel, and Lee (1993)
Gianutsos and Campbell (1988, 1991)
Gianutsos, Campbell, Beattie, and Mandroita (1992)
Gianutsos (1994)
Imago Systems, Inc.
Janke and Hersch (1997)
Liu and Miyazaki (in press)
pers. comm., Linda Hirsekorn, Imago Systems, 7/22/98
Rizzo, Reinach, McGehee, and Dawson (1997)
Schiff and Oldak (1993)
Staplin, Gish, Decina, Lococo, and McKnight (1998)
Szlyk, Brigell, and Seiple (1993)
IC2(b)v. Comprehensive Physical Examination
Summary:
A recent Consumer Report's article (1998) reported on an analysis
of data from the National Ambulatory Medical Care Survey that is conducted annually
by the National Center for Health Statistics. The survey data were provided
by physicians on approximately 35,000 patients. Extrapolating the results to
the entire U.S. population, their analysis found that only 30 percent of people
ages 45 to 64 get a yearly checkup, and only one-half of those age 65 and older
get an annual checkup. The analysis points out that history-taking time is well
spent, citing a report by the Mayo clinic, that history-taking identified 10
times as many health problems as a urinalysis and five times as many as a complete
blood count. In addition, counseling is an important part of a comprehensive
exam; however, physicians are not educated on how to do effective counseling
for healthy people. The article reported that every checkup should contain counseling
regarding diet, exercise, smoking, and injury prevention. But, Consumer
Report's analysis found that dietary counseling is given only to 1 in 5
patients, and injury prevention counseling is presented to only 1 in 100. Interesting
to note is that the article did not specifically cite driving as part of the
history-taking or counseling components of a physical exam.
Stutts (1998) cites research indicating that physicians and other members of
the medical community can be influential in older drivers' decisions to reduce
their driving exposure. In a focus group study, most older adults agreed that
if their physician advised them to stop driving and their family concurred,
they would stop. However, only 27 percent of the participants (15 of 56) said
that advice from a physician had affected their decision to stop driving, and
only 32 percent (18 of 56) said that their physician had discussed driving with
them (Persson, 1993). They pointed to ophthalmologists as the group of physicians
most likely to discuss driving with them.
Uniformity does not exist among the states with regard to medical qualifications
of drivers. It is often up to the individual physician to become familiar with
the medical classifications of drivers and the physical examination forms used
by their State. The Texas Medical Association (The Physician, the Older
Patient, and Driving Safety) states that, "The physician has much of the
responsibility for determining medical competence to drive. This implies that
the physician has four duties: (1) to be aware of such medical conditions; (2)
to detect these conditions in their patients; (3) to discuss with their patients
any limitations on driving imposed by the medical condition; and (4) if necessary,
report the patient's condition to the appropriate state agencies." In Pennsylvania,
the driver licensing bureau sends physicians the specific laws and regulations
formulated by their Medical Advisory Board, as well as a information on the
purpose of physician reporting. Pennsylvania has an initial reporting form that
is completed by the physician after completing a physical examination of the
patient. This form has four sections, including: (1) patient information and
date of examination; (2) diagnosis of disorder or disability (i.e., a checklist
for loss of, or impairment of function in an appendage; unstable diabetes; cerebral
vascular disease; cardiovascular disease; loss of consciousness and cause; neurological
disorder; mental deficiency or marked mental retardation; mental or emotional
disorder; alcohol abuse; drug or controlled substance abuse; vision deficiency;
and other medical conditions; (3) seizure disorder and waiver requirements;
and (4) name, address, telephone, signature, and state physician license number
of provider.
In a recent literature review, Carr (1998) identified several different recommendations
by physicians and researchers on what to assess for older drivers during a physical
examination. Reuben (1993) suggested that an office-based assessment should
focus on static visual acuity, hearing, the presence of arthritis, and dementia.
Underwood (1993) recommended the following assessments: static visual acuity
and fields, auditory, cognitive including mental status examination, functional
status, musculoskeletal, sleep disorders, alcohol screening, and a medication
review. Marottoli and Drickamer (1993) suggested that the motor abilities of
muscle strength and a range of motion for neck and extremities should be measured.
Carr (1998) suggested that brief physiological or functional measures can be
administered cost-efficiently and are reliable in an outpatient setting. He
identified several functional measures that should be assessed by a primary
care physician, including: driving performance history; vision; hearing; reaction
time; attention; visuospatial skills; judgment; muscle strength; and joint flexibility.
He also identified several medical conditions, as well, which should be assessed,
including: cardiac disease; risk of heart attack; diabetes; pulmonary disorders;
alcoholism; use of sedating medications; dementia; cerebrovascular disease;
risk for stroke; arthritis; visual impairments; and hearing impairments. Marottoli
(1993) states that physicians should include driving issues as part of their
functional assessment. They should ask the patient (and family) whether there
have been problems with driving, such as getting lost or having moving violations
or crashes. The Texas Medical Association lists specific questions a physician
may pose to a patient that may help identify a driver who is at risk:
Do you still drive? Where and when do you drive?
How many physicians are you currently seeing? For what conditions?
How many medications are you taking? What are they? (Include over-the-counter
drugs)
Have you noticed any changes in your eyesight recently?
Any recent falls or weakness?
Have you experienced any loss of consciousness? Any dizziness? Any drowsiness?
Have you experienced any confusion or memory loss?
Have you experienced any hearing loss? Since when?
Have you experienced any problems with mobility? (Such as difficulty turning
your head?)
Have you had any medical conditions such as a heart attack or stroke which
makes movement of the arms and legs difficult? If yes, what type of vehicle
are you driving?
Are you willing to follow my advice about driving?
Finally, the physician should take an active role at this time during the physical
examination to assess risk for injury and promote injury prevention (e.g., use
of seat belts) in a motor vehicle; and address the possibility of driving cessation
or restriction for the patient. For the latter, empathy, sensitivity, along
with counseling to discuss alternate methods of transportation are important
and necessary.
Several sections in this Notebook seem particularly relevant for use
by physicians in assessing fitness to drive. To detect gross functional impairments
in an office setting, the procedures described in Section IC2(a)i: GRIMPS battery
of general physical and mental abilities, would be a logical starting point.
Also, Section IC3(b)i describing Rehabilitation Procedures: physician/occupational
therapist review, provides more information about specific diagnoses, their
effects on driving, and potential remediation.
A Guide to Physical Examination (Bates, 1983) provides a comprehensive
description on conducting a physical examination.
Conclusions/Preliminary Recommendations:
Physicians have frequent contact with older persons and have the ability to
perform functional assessments of the abilities required for safe driving. Simple
assessments of physical, visual, and cognitive abilities along with asking the
right questions (such as those listed above) can provide the information required
for counseling older drivers about reducing their driving risks. In addition,
early detection of problems allows for treatment/rehabilitation by specialists
(e.g., ophthalmologists, OTs, PTs, driving schools, to whom the physician may
refer a patient) so that older persons can maintain their ability to drive.
References:
Bates (1983)
Carr (1993)
Carr (1998)
"Checkups: Are you getting what you need?" Consumer Reports (1998)
Marottoli and Drickamer (1993)
Marottoli (1993)
Persson (1993)
Reuben (1993)
Stutts (1998)
Underwood (1992)
IC2(b)vi. Functional Abilities and Driving Evaluations
Summary:
Hunt (1993) states that "many individuals who have had strokes, amputations,
painful joints, or visual problems assume that they can no longer drive." Occupational
therapists (OTs) assess and treat people whose ability to carry out life tasks
has been impaired by disease, injury, birth defect, or the aging process. OTs
have developed programs to evaluate the driving abilities of people with disabilities
and healthy older individuals. These programs have two goals: to provide a decision
about an individual's capacity for driving; and to identify factors that may
respond to training in those individuals who have the capacity to drive. Although
the specific methods for evaluation vary in different programs, evaluations
generally consist of a predriving assessment using psychometric tests and an
in-car, on-the-road driving test. The predriving evaluation usually consists
of an interview, motor evaluation, cognitive evaluation, and sensory evaluation.
A major focus of the interview is to gain insight as to why the client's driving
ability requires evaluation, and to determine whether a client recognizes his
or her limitations. Often when there is cerebral damage from a head injury,
stroke, dementia, or multiple sclerosis, patients are unaware that they have
cognitive, judgment, visual, or perceptual deficits; clients who fail to recognize
their limitations do not compensate. Hunt (1993) provides examples of questions
used to elicit client information:
Has your illness left you with any physical problems?
Are you able to perform all your everyday activities as you did prior to
your illness?
Why do you think your doctor wanted your driving skills to be evaluated?
Do you have any fears about driving?
Is your thinking as clear as it was 2 years ago?
If you are driving now, have you gotten lost on an often-traveled route?
These questions provide some baseline information to be compared with test
results, and discrepancies also provide evidence regarding why a training program
may not be appropriate for a particular client. Hunt's hierarchy of driving
assessments (Hunt and Weston, in press) is presented on the following
page.
A description of five evaluation programs follows, highlighting specific tests
and methods used in the predriving and driving assessments.
Ohio "Older Driver Evaluation Program"
This evaluation, conducted by the Ohio State University Medical Center, is
physician driven in that a physician is contacted prior to an evaluation to
obtain medical and pharmacological history, and a physician signs all of the
consultations. Evaluations last 3 hours, require 2 visits, and cost $330. A
physician oversees the program, which is staffed by an occupational therapist,
a geriatric clinical nurse specialist, and an on-the-road evaluator. If Medicare
or private insurance will not cover the evaluation, fees can be collected on
a sliding scale through funds provided by the Franklin County Office on Aging.
The point was made that county money can be used for many things that might
not otherwise be covered by Medicare or Medicaid.
Before the first visit, a geriatric nurse conducts an analysis of the client's
medications and interaction effects. Often this starts needed communication
among a client's physicians. During the first visit, which lasts 1½ -2 hours,
the client completes a self-report questionnaire to obtain information regarding
disease, driving habits, and sleep habits; a hearing screening is conducted;
and a battery of cognitive, vision, and mobility tests is conducted. The cognitive
tests consist of the MMSE, Trails A and Trails B. The vision test utilizes the
Optec 2000 Vision Screener, and assesses static acuity, depth perception, visual
fields, and acuity under glare. The mobility portion assesses range of motion,
strength, and endurance.
[ Linda Hunt's "Hierarchy of Driving
Assessments" ]
The second visit consists of reaction time and recognition subtests using the
Doron Simulator L225, and on-road assessments, first in the parking lot and
then in traffic. The results of the assessment are given to the referring physician,
and a copy is sent to the older adult. A consultation letter never goes to the
Bureau of Motor Vehicles, however. The individuals responsible for this program
feel strongly that the evaluation is part of the health care system. It is the
physician's responsibility (moral obligation, as opposed to a legal obligation
in Ohio) to ensure that an unsafe driver doesn't drive, and the evaluators work
closely with the referring physician to explain the risks of driving to the
unsafe driver.
Training may be prescribed or doctor visits recommended. A transportation resource
guide has been developed to lead people to alternative transportation, if they
must restrict or eliminate driving. The program works closely with the family,
as the older driver issue is a family issue. The program can also help with
alternative housing choices (to make alternative transportation/mobility easier)
and other spin-offs of the older driving issue.
This program is not meeting the need of all the older drivers in the jurisdiction,
based on cost and time to administer the evaluation. The program developers
are working to create a short screening tool to be administered in physician's
offices. They have followed the mammography model regarding desired sensitivity
and specificity, in that they cannot tolerate sending a poor driver out on the
road; therefore they err on the side of conducting full assessments on drivers
whose driving ability is not compromised (pers. comm., Bonnie Kantor
and Linda Mauger, 1/20/98).
Program administrators have found that stopping driving can have a negative
impact on health, and become involved in conversations with older adults and
their families which illustrate these issues on a regular basis. Evaluation
outcomes for the 400 drivers evaluated to date are as follows: 56 percent of
the clients were found to be capable to drive safely at the time of the evaluation,
or were capable with vehicle modifications; and 44 percent were determined to
be incapable, which included those who are unsafe now, but may be safe after
rehabilitation, surgery (cataracts), etc.
Bryn Mawr Rehab Hospital, Malvern, PA: Adapted Driving Program
Bryn Mawr Rehab's Adapted Driving Program provides driving evaluations, training
and special equipment recommendations to help older and disabled drivers achieve
or maintain independence through safe driving. The program started in 1983.
It is staffed by a driving instructor, and an occupational therapist who is
also licensed as a driving instructor. Both are Certified Driver Rehabilitation
Specialists.
Clients evaluated include people with the following disabilities: cerebral
vascular accident (CVA); dementia; brain injury; arthritis; amputation; spinal
cord injury; cerebral palsy; learning disabilities; Multiple Sclerosis; hand
injuries; small stature; psychiatric conditions; or any other condition that
could influence driving. The majority of clients are older drivers that have
had a CVA. Drivers of advanced age with no specific diagnosis are also referred
to the program. A physician's referral is required to enter the program. As
Pennsylvania has a mandatory reporting law, physicians frequently refer drivers
to the program to gain information to guide them in filing reports with PennDOT.
The driving evaluation consists of a one-hour pre-driver screening (clinical
testing) and a one-hour in-vehicle assessment, conducted on the same day.
The clinic screening consists of a medical history; driving history; visual
assessment (acuity, fields, tracking, saccades, depth perception); physical
assessment (range of motion, strength, coordination, sensation, cervical ROM,
trunk balance, ambulation status); reaction time; traffic sign recognition;
simultaneous attention; and perception. If the driver is physically disabled,
adapted equipment options are explored. The perceptual tests used during the
screening can include (depending on time constraints): The Motor-Free Visual
Perception Test (MVPT), Hooper Visual Organization Test and Trail-Making A and
B.
The simultaneous attention task used during the screening yields a large amount
of useful information in a short period of time (2-5 minutes). During this task
the client is asked to copy a simple peg pattern while watching a clock. Every
15 seconds a green peg must be placed in a box. This forces the person to simultaneously
attend to two simple tasks. During the task the evaluator observes the person
and documents the following areas: ability to follow directions; problem solving;
speed of performance; simultaneous attention; functional memory; new learning;
performance under stress; and color discrimination. The person is scored by
time taken to complete the task and the number of green pegs missed.
The primary purpose of the screening is to document key areas of performance
that will be useful for the in-car evaluation. The information is also useful
to help explain deficit areas should a person fail the on-road evaluation. It
is not meant to predict performance, per se. Bryn Mawr's experience has indicated
that the best information regarding a patient's ability to drive is determined
through a behind-the-wheel evaluation.
The behind-the-wheel evaluation is conducted on nearly everyone that meets
the basic State vision and seizure standards. Occasionally, a combination of
several significant deficits will preclude the in-car evaluation. To control
for risk, the in-car (or van) evaluation starts off on the Bryn Mawr Rehab grounds.
The driver is evaluated in the program's vehicle with a dual-control brake.
If the driver cannot control the vehicle, he or she is not advanced to the on-road
portion. If adapted equipment is required, the evaluation may be limited to
the campus, as the driver may not be ready for traffic in the first session.
If the driver demonstrates basic vehicle control and has a valid license, he
or she is then observed driving in a variety of traffic situations (rural secondary
roads, limited access highway, shopping center, downtown traffic in West Chester).
If the person is not ready for the full evaluation route, he or she is observed
in more simple traffic in a nearby small town. The driver is scored as pass,
fail or questionable on 30 areas of performance (i.e. lane position, visual
checks, following distance, judgment of space, speed control, attention to traffic
devices, memory, etc.). The final score is pass, fail, or questionable based
on the observed performance.
Training may be recommended if the deficits observed could be overcome with
training. Lessons and re-testing with PennDOT for license coding are required
if the person needs adapted devices. Trial lessons are recommended for questionable
candidates that appear to have potential to drive. Lessons are not recommended
for people with advanced dementia or severe neurological deficits that will
not be overcome with training. The driver, family members, and the physician(s)
are consulted extensively when making difficult decisions. A re-evaluation can
be considered if the person's status may improve over time. If a driver fails
the evaluation and is not a candidate for any follow-up driving services, extra
time is spent reviewing the results and counseling the person and family to
help them adjust to this significant life change. The person is given reprints
of articles concerning stopping driving, and alternative transportation options
are discussed.
UAB Health System, Birmingham, AL: Driving Assessment Clinic
The UAB Driving Assessment Clinic opened in December 1998 in response to the
need for a way to evaluate driving fitness in individuals with medical problems
and functional impairments. Most patients seen in the clinic are over age 50,
although drivers of any age can be evaluated. The development of the clinic
was funded by a grant from the University of Alabama Health Services Foundation.
The clinic is integrated into a health system, operating as one of a myriad
of health services available to the community and State. The Clinic accepts
referrals from physicians, other health care providers, families, as well as
self-referrals. The Clinic Director is Cynthia Owsley, PhD, MSPH, and the Clinic
Coordinator is Jennifer Wells, CDRS, a certified driving rehabilitation specialist.
It is located in the Eye Foundation Hospital at the University of Alabama at
Birmingham Medical Center.
There are two parts to the assessment. The in-clinic battery takes about 1.5
hours to administer, and consists of an evaluation of characteristics that are
known risk factors for crash involvement and unsafe driving in older adults.
Included in the battery are a vision screening, a cognitive assessment, the
UFOV test, a review of medical conditions and medications, driving needs, driving
habits, social support, and knowledge about the rules of the road and safe driving
practices. After the in-clinic screening, there is an evaluation of on-road
driving performance in the clinic's specially equipped vehicle. This evaluation
lasts for 30 to 45 minutes and addresses the patient's ability to perform a
variety of typical driving maneuvers in real traffic situations. This on-road
component is offered to those patients who meet minimum requirements from the
in-clinic battery. The cost of each component is $150.00, and is an out-of-pocket
expense for the clients, as Medicare does not reimburse for driving evaluations
in the State of Alabama. The clinic does not refuse clients on the basis of
not being able to pay, however.
The results of the assessment are summarized in a written report that is provided
to the patient and the referring physician or other health care provider. The
report includes an assessment of risk for crash involvement and unsafe driving
based on the in-clinic battery and on-road evaluation, and makes a recommendation
about the patient's fitness to drive. This recommendation can take a variety
of forms (e.g., the patient has adequate skills to continue driving, the patient
has significantly deficient skills so should refrain from driving, the patient
should avoid driving in certain situations--night, rush hour traffic, inclement
weather). If a recommendation is made for driving cessation, the clinic provides
counseling on alternative transportation services and strategies.
The clinic's assessment battery is a work in progress. As research points out
new risk factors for crash involvement and screening tools for identifying those
risks, these tests and evaluations will be incorporated into the clinic's battery.
Similarly, as interventions to improve driving are demonstrated to be effective
(e.g., health education, cognitive training, on-road training), a training module
will be added to the clinic. Finally, the clinic's effectiveness in enhancing
safety and preserving mobility, as well as its financial feasibility within
the health system, will be evaluated after a sufficient number of patients have
been seen.
Sinai Rehabilitation Center, Baltimore, MD: Driver Evaluation and Training
Program
Sinai Hospital of Baltimore, Maryland offers a driving rehabilitation program
that consists of a clinical driving evaluation, behind the wheel evaluation,
and driver training. The driver evaluation and training specialist (Kim Harwood
White) is a Certified Driving Rehabilitation Specialist. The goals of the Driver
Evaluation and Training Program are:
To assess the client's functional ability to produce controlled physical
motions necessary for the safe and efficient operation of a motor vehicle.
To screen the client's visual, visual-perceptual, and cognitive skills as
related to driving.
To provide evaluation of the client's ability to integrate physical, visual,
perceptual, and cognitive abilities in multiple traffic situations.
To provide graded behind-the-wheel training and instruction for those clients
requiring training/re-training to enable them to safely operate a vehicle without
endangering their lives or the lives and property of others.
To provide recommendations for appropriate vehicles and adaptive driving
equipment/devices that will best meet the client's personal transportation needs
and allow the client to operate a vehicle within the Highway traffic systems.
To provide the Medical Advisory board of the Department of Motor Vehicles
with reports and recommendations regarding a client's ability to safely operate
a motor vehicle as demonstrated during participation in the Driver Training
Program.
To refer clients for further diagnostic measures and/or rehabilitation to
improve the client's ability or provide further evaluation of a client's ability
to safely operate a personal motor vehicle.
In Maryland, any person who has been treated by a physician or hospital for
any of the following physical or mental disorders must report the disorder when
applying for or renewing a driver's license for evaluation by the Medical Advisory
Board (MAB):
Alcoholism or Alcohol Abuse
Cerebral Palsy
Diabetes
Drug/Narcotic Abuse or Addiction
Epilepsy/Loss of Consciousness
Heart Condition
Loss of Limb (or loss of use)
Multiple Sclerosis
Muscular Dystrophy
Organic Brain Syndrome
Schizophrenic Disorders
Severe Anxiety Disorders
Stroke
Major Affective Disorders
Any other illness in which there was a lapse of consciousness, blackout,
or seizure
This is a self-reporting law; and does not mandate responsibility by the treating
health-care professionals.
A referral to and participation in the driving evaluation and training program
assures the patient, his or her family, the Medical Advisory Board, and referral
source that a patient's condition has been evaluated for its effect on his or
her ability to safely operate a motor vehicle. Many patients with the above-referenced
disorders may also need adaptive equipment to resume driving, such as left foot
accelerators, spinner knobs, hand controls, extra mirrors, etc. Patients must
be trained in the use of adaptive equipment, and the need for adaptive equipment
to drive requires a notation on the driver's license. A physician referral is
required for participation in the driver training program, if medical insurance
will be billed; however, friends, family, and self-referral occur, and are often
self-pay. If a client is referred to the driver training program but refuses
to participate, the name of the client is submitted to the referring physician,
who is encouraged to notify the Motor Vehicle Administration (MVA) if he or
she has reasonable doubt as to the client's ability to operate a motor vehicle.
This can be done without violating patient confidentiality by providing the
MVA with only the client's name, date of birth, and address.
Patients who participate in the driving program must agree to allow the results
to be reported to the MAB. The report may add necessary support for a patient
to be allowed to resume driving; however, it may suggest that a patient cease
driving (i.e., the effects of the condition compromise the ability to safely
operate a motor vehicle).
The clinical driving evaluation costs $80.00 per hour. The time for evaluation
varies depending upon a person's speed and level of disability, and rarely exceeds
1.5 hours. The following assessments are performed:
Upper extremity range of motion, strength, coordination, and sensation;
Lower extremity range of motion, strength, coordination, and sensation;
Ambulatory status;
Sitting balance and endurance;
Keystone View vision tests: acuity, peripheral vision, sign recognition,
depth perception, phoria, night vision, color recognition;
Motor-Free Visual Perception Test;
Block Design: construction, apraxia, spatial relations, depth perception;
Trail-Making Tests (A and B): attention, sequencing, alternating attention;
Auditory attention tests;
Driver situation problem solving scenarios;
Reaction time.
The behind-the-wheel evaluation costs $80.00 per hour. Evaluation time varies
slightly, but minimal time for completion of the standardized driving exercises
and completion of the designated testing route is 1.5 hours. Assessment areas
include:
Performance Skills
Vehicle entry
Starting procedures
Parking lot driving and procedures
General driving skills on residential roads, country roads, and city roads
Acceleration
Braking
Lane position
Anticipating other vehicles and situations
Managing hazards
Signaling intent
Lane changes
Following distance
Yielding right-of-way
Controlled Intersections
Uncontrolled intersections
Turns
Expressway driving
Parking
Lot parking
Parallel Parking
Driveway parking
Observation skills
Compensation for areas of limited vision
Anticipating
Observes cues from other drivers
Observes posted cues (speed limit signs, regulatory signs, street and highway
markings)
Follows lane markings
Checks blind spots
Looks when backing up
Observes dash board indicators
Endurance
Driver training is provided at a cost of $50.00 per hour. The duration of the
training program varies according to a person's weaknesses and targeted training
areas; duration of training estimates are discussed after the BTW evaluation
has been conducted, as well as at the end of each session. Training is ceased
when the driver can complete the behind-the-wheel evaluation driving exercises
and the designated testing route safely and with no significant errors. The
client may then be scheduled to use the Sinai adapted vehicle to complete the
State of Maryland's Motor Vehicle Administration's driving test. Adapted equipment
can then be ordered and installed on the client's own vehicle. This may insure
that the cost of adapting a vehicle is justified, and supported by the State
of Maryland.
Beth Israel Deaconess Medical Center, Boston, MA: DriveWise
This driving evaluation program was designed by the departments of behavioral
neurology and occupational therapy for drivers of any age who have neurological,
psychological, and/or physical impairments. In the two years that the program
has been in operation, approximately 70 drivers have been evaluated. Drivers
are referred into the program by family members, primary care physicians, or
specialists. There are five parts to the evaluation of driving ability. First
is an assessment by a clinical social worker to determine what role driving
plays in the individual's life, what it would mean to restrict or cease driving,
and what types of alternative transportation are available. Second is an assessment
by a neuropsychologist to determine concentration, organizational skills, reasoning,
judgment, and speed of information processing. This portion lasts approximately
two hours and includes standardized tests as follows: WAIS block design subtest;
Raven's Colored Matrices; Mattis Dementia Rating Scale; Digit Span Test; FAS
Categories Test; Stroop Test; Go No-Go test; Trail-Making A and B; Written Sequences
(months, serial numbers, counting backwards from 20 to 1, alphabet); several
subtests from the Wechsler Memory Scale III Test; Rey Osterreith Figure Test;
Boston Naming Test; Facial Recognition subtest of the Benton Visual Test; Letter
Cancellation; Clock Drawing; and Peg Board test. Third, is a one-hour assessment
of mobility, vision, and brake reaction time by an occupational therapist. Fourth,
is a 45-minute on-road driving evaluation by a driving instructor and the occupational
therapist, which is conducted in a specially equipped vehicle. The on-road test
is conducted by a driving school, using a modification of Linda Hunt's Washington
University Road Test (WURT). Maneuvers are designed to measure abilities that
are difficult for those with brain damage/cognitive impairment (e.g., left-hand
turns).
The evaluation team then meets to review their findings, and a written set
of recommendations is sent to the participant and referring physician. The fifth
component is a follow-up session with the participant and family members, where
the social worker presents the team's findings. The social worker can provide
educational materials about driving, arrange transportation alternatives, and
refer participants to training programs to improve driving skills. If driving
cessation is recommended, practical and emotional support is provided for the
individual and family members by the clinical social worker, and alternative
methods of transportation are identified. If the participant does not follow
the recommendation to stop driving, the team may report their findings to the
Registry of Motor Vehicles.
An evaluation costs approximately $700-800; each discipline is billed to Medicare
or other insurance providers separately. Medicare has been paying for all but
the on-road evaluation. The driving school that conducts this portion charges
$40, which participants pay for out-of-pocket. The neurologist stated that when
billing insurance she writes, "the patient was referred within the context of
mental decline of functional capabilities relative to the issue of driving and
safety awareness." Medicare and many other insurance providers have paid for
the social work evaluation, the neuropsychological evaluation, and the occupational
therapy evaluation, using this terminology.
References:
Hunt (1993)
Hunt and Weston (in press)
Bryn Mawr Rehabilitation Hospital: Info. provided by Tom Kalina
Ohio State University Medical Center Older Driver Evaluation Program Evaluation
(pers. comm., Bonnie Kantor and Linda Mauger, 1/20/98)
Sinai Rehabilitation Driver Evaluation and Training Program descriptions
DriveWise Evaluation, Beth Israel Deaconess Medical Center (a teaching affiliate
of Harvard Medical School): Program descriptions; pers. comm., Margaret
O'Connor (Neuropsychologist); Jane Matlaw (Public Relations); and Suzanne Curley
(Occupational Therapist), 11/19/98.
Driving Assessment Clinic, UAB Health System: Info. provided by Cynthia Owsley.
For more information about the clinic, interested persons can contact (205)
325-8646 or driving@eyes.uab.edu.
IC2(c)i. Standardized Exam over a Common Route
Summary:
Based on the consensus of researchers who have performed work for several State/Provincial
DOTs (Romanowicz and Hagge, 1995; McKnight and Stewart, 1990; Jones 1978; McPherson
and McKnight, 1981; Engel and Townsend, 1984; Janke and Hersch, 1997) an on-road
driving test should measure the constructs of visual search, speed control,
and directional control. It should feature a fixed number of possible errors,
objective scoring criteria, and the scoring of elements of specific ("structured')
maneuvers at specific locations. Examples of structured maneuver errors
are "inadequate traffic check," "poor lane position," and "turns too wide or
too short." (See attached score sheet). It should also include a destination-finding
task (e.g., requiring a driver to safely return to the field office after being
directed to drive a short distance past the office; or a "take me to instruction")
if implemented in an area familiar to the driver. McPherson and McKnight (1981)
state that the use of a set of planned observations of specified performances
at particular locations improves uniformity of drive test administration by:
Allowing the total number of observations and the observations of each type
of performance to be standardized regardless of where the test is given.
Assuring that the examiners' attention is directed toward the same performances
at the same time.
Allowing examiners to practice application of scoring criteria at specific
locations until they achieve uniformity of scoring.
They note that the inability to include errors where observations are not planned
is frustrating to examiners; however, if the locations of observations are well
planned, examiners will be looking where errors are most likely to occur, and
the increase in the proportion of total errors that will be observed can outweigh
the disregard of errors that occur at other locations. The response of drivers
to uncontrollable traffic and weather conditions can say a lot about their competency.
To ignore them passes up information concerning an applicant's competency in
a manner that can be frustrating to examiners. In addition to the scoring of
specific behaviors at specific locations, critical driving errors may
be listed in a separate section of the score sheet, and marked if committed.
These are serious errors that include: examiner intervention; driver strikes
object; drives up/over curb/sidewalk; drives in oncoming traffic lane; disobeys
sign/signal; dangerous maneuver; inappropriate reaction to school bus; inappropriate
reaction to emergency vehicle; inappropriate speed; inappropriate auxiliary
equipment use; turn from improper lane.
There are several recommendations regarding delivery of instructions. Instructions
should be brief, nontechnical, and use general terms. Instructions should use
easily recognized landmarks rather than street names, as street-name use favors
drivers who are familiar with the area, penalizes nonreaders, and poses an additional
visual task. Instructions should relate only to the route; examiners should
not tell applicants which lane to use or give instructions relating to speed,
except during the rapid stop check (if it is part of the exam). Wisconsin uses
the following language to help clarify instruction, put the person at ease,
and avoid misunderstanding or arguments, "I will tell you at least a block ahead
of time where to turn. However, I won't tell you which lanes to get into for
making a turn or if you should change lanes. I will expect you to decide what
is the safe way to turn or change lanes." Further instruction given by Wisconsin
DOT driving evaluators is as follows, "I want you to drive as if other traffic
is present. That is, drive as if other vehicles are in the next lane, approaching
from side streets, and coming toward you." Do not use phrases or words that
are instructional (light, signal, stop sign). Always state where to
do a maneuver before stating what the maneuver will be. Maneuvers should require
planning (e.g., a lane change prior to a turn) and some maneuvers should require
working memory skills (e.g., after two blocks turn left). A "take me to" instruction
(destination-finding task) is useful in identifying cognitively impaired drivers.
Dobbs (1997) makes the following conclusions about the optimal type of on-road
course for road testing of older drivers:
A lengthy course is unnecessary, if it has been properly designed.
It should include a large number of left and right turns under varying intersection
control conditions.
It should include left, right, and through maneuvers at uncontrolled intersections.
It should include a visually complex environment, preferably with moderate
to heavy traffic flow and with multiple lanes of traffic in each direction.
A freeway or highway portion appears to be unnecessary.
Finally, McKnight and McKnight (1998) caution that the road test does not appear
to be well-suited to detection of age-related functional declines, unless
observations of on-road performance are made by professionals who are trained
and experienced in the identification of age-related disabilities. In their
study of 407 drivers age 62 and older (two-thirds of whom were referred for
reexamination due to incidents of unsafe driving), the correlations between
road test deficiencies and subject group (incident-involved vs. incident-free)
were small (in the 0.1 to 0.2 range). When the effects of road test site and
examiner differences were partialled out, the correlations of individual ability-related
road test measures with unsafe driving incidents increased to the 0.2 to 0.3
range, with a correlation of 0.41 for navigation errors and 0.46 for the overall
test.
Taking into account the considerations described thus far, the Modified Driver
Performance Evaluation (Janke and Hersch, 1997) appears to be an appropriate
road-test template for a standardized test of older driver ability. Test times
range from 30 to 45 minutes. The MDPE differs from the DPE(2), in
that it omits the DPE's freeway driving segment and includes a destination-finding
task that requires a subject to safely return to the field office after being
directed to drive a short distance past the office. A scoresheet is presented
on the following page. The MDPE includes:
4 left turns and 4 right turns (mixed difficulty levels; 2 of the left and
2 of the right turns should have multiple lanes requiring correct lane choice
on approach and finish; 1 left and 1 right should be at signal controlled intersections;
2 additional turns preferably at stop controlled intersections but may be uncontrolled
with limit lines, crosswalks, turn lanes).
8 through intersections (2 controlled by a light [red, yellow, and green];
2 controlled by a stop sign; 2 through/straight ahead intersections not involving
stops; 2 additional intersections preferably controlled by traffic lights).
Merging at a lane drop.
[ MDPE scoresheet ]
Curve negotiation (preferably a left curve; lanes should be marked, must
require driver to adjust speed).
3 lane changes (1 left, 1 right, 1 located anywhere on the route, preferably
at higher speeds).
Minimum of 3 blocks of driving in a business area with moderate traffic density.
Minimum of 3 blocks of driving in a residential areas preferably with narrow
streets.
Performing parking lot maneuvers, backing, and a street park.
The destination driving task may be incorporated to test for possible cognitive
impairment. In their research, Janke and Hersch (1997) found that cognitively
impaired referrals had significantly more "confusion errors" than cognitively
nonimpaired referrals. This particular MDPE measure was the only driving performance
measure where there was a difference in driving performance between cognitively
impaired and cognitively nonimpaired drivers.(Subjects were told prior to the
"detour" that they would be expected to find their way back).
Consideration should be given to testing an individual who fails the on-road
evaluation administered at the DMV in their home area; route familiarity and
familiarity with the traffic control devices and traffic patterns in a person's
home area may improve driving performance and allow for licensing restrictions
to be imposed (e.g., 15 mile radius from home address; no driving on U.S. Route
____), as opposed to license revocation. Staplin et al. (in press)
found that drivers' error rates vary as a function of the type of traffic control
(signal, stop sign, yield, or no control), the familiarity of the course, and
the type of movement (straight through, left turn, right turn). Route familiarity
had little to no effect on error rates exhibited at signalized intersections.
However, for right turns in yield and uncontrolled intersections, error rates
were noticeably higher on the unfamiliar course. This may have resulted from
drivers "knowing what to look for" as a result of experience in familiar areas.
Turning toward a consideration of road tests for persons with physical and
cognitive disabilities, Wisconsin DOT employs a tailored road test for persons
with medical conditions or functional impairments. In Wisconsin, a "driving
evaluation" is a limited skills test conducted to determine if a person adequately
compensates for his or her medical condition or functional impairments. A "skills
test," in contrast, is a driving examination consisting of a standard number
of driving skills or traffic situations, designed to examine the ability of
a person who has not been previously licensed in any jurisdiction to safely
operate a representative motor vehicle.
Wisconsin's Administrative Code §Trans 104.08 provides that driving evaluations
may be conducted on either a pre-established route or in an area and at a time
that can best demonstrate the person's ability to compensate for a medical condition
or functional impairment. It also provides that any of the driving skills specified
for the "skills test" may be tested, but a complete skills test shall be administered
only if the applicant "demonstrates an inability to exercise ordinary and reasonable
control in the operation of the vehicle, and the inability is not related to
the medical condition or functional impairment." WisDOT DMV Guidelines for administering
the driving evaluation further provide that "only those maneuvers that evaluate
the disability" are to be included in this test. It must include "maneuvers/situations
necessary to determine if a person adequately compensates for the condition
or impairment." Examples of functional impairment for which an evaluation may
be given include: limited mobility of upper body and neck, which prevents/restricts
ability to check for traffic to the sides and rear of the vehicle; substandard
vision; severe arthritis that affects range of motion; and mental/emotional
condition or brain trauma.
All Wisconsin passenger vehicle skills tests (driving
examination) must evaluate the following driving skills: (1) four right and
four left turns; (2) two stopped and two through intersections; (3) business/residential
driving; (4) lane changes; (5) Y turn; (6) hill park; (7) parking lot; (8) parking;
and (9) backing. A skills tests may also include a test of the operator's ability
to stop the vehicle quickly.
A limited skills test (driving evaluation) must include maneuvers/situations
necessary to determine if the person adequately compensates for a condition
or impairment. The basic maneuvers that are required for all special examinations
are as follows: minimum of two left turns; minimum of two right turns; minimum
of two intersections (stopped, through, controlled or uncontrolled); urban and
rural area (may be optional on driving evaluations); lane change (may be optional
on driving evaluations); driveway turn around (may be optional on driving evaluations);
curb stop on hill, hazard recognition; and quick stop. Optional maneuvers are
at the examiner's discretion, based on the reason for the driving evaluation
and the person's physical condition or functional ability. The maneuvers listed
are minimum maneuver requirements. When conducting re-exams or limited area
special exams, there may be more than two left and two right turns or intersections.
The examiner must pay particular attention to the customer's range of motion;
reaction time; endurance; coordination; speed in operating/moving controls;
strength to operate controls; ability to cope with traffic; and alertness and
ability to turn head/body.
The Wisconsin Class D Skills Test scoring sheet (MV3544) is presented on the
next page, followed by the Reexamination Score Sheet (MV3137).
A limited area examination may be given in Wisconsin to a driver who
is unable to cope with complex traffic situations. It may also be appropriate
for a customer who has a medical or functional impairment that severely limits
driving ability. The objective of this non-directed test is to determine whether
the driver can safely operate a motor vehicle in a familiar area. The test is
constructed around the driver's home area and on routes that take the driver
where he/she needs to go (e.g., doctor, grocery store). A customer does not
need to fail the standard exam before qualifying for a limited area exam; however,
if a driver chooses to be tested in the limited area, he/she will not be able
to drive outside of the designated limit.
Wisconsin provides the following tips to examiners for testing drivers with
functional impairment or medical conditions.
Limited mobility of upper body and neck: Have driver turn around in
driveway, perform lane changes, and pull over/enter traffic from the curb. These
maneuvers require head and body movement, and will help answer the question
of whether a driver has enough strength and range of motion to safely operate
the vehicle.
Substandard vision: Use a highway with various speed limits and traffic
signs. Have the driver read/tell you what action(s) he or she takes in response
to the signs. Do this at different speeds to determine the maximum speed at
which the driver can safely operate and still make necessary decisions using
information on the signs. Also evaluate the driver's positioning in traffic
lanes, especially when configuration changes, and the ability to read, understand,
and obey other traffic warning signs and follow lane markings.
Severe arthritis or other conditions that affect range of motion: Test
the driver in moderate/heavy traffic where there are many stops and starts.
If heavy traffic is unavailable, ask driver to pull over.
[ Wisconsin Class D Skills Test ]
[ Wisconsin Re-examination Report
]
to the side of the street and do several pulling from and to the curb maneuvers.
In addition, a driver who has difficulty moving his or her legs should be asked
to perform the quick stop maneuver.
Mental and emotional condition or brain trauma: The following questions
should direct tests chosen: Is the driver able to follow directions? Does the
driver appear confused? Does the driver require several seconds of thinking
and follow through time before reacting? Does the driver see and react in sufficient
time to on/off street situations? Does the driver take several seconds of thinking
time to respond to questions or instructions?
Wisconsin was identified by several other Driver License Administrators as
having recently been acquitted of violating the ADA or Section 504 of the Rehabilitation
Act by requiring an out-of-state applicant with a disability (but whose license
was not appropriately restricted) to take a driving evaluation before being
issued a driver's license in the state of Wisconsin. The NHTSA Office of Civil
Rights stated that WisDOT regulations authorizing a driving evaluation for disabled
drivers' license applicants constitutes a safety qualification of Wisconsin's
drivers' licensing program. It is less extensive than the "skills test," which
is given to applicants who have never held a license in any jurisdiction. In
contrast, the DMV guidelines specify that the "driving evaluation" is to be
tailored specifically to the physical limitations presented by the individual
applicant's impairment. Wisconsin regulations permit waiver of the driving evaluation
for disabled persons who already have restrictions on their out-of-state licenses.
The restrictions appearing on these licenses give Wisconsin DMV the information
it needs about the individual's ability to drive safely with a functional impairment;
and therefore it is reasonable for Wisconsin to accept those restrictions as
evidence equivalent to a driving evaluation.
The fact that Wisconsin permits some disabled applicants--those for whom it
has information about their ability to drive safely--to obtain a license without
taking a driving evaluation indicates that the driving evaluation requirement
challenged by the Complainant in the discrimination case is not discriminatory
within the meaning of the ADA and the Rehabilitation Act.
Hunt, Murphy, Carr, Duchek, Buckles, and Morris (1997a, and 1997b) conducted
a study to assess the reliability and stability of a standardized road test
for healthy aging people and those with dementia of the Alzheimer type (DAT).
The Washington University Road Test (WURT) is a 9.6-km (6 miles) course with
urban 2-, 4-, and 6-lane streets providing various road and traffic conditions
to enable detection of driving behaviors associated with crashes in the elderly:
failing to yield right-of way, responding inappropriately to traffic signs and
signals, and difficulty negotiating intersections.
The initial test site (a large empty asphalt parking lot) was used for familiarization
of the subject with the test vehicle (standard-model car with automatic transmission,
and dual brake pedals). Seven basic motor vehicle operational tasks were assessed
on a pass/fail basis: insert key into ignition; start engine; shift from park
to drive; drive forward 45 meters (148 feet), make a left turn; stop. Subjects
proceeded from closed course to open segment, unless major safety concerns were
detected during familiarization. A commercial driving instructor plus the Principal
Investigator accompanied each subject during the drive. A global "safe/behavior
unlikely to result in crash," "marginal/small-to-moderate risk of crash," or
"unsafe/substantial risk of crash" subjective rating of driving performance
was made by the instructor and Principal Investigator (PI). A quantitative score
was also calculated independently by the instructor and PI. The best possible
score was 108, the worst possible score was 0. A 3-point scale (0=moderate to
severe impairment; 1=mild impairment; 2=no impairment) was used at predetermined
locations on the following maneuvers: left turns, stops, lane maintenance, speed,
traffic awareness, merging, concentration, lane changes, traffic signs, comprehension
of directions, attention to task, awareness of how driving is affecting others,
judgment, need for intervention by instructor for safety reasons.
The subjects were recruited from the Alzheimer's Disease Research Center (ADRC)
at Washington University School of Medicine and included:
58 healthy elderly control subjects, mean age = 76.8 years; Clinical Dementia
Rating =0
65 subjects with Dementia of the Alzheimer's type (DAT), mean age = 73.7
years; divided into 2 groups:
36 subjects with Clinical Dementia Rating = 0.5 (very mild DAT)
29 subjects with CDR = 1.0 (mild DAT).
There was a significant relationship between global rating and CDR, such that
most CDR-0 subjects were rated as "safe" [78% (45/58) compared to 67% (24/36)
of CDR-0.5 subjects and 41% (12/29) of CDR-1 subjects. Only 3 percent of CDR-0
subjects were judged "unsafe," but 19 percent of CDR-0.5 and 41 percent of CDR-1
subjects were judged "unsafe." The remaining subjects in each CDR group were
rated "marginal." As dementia severity increased, the quantitative scores decreased.
Mean road test scores for the CDR-0, CDR-0.5, and CDR-1 groups were 94.3, 92.0,
and 85.6, respectively. Correlational analyses showed a significant association
between drive performance scores and CDR level.
The stability of driving behavior over time was examined with a 1-month test-retest
paradigm for 63 subjects. The stability of the global rating by the same driving
instructor on the same course was 0.53, and for the quantitative score, reliability
was 0.76. Few safe drivers at baseline became unsafe at 1 month, and few unsafe
drivers at baseline became safe at 1 month. The disproportionate instability
came from the "marginal' drivers. It was suggested that visual environmental
cuing (e.g., following a lead vehicle) may affect driving performance; cognitively
impaired drivers may seek the actions of other drivers to follow the flow of
traffic.
For specific driving behaviors, 24 (81%) of the unsafe drivers required assistance
[vs 11 (14%) of the safe drivers]. Turn signal use/non use did not discriminate
between safe and unsafe drivers. The strongest correlation with the global rating
was with qualitative judgments on WURT driving performance. These judgments
evolved from observing the overall cognitive performance of the subject's driving.
The WURT scoresheet is presented in the following four pages.
Dobbs (1997) used subjects in the DrivAble cognitive screen development research
to develop road test procedures and scoring. The majority of the drivers who
failed the road test received low scores on the cognitive screen; the majority
of the drivers who passed the road test received high scores on the cognitive
screen. The subjects included 279 drivers across three groups:
176 patients who were referred to a clinic with suspected decline in mental
abilities (majority were diagnosed with Alzheimer's) with a mean age of 72 years;
70 mature healthy drivers, who volunteered for the research, with a mean
age of 69 years;
33 young healthy controls, who also volunteered, ranging in age from 30
to 40, with a mean age of 36 years.
[ Washington University Road Test
page 1 | page 2
| page 3 | page
4 ]
A two-part road test was administered by two experienced driving
instructors from the Canadian Automobile Association. Testing was conducted
in a mid-sized American car equipped with dual brakes. The first part was a
closed course on paved streets with curbs, but was undeveloped allowing traffic
to be restricted and signs to be placed as desired. The open road test consisted
of 37 maneuvers, required 40 minutes to administer, and was conducted on commercial
and residential streets, and an urban freeway. Maneuvers were selected to maximize
those implicated in older-driver crashes. Some instructions for downstream maneuvers
were given; other maneuvers required planning (e.g., a lane change prior to
a turn); and some maneuvers required working memory skills (e.g., turn left
after two blocks). There was also a "take me to" instruction. Definition and
scoring of errors was as follows:
Hazardous or potentially catastrophic driving errors: errors committed
by drivers who are no longer competent to drive (e.g., wrong-way on a freeway,
stop at green light), and would result in a crash if examiner did not intervene
or traffic did not adjust.
Discriminating driving errors: potentially dangerous errors that signal
declining driving skill (e.g., poor positioning on turns and straight aways,
observational and scanning errors, and overcautiousness).
Non-Discriminating driving errors: errors made equally often by good
and bad drivers, reflecting bad habits as opposed to declining ability (e.g.,
rolled stops and speed errors). Drivers are not penalized for non-discriminating
errors. Discriminating errors are documented and scored in terms of their severity
(5, 10, or 51 points). Hazardous errors were renamed as Criterion errors and
the commission results in an automatic fail. A combined criterion of one or
more criterion errors and/or discriminating point total exceeding criterion,
results in a failure on the road test.
Using the joint criterion, all of the young normal drivers passed the road
test, approximately 95 percent of the mature control group drivers passed the
road test, and only 25 percent of the cognitively impaired (patient) group passed
the road test.
A driving assessment procedure in the United Kingdom is described next. The
procedures used at Mobility Advice and Vehicle Information Service (MAVIS) are
to help answer the question of whether a license holder can safely return to
driving following a crash or injury, or if a physical, mental, or medical condition
is acquired that is likely to affect fitness to drive. MAVIS is located on the
site of the Transport Research Laboratory, Department of the Environment, Transport
and the Regions, Crowthorne, Berkshire, England. The assessment consists of
four complementary modules: two in the office (i.e., an interview and a physical/sensory
assessment); and two sessions in a car, which require driving on a private road
course and driving in real traffic. The in-car exercises are used to evaluate
a client's physical and cognitive driving skills. The full assessment (in-office
plus in-car) takes approximately 4 to 4.5 hours with a 0.5- to 1-hour lunch
break. Following the assessment, the findings are discussed with the client
and advice is provided regarding appropriate courses of action. The in-car assessment
is described below.
Private Road Course. The testing is divided into 10 exercises and takes
about 1 hour to complete. A warm-up drive is completed around the outer roads
before the exercises are begun. The exercises are scored on a scale of 1 to
4; a score of 4 indicating "definitely safe," a score of 3 indicating "probably
safe," a score of 2 indicating "probably unsafe," and a score of 1 indicating
"definitely unsafe." Second attempts are given for some of the exercises. The
maneuvers and skills assessed include:
| Exercise |
Maneuver |
Skills Assessed |
| 1 |
Routine drive around course, maintaining
proper lane position, stopping at stop lines, and yielding at give way lines. |
Operation of car controls; perception of
environment; spatial ability |
| 2 |
Routine drive making 3 passes through traffic
lights, stopping for red lights and proceeding on green. |
Choice reaction |
| 3 |
Similar to previous exercise, however client
must also look for directional information sign and follow the direction
indicated. |
Assessing choice reaction; work load; and
orientation |
| 4 |
Drive which includes following instructions
along a certain path, entering a dead-end area and turning around, and driving
out of the dead-end, and back on the course. |
Audio/visual memory, operation of car controls,
spatial ability, and orientation |
| 5 |
A reverse onto a side road. |
Spatial ability and operation of car controls |
| 6 |
Conducting a parking maneuver. |
Spatial ability and orientation |
| 7 |
Conducting a driving maneuver which requires
the car running on one side of the center line, then upon adviser instruction
positioning car on to other side of center line. |
Spatial ability |
| 8 |
Task requires driving down a hill and weaving
in and out of cones. |
Motor coordination and spatial ability |
| 9 |
Driver given instructions and a map, and
asked to follow course along map. |
Information processing and cognitive mapping |
| 10 |
Upon successful completion of Exercise 9,
client is instructed to drive around same route without instruction. |
Memory |
In-Car Assessment in Real Traffic Conditions. This assessment is a continuation
of the evaluation of skills from the private road course (i.e., use of car controls,
spatial skills, and perception of the environment) plus an assessment of decision
making, steering while driving at 60 mph, attention, interaction with other
road users, and the effect of motor/cognitive workload in multitasking exercises.
Although the route is standardized and each client drives the same route (which
is about 10 miles in length and takes about 25 minutes to complete), the same
traffic and operating conditions do not prevail for each client. Therefore the
advisor scores particular actions and not every event. A brief description of
each exercise and what it assesses, follows:
| Exercise |
Maneuver |
Skills Assessed |
| 1 |
Observed driving behavior through 5 roundabouts.
Elements for scoring: unnecessary stops at roundabout, necessary stops at
roundabout, speed of approach, position with regard to other traffic |
Decision making |
| 2 |
Counting to 30 while negotiating roundabout.
Elements for scoring: effect of counting on driving performance, effect
of driving performance on counting, choice of which is given priority (driving
or counting) |
Divided attention |
| 3 |
Observed driving behavior at 4 mini roundabouts. |
Decision making |
| 4 |
Interactions with other road users. Elements
for scoring: does client observe and take appropriate action for pedestrians
using crossings? Does client observe speed restrictions, both signs and
physical barriers? Does client take note of happenings in busy center? |
Interactions with other road users |
| 5 |
Driving at 60 mph keeping a safe course and
avoiding centerlines and edgelines. |
Spatial ability at speed |
| 6 |
Detection of traffic signs |
Attention |
| 7 |
Behavior when making two specific lane changes.
Elements for scoring: client observation and awareness of conditions prior
to lane change, signaling, appropriate speed for safe lane change. |
Interaction with and awareness of other road
users |
| 8 |
Taking a route which encounters 4 roundabouts
by following signs to a destination. Elements for scoring: correct direction,
safe and accurate positioning, client awareness of other traffic, behavior
at roundabouts. |
Information processing in high workloads |
A written report is provided to the client, but client confidentiality is practiced.
The aim of MAVIS is to offer information on driving ability, not to decide on
driving license status.
References:
Dobbs (1997)
Engel (1991)
Engel and Townsend (1984)
Janke (1994)
Janke and Hersch (1997)
Jones (1978)
MAVIS (1998)
McKnight and Adams (1970)
McKnight and Stewart (1990)
McPherson and McKnight (1981)
Ranney and Pulling (1990)
Romanowicz and Hagge (1995)
Staplin, Gish, Decina, Lococo, and McKnight (1998)
Tarawneh, McCoy, Bishu, and Ballard (1993)
Vanosdall and Rudisill (1979)
Wisconsin DMV Driver Skills Test (Section 335,5/1/97) and Special Examination
(Section 345, Draft 12/1/97)
IC2(c)ii.Customized ("Home Area") Exam, Tailored to
Individuals' Driving Patterns
Summary:
A study was conducted in cooperation with the CA DMV, using a sample of drivers
over the age of 60 who had been referred to the Department for reexamination
(Staplin et al, 1998; Janke and Hersch, 1997). A within-subjects research design
was applied, calling for two test drives by each subject: one drive on a standard
route presumed to be of relatively lower familiarity, common to all study participants;
and a second drive over a route of relatively higher familiarity that was unique
to each individual, in the immediate area of the person's residence. Field measures
of driving competency were obtained, using a Modified Driver Performance Evaluation
protocol (Janke and Hersch, 1997) with demonstrated interrater reliability,
scored by examiners who were specially-trained in its use and in the testing
of older, frail individuals. The road test route was free-form, rather than
pre-planned (of necessity); structured maneuvers could not be assigned to specific
points on the route. However, the maneuvers and scoresheet were as described
in section IC2ci of this Notebook, except a merge maneuver was not
required. The home area drive included 1 to 3 destination trips, each beginning
at the driver's home. The driver chose a destination (doctor's office, bank,
grocery store) then drove to the destination and back home again. Eighty subjects
in the Staplin et al. study took the standard exam (28 passed and 52 failed)
and 61 subjects took the home area exam (25 passed and 36 failed). Seventeen
of the drivers who failed the standard exam, did so because of hazardous performance;
their drive tests were terminated and they were not allowed to take the home
area exam. Eight of the subjects who completed the standard exam but "failed"
it were able to perform the home area drive test satisfactorily.
In this study, error rates varied as a function of the type of traffic control
(signal, stop sign, yield, or no control), the familiarity of the course, and
the type of movement (straight through, left turn, right turn). Route familiarity
had little to no effect on error rates exhibited at signalized intersections.
However, for right turns in yield and uncontrolled intersections, error rates
were noticeably higher on the unfamiliar course. This may have resulted from
drivers "knowing what to look for" as a result of experience in familiar areas.
The more common maneuver problems included "failure to come to a complete stop
at a stop sign," which was noted on 53 percent of the test drives over unfamiliar
routes and 57 percent of the test drives over familiar routes. "Stopping for
no reason" was noted on 39 percent and "turning too wide or too short" on 46
percent of test drives over unfamiliar routes; both were noted on 26 percent
of test drives on familiar routes. Other potentially serious safety problems
noted on at least 20 percent of test drives (on unfamiliar routes) by the examiners
included "stopped over limit lines (stop bars)," "consistently drives too slowly,"
and "unsafe left turn gap acceptance." These errors were less common on the
familiar routes; presumably this reflected differences in drivers' expectancies
for the demands encountered along each route type. Errors that were more
frequent on the familiar routes, being noted on at least 20 percent of
test drives, included "infringes on others' right-of-way when changing lanes"
and "near miss (pedestrian or car) other than during gap acceptance."
In their profiles of State practices, Petrucelli and Malinowski (1992) indicated
that the following States specifically issue license restrictions for a geographical
area or radius from home: Alabama, California, Colorado, Delaware, Illinois,
Iowa, Michigan, Missouri, Nebraska, New Mexico, North Dakota, Oklahoma, Oregon,
South Dakota, Utah, Virginia, Washington, and Wisconsin. They reported that
in Illinois, a restricted local license may be issued to applicants who have
difficulty operating a vehicle in more populated areas. The applicant must live
in a non-urban area or a town with a population of less than 3,500. Applicants
must successfully complete a vision, written, and driving evaluation. The driving
evaluation is administered over a route that the applicant would normally drive
to go to the grocery store, doctor, etc. in his or her local area. In most cases,
the applicant is not permitted to drive on or cross over any federal or state
highways. A driver who passes this type of road test is restricted to the tested
route.
In the State of Wisconsin, a limited area examination may be given
to a driver who is unable to cope with complex traffic situations. It may also
be appropriate for a customer who has a medical or functional impairment that
severely limits driving ability. The objective of this non-directed test is
to determine whether the driver can safely operate a motor vehicle in a familiar
area. The test is constructed around the driver's home area and on routes that
take the driver where he/she needs to go (e.g., doctor, grocery store). A customer
does not need to fail the standard exam before qualifying for a limited area
exam; however, if a driver chooses to be tested in the limited area, he/she
will not be able to drive outside of the designated limit (i.e., a limited area
test will always result in a restricted license). The required minimum maneuvers
are the same as those required for all special examinations (see earlier description
in Notebook section IC2ci).
Janke and Hersch (1997) point out that a home-area drive test is one of the
necessary bases of a graded licensing system in its attempt to devise workable
tradeoffs between increments of safety and increments of mobility for individual
drivers.
References:
Janke and Eberhard (1998)
Janke and Hersch (1997)
Petrucelli and Malinowski (1992)
Staplin, Gish, Decina, Lococo, and McKnight (1998)
Wisconsin DMV Special Examination (Section 345, Draft 12/1/97)
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