#88: OT and Driving with Ganesh M. Babulal

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Learn more about our guest: Ganesh M. Babulal, PhD, OTD, MSCI, MOT

The population of the United States is older than it has ever been.

And, by 2050 the older adult population (>65 years) is projected to increase another 47% (from 58 million in 2022 to 82 million by 2050). This will transform many aspects of our society—and one change we need to prepare for is:

The safety of older drivers.

Because by 2050 the older adult population (>65 years) will make up 25% of all drivers.

You may be aware that our youngest, newly licensed drivers are the most likely to be in a crash— but it is older drivers who are more likely to be in a fatal crash.

In our featured article from JAMA gives a high-level overview of the complex driving needs of an older population—and tucked inside you’ll see OT’s role in helping to address these needs.

After we review the article, we’ll welcome one of the article’s authors Ganesh M. Babulal, PhD, OTD, MSCI, MOT, who leads the DRIVES Project at Washington University School of Medicine in St. Louis. Through this project he is working to understand how preclinical Alzheimer’s disease (AD) impacts driving behavior.

:white_check_mark: Agenda

Intro and breakdown and analysis of journal article

  • Introduction to Safety and Older Drivers
  • Medical Impairment
  • Fitness to Drive and Driving Cessation
  • Available Safety Technologies
  • The Impact of Autonomous Vehicles

Discussion on practical implications for OTs

  • How did you become interested in OT and driving?
  • How did this paper in JAMA come to be?
  • As you revisit this paper, what stands out to you? And, has your thinking changed on anything?
  • What are you learning from your tracking research? Are there driving safety screens that are accessible to the OT professional?
  • What considerations do you think an OT should have when they are performing a full driving evaluation?
  • Are there driving simulations that are accessible to the average clinician?
  • What recommendations do you have for having conversations about driving cessation? (And how can we learn our state’s reporting laws?)
  • What suggestions could OTs provide to improve driving safety, post eval?
  • Are autonomous vehicles going to solve the problems of driver safety for us?
  • What future business models/legislation do you think we need to make OT services for driving more accessible?

:white_check_mark: Supplemental Resources

Information about increase in traffic deaths

Duty to warn regulation about unsafe drivers

Driving Risk/Fitness to Drive Screens

OT’s Role in Driver Safety

Driver Cessation

More Supporting Journal Articles

:white_check_mark: Article Review

Read Full Text: Addressing the complex driving needs of an aging population (This is a paid article, but we still thought it was important to cover.)
Journal: JAMA
Year Published: 2023

The U.S. population is older than it has ever been.

And, the older adult population (>65 years) in the United States is projected to grow another 47% by 2050—up to 82 million compared to 58 million in 2022. This will transform many aspects of our society, but one change we definitely need to prepare for is:

The safety of older drivers.

Because by 2050, 25% of all drivers will be over the age of 65.

While it’s true that younger, newly licensed drivers are the most likely to be involved in a crash, older drivers are more likely to be in a fatal crash.

Today’s featured article from JAMA provides a high-level overview of the complex driving needs of an older population—and gives a glimpse into OT’s role in addressing these needs.

Next week on the podcast, we’ll welcome Ganesh M. Babulal, PhD, OTD, MSCI, MOT, one of the article’s authors and the leader of the DRIVES Project at Washington University School of Medicine in St. Louis. Through this project, Dr. Babulal is working to understand how preclinical Alzheimer’s disease (AD) impacts driving behavior.

Let’s dive in…

About this article

This article is from the JAMA Insights series, which aims to highlight issues of high clinical relevance in a concise way. JAMA is among the top 5 journals in medicine and science. The full article is a relatively quick read, so I encourage you to check it out—but here’s a summary of the most important takeaways for OTs:

Intro to safety and older drivers

Older adults can experience a decline in visual, cognitive, and motor functions. These age-related changes can work in combination to adversely impact driving skills (for example, by causing delayed reaction time). As we’ll cover in the next section, these changes often occur in conjunction with chronic diseases.

These aging factors may explain why older adults have the highest rate of death associated with driving.

Compared with younger drivers:

  • :rotating_light: Drivers ages 75–79 are at a 2.5x higher risk of a crash death.
  • :rotating_light: Drivers over the age of 80 are at a 5x higher risk of a crash death.

Medical impairment

Numerous age-associated conditions increase the risk of driving impairment for older adults. For example, neurological conditions can lead to dementia impairments that cause drivers to:

  • Confuse the break and gas pedals.
  • Fail to locate familiar routes.
  • Not observe traffic signs.
  • Not maintain range control or appropriate speed.

Conditions like seizures, syncope, arrhythmia, sleep apnea, and orthostatic hypotension also have associated symptoms that can threaten safe driving.

Unfortunately, the medications we use to treat these chronic conditions can also have a negative impact. In case control studies, medication classes with increased risk of a crash included:

  • Benzodiazepines
  • Anticholinergic drugs
  • Anticonvulsants
  • Antipsychotics

Polypharmacy is also a growing concern for the aging population, as it can lead to drowsiness.

Strategies to address “fitness to drive”

Despite the obvious risks, there are currently NO validated criterion standard measures to determine driver safety.

Still, primary care physicians can take several steps to assess fitness to drive:

  1. Encourage family members to accompany the older driver when appropriate so they can identify potentially unsafe behaviors.
  2. Reduce distractions (e.g., by turning off cell phones).
  3. Investigate and correct reversible causes of driving impairment:
    a. Eliminate sedating medications.
    b. Treat sleep apnea.
    c. Refer to cataract surgery.

In ambiguous cases, physicians can refer patients to a comprehensive driving test administered by an occupational therapist or driving instructor. (Note that Medicare, Medicaid, and private insurance typically do not cover evaluations purely to assess driving ability.)

Driving simulators can be used by OT professionals to test performance skills that may not be safely replicable on the road (e.g., the driver’s response to a pedestrian walking into traffic).

Another option is to use a GPS tracker to assess real-life driving behaviors. Hypothetically, this naturalistic driving data could be used to facilitate risk modeling.

Driving cessation and duty to warn

Driving cessation discussions should be conducted with sensitivity—and with family support, if available. Considerations should be made for alternative transportation.

Please note that as a clinician, you may have an ethical “duty to warn” your state licensing agencies of potentially unsafe drivers who refuse to stop driving. Some states provide civil immunity for clinicians who report unsafe drivers, while others have mandatory reporting laws.

(I found this article in JAMA a helpful read on reporting requirements for medically impaired drivers. The 6 states with mandatory reporting laws are: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania.)

New driving safety technologies

90% of all vehicle crashes are due to human error.

Many new technologies are being deployed to help make driving safer. Two trends highlighted in the article are advanced driver assistance systems and autonomous vehicle technology.

Advanced driver assistance systems

These advanced systems are designed to help detect crash risk stimuli and reduce driver error. Some systems will engage the brake when a significant risk is detected.

But, despite the promise of these systems, there is a lack of standardization—and no comprehensive studies have been conducted to prove their effectiveness.

Autonomous vehicles

The Society of Automotive Engineers provides this helpful taxonomy of driving automation:

1600×1239 549 KB

Contemporary manufacturers of autonomous vehicles are only at level 2. And, automotive engineers predict that vehicles will remain heavily dependent on human interaction for many years to come.

The industry still needs to:

  • Reduce costs.
  • Refine decision-making AI algorithms.
  • Conduct extensive testing.
  • Improve reliability in inclement weather.
  • Ensure security systems are tamper-proof.
  • Work with federal driving regulations.

Conclusion

While technology holds promise in helping older drivers, the reality is that it cannot replace human driving skills—and cannot independently determine crash risk and safety.

At this point, clinicians seeking to determine an individual’s fitness to drive are best served by objective data from technologies coupled with clinical assessment.

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

2

I wanted to be the first to jump in here, because I was really suprised by the data I saw that that fatalities on the road have actually been going up in the United States, even as we roll out vehicles with more and more safety features.

Technology does not seem to be the panacea what had hoped for, and it seems like OT evaluation and intervention is going to be more important than I realized in the upcoming years.

https://www.transportation.gov/sites/dot.gov/files/2024-02/2024%20NRSS%20Progress%20Report.pdf

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1 Like
4

As an OT educator, I have an OT and her husband come to class as guest speakers. Together they own a company that provides driving evaluations and interventions, including on the road training. The OT gives a lecture on the role of OT in driving rehabilitation. She speaks from her experience as a specialist, but also discusses the role of all OTs in driver rehabilitation. The students get an opportunity to drive and learn about adaptations for cars.

As profession, we more educational opportunities for those working in more of a general setting and for those who want to specialize. There is not enough professionals to address the current need, let alone the term need.

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5

I know Susie Touchinsky does some in-depth courses, but I also feel like we need more short courses directed at outpatients OTs.

And, it it just mind-boggling that a drivers eval isnt covered by insurance in a more straightforward way… My take away from the past few months is insurance needs to be covered swim safety and drivers safety. We are completely missing the boat from a public health perspective.

https://adaptivemobility.thinkific.com/collections

1 Like
6

I am really interested in the family dynamics around driving. As I have engaged with older adults in the community, many family members are not prepared to broach the topic or don’t have access to or sometimes don’t know how to navigate other systems beside single car transport. I always encouraged families to begin trying out other forms of transport before it was “needed” because it would allow for these uses to be more familiar and less stigmatized/associated with cessation. But transport options are always a limiting factor in communities largely built for car-only transport, particularly rural areas.

To answer the second question: we can advocate for less car-centric urban development and more accessible/affordable forms of public transit.

We’ve also seen success in training our public transit drivers in dementia friendly skills so caregivers and people living with dementia might feel more comfortable riding buses.

4 Likes
7

Occupational Therapists can do a lot to help in this area. We can refer clients to AARP which has a great program helping us to educate families on how to approach the topic of driving either modifying driving or giving it up altogether. I think the program may be called Can We Talk. We can help clients connect with alternative transportation options. We can alert physicians when we see those signs of medication impact, sleep apnea and cataracts. I have seen a reaction time simulated driving video on the AARP site that could the client a little insight into their skills. This helps to bring up the topic for discussion.

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8

As I dug into this topics, my biggest regret on how I managed driving concerns in the past was that I totally focused on cessation. I was not focused on building a plan for community mobility and decreasing isolation.

In one of the supplementary readings, I saw that depression risk increases 2 fold once patients stop driving… I wish had known that statistic.

Here’s the article that stat was in…https://www.neurology.org/doi/10.1212/WNL.0000000000209426

ALSO, @rachel12 I thought of you so many times while I was looking Ganesh’s publications. Are you connected with Ganesh already? I definitely think you should be!

1 Like
9

This is truly a much-needed conversation under the current circumstances. In our OT program, we invite an expert OT with a driving program in private practice to talk and demonstrate adaptive driving techniques. Students get a chance to look at AT which can be utilized for various conditions. Recently we obtained a driving simulator at our grant-funded Intergenerational Center that is used by my colleague who teaches this course and uses it in her research. Students are trained to use the simulator and perform assessments and interventions.
In acute care, we did driving screens to identify persons who may need to stop driving or need a full driving assessment.
I have broached the subject of driving cessation and alternative modes of transportation with patients and families in acute care.
I also think that more education is needed for a generalist OT on topics such as driving evaluations, available resources for patients and families, comfort with talking about driving cessation, and knowledge in alternative transport in their areas.

4 Likes
10

YES! There is so much good information out there to be disseminated to clinicans. I’m going to gather the resources I’ve found for this podcast, then maybe @Ganesh and @susan9 can help me add to it! (I’ll ping you both when the episode is live.

Also, @Ganesh, I keep getting messages with amazing OTs involved in driving, so if you ever need more connections to clinicians, please let me know!

11

I enjoy reading the comments and discussion–thanks for your insights. There is so much to be done in terms of education, dissemination, allocation of resources, and awareness in general around this topic. I am happy to help provide whatever I can from the research and academic realm.

Happy to connect with OTs involved in driving. We need to collective support this work as a consortium/united field.

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12

So great to have you in here @Ganesh! I’m looking for fitness to drive screens and I can only find this one that is publicly available. Is this a good one to recommend?

https://ftds.phhp.ufl.edu/ca/questionnaire.php

I’m bummed because I can’t find the The DrivingHealth® Inventory in a format that is available for use!

@susan9 if you have any recommendations for me please let me know!

13

Ok! Found this nice self-report checklist for AAA. https://exchange.aaa.com/wp-content/uploads/2021/03/Driver-65-Plus.pdf

14

This also looks like a nice driving cessation program OTs could take to learn about coaching through cessation. I’d be curious if any OTs have done this!

15

I think you might be hitting a little trouble because ‘fitness to drive’ has to do with the OT driving rehab specialist… it sounds like you are looking into driving risk assessments, which is the role of the OTP in general practice.

With that in mind, for the OTP in general practice I recommend resources like the Generalist Resource to Integrate Driving (GRID) FREE GRID Generalist Resource to Integrate Driving and the free CE OT Role with Driving OTs Role with Driving

My best best best advice is to remind OTP generalist you are looking at risk and potential - you will never see a client engaged in the occupation of driving, so you can’t pass judgement on fitness to drive, only driving risk.

With this in mind you want to assess the performance skills and client factors needed for driving - vision, movement, reaction, cognition AND you want to assess these skills NOT just with paper and pencil tests BUT with occupation based assessments. This is critical. Driving is an occupation. We are occupational therapy practitioners. We need to observe other - less difficult - occupations. Then if there is trouble with scheduling a doctor’s appointment, or managing medications, or making and organizing a grocery list - then we know that harder IADLs like driving might also be impacted. When we know this, it’s time to call in an OT driver rehab specialist to help look at the task of driving.

I would LOVE LOVE LOVE to join forces to help champion these ideas and expand resources to the OTP.

3 Likes
16

When it comes to driving retirement, I feel very strongly that it should be more than a one time conversation and include more than one professional and more than one test. Even for myself, when I am see high risk behavior and I am strongly recommending driving retirement, I still connect with teh referring doctor for collaboration. It is a must for the patient and because of the weight of this recommendation.

In addition, when it is time for driving retirement, this is where we as OTP can really help patients and families. I strongly recommend the 3 R’s of Driving Retirement.

2 Likes
17

@susan9 THANK YOU for being here!! Now I’m wishing I had talked to you before my podcast, because you have such great langauge to differeniate between both “driver risk” and “fitness to drive” AND the OT driver generalist versus specialist!

Luckily, people who take the course will be able to see your helpful comments!

I’m adding the resources you shared to my resource list! Here’s my current list! @susan9 and @Ganesh Let me know if I am missing anything!!

Information about increase in traffic deaths

Duty to warn regulation about unsafe drivers

Driving Risk/Fitness to Drive Screens

OT’s Role in Driver Safety

Driver Cessation

18

Thank you, Sarah for bringing this topic up a very important IADL for our OT Professionals.
Great discussion Ganesh was excellent . Ganesh explained very well various roles and OT can be involved in addressing the IADL of driving and how it requires a teamwork to address This very sensitive conversation on driving cessation.
One of the thing I would like to ask Ganesh is if he has ever been in the car with the specialist to see what it takes or what does it involve for an on road assessment.
Thank you so much Sara for discussing this topic. Love it.

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19

I would also like to add this wonderful website created by my colleague, Dr. Anne Dickerson. There are lots of great resources about driving in general, along with a thoughtful focus on driving retirement with mobility planning.

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20

Hi Purnima, thank you for listening and kind comments. Yes to your question. I have not only been in a vehicle for road test/evaluation/assessment, but we have used the road test as the gold standard for assessing driving performance for 12 years in our research. I attached a few studies where we used the RT as the outcome.

Longitudinal.pdf (528.0 KB)
Meds and driving 23.pdf (1013.5 KB)
NPS and Preclinical AD.pdf (264.4 KB)