socialization, and the maintenance of family and friendship ties. For pa- tients recovering from a stroke or a head injury, driving is one compo- nent of community ...
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Nicol Korner-Bitensky, MSc Henry Coopersmith, MD, CM, CCFP Nancy Mayo, PhD Ginette Leblanc, BSc Franceen Kalzer, BSc
Perceptual and Cognitive Impairments and Driving SUMMARY
RESUME
Perceptual and cognitive disorders that frequently accompany stroke and head injury influence an individual's ability to drive a motor vehicle. Canadian physicians are legally responsible for identify ing patients who are potentially unsafe to drive and, if they fail to do so, may be held liable in a civil action suit. The authors review the guidelines for physicians evaluating a patient's fitness to drive after brain injury. They also examine the actions a physician should take when a patient with perceptual and cognitive problems wants to drive. Ultimately, by taking these actions, physicians will help to prevent driving accidents. (Can Fam Physician 1990;
Les desordres cognitifs et perceptuels qui accompagnent frequemment l'accident vasculaire cerebral et les traumatismes craniens influencent la capacite d'un individu de conduire un vehicule automobile. Les medecins canadiens sont legalement responsables d'identifier les patients dont la capacite de conduire constitue un risque potentiel et, s'ils ne le font pas, ils sont passibles d'une poursuite au civil. Les auteurs passent en revue les criteres qu'utilisent les medecins pour evaluer la capacite de conduire d'un patient apres un traumatisme cranien. Ils examinent aussi les actions que peut entreprendre le medecin dont le patient, aux prises avec des problemes perceptuels et cognitifs, veut conduire son automobile. Finalement, par ces mesures preventives, les medecins contribuent a prevenir les accidents d'automobile.
36:323-325.) Key words: cognitive impairment, disabilities, family medicine, functional impairment, neurology, perceptual impairmen M El
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Ms. Korner-Bitensky is Co-chief of Research, Department of Research, Jewish Rehabilitation Hospital, Laval, Quebec. Dr. Coopersmith is Director of Professional Services, Department of Medicine, Jewish Rehabilitation Hospital, Laval. Dr. Mayo is Epidemiologist and Co-chief of Research, Department of Research, Jewish Rehabilitation Hospital, Laval. Ms. Leblanc is Occupational Therapist, Department of Occupational Therapy, Jewish Rehabilitation Hospital, Laval. Ms. Kaizer is Co-chief of Occupational Therapy, Department of Occupational Therapy, Jewish Rehabilitation Hospital, Laval. Requests for reprints to: Ms. Nicol Korner-Bitensky, Co-Chief of Research, Department of Research, Jewish Rehabilitation Hospital, 3205
nitive dysfunctions. An additional 20 000 individuals survive traumatic brain injury. 12.13 These two conditions D RIVING a motor vehicle re- alone suggest a considerable prevaquires the combination of motor, lence of disturbances in perception visual, cognitive, and perceptual and cognition. skills. Severely limited vision, unDriving is an integral part of the controlled seizures, or major physical modern lifestyle. The ability to drive disabilities are contra-indications to contributes to vocational opportunidriving and physicians are aware of ties, the running of most households, their responsibility to report these socialization, and the maintenance of conditions to licensing bodies. Physi- family and friendship ties. For pacians are also expected to report oth- tients recovering from a stroke or a er less overt contra-indications to head injury, driving is one compodriving, such as disorders of percep- nent of community reintegration and tion and cognition, that frequently the resumption of their lifestyle; follow stroke or traumatic brain about 40% of people who have had a stroke'4 and up to 80% of patients injury. IEach year an estimated 50 000 Ca- who have had a head injury will nadians suffer the effects of a drive. (For a review, see van Zomerstroke,7-10 and 70% of those surviving en and co-workers .5) Increasingly, will have residual perceptual and cog- physicians will encounter patients
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who have impairments in perception and cognition and who want and need to drive. Therefore, it is important for physicians to be able to identify these disorders and to take appropriate action.
Identification of Impairment Individuals with physical impairments will often need to acquire new driving techniques to compensate for altered function. For these individuals, adaptations to the motor vehicle may be sufficient for safe driving. In contrast, vehicle adaptations cannot compensate for cognitive and perceptual disorders. Disorders of spatial relations and of the discrimination of foreground from background will affect the driver's ability to identify the position of the car in relation to other cars, pedestrians, and stationary objects. Disorders of depth perception will hinder the driver's ability to judge safe distance from other cars and objects. Memory disorders will affect the ability to follow directions and to respond to road signs, while impairments in problem-solving, concentration, and judgement alters the ability to make appropriate decisions, such as adjusting driving style to correspond with weather conditions.
Canadian Guidelines The physician whose patient has perceptual or cognitive disorders does not have specific guidelines to direct the evaluation of these disorders. The Canadian Medical Association's Physicians' Guide to Driver Examination,'s however, does provide information on head injury and stroke. Section 5.2 on cerebrovascular accidents states: A person who has had a cerebrovascular hemorrhage or infarction that has resulted in a temporary loss of coordination or motor power can usually drive a private motor vehicle safely if there has been a good recovery. There must be careful evaluation to make sure the condition has stabilized and that there are no signs of an impending recurrence. . . Particular care must be taken to ensure that there are no changes in personality, alertness or decision-making ability which, though quite subtle and inconsistent, could significantly af324
fect driving ability. . . . Patients who have had a cerebrovascular hemorrhage or infarction and who resume driving should remain under medical regular supervision.'s Section 7.8 of the Physicians' Guide to Driver Examination states the following about head injuries: A person who has had a recent head injury should always be carefully examined to determine if there is any evidence of confusion that could cause temporary inability to drive. A minor head injury should not impair driving ability for more than a few hours, if at all. A more serious injury, which results in even minimal residual brain damage, must always be fully evaluated before driving is resumed. The major factors that may prohibit driving for an extended period are loss of good judgement, decreased intellectual capacity, post-traumatic seizures, visual difficulties and loss of motor power.... 15 Although these guidelines list some specific deficits resulting from brain injury that may affect driving, the guidelines do not address the effects of changes in visual perception, problem-solving, memory, and visual inattention on driving; nor are there any suggestions of assessment tools physicians could be using to evaluate these skills. It is also unclear which medical speciality should take the responsibility for identifying perceptual and cognitive deficits in patients who want to drive and for subsequently notifying the licensing body of these deficits. A patient is likely to encounter a number of physicians from different medical specialties during acute hospitalization, but driving ability is unlikely to be of primary concern at that time. For example, the neurologist or neuro-ophthalmologist who sees the patient will identify conditions that are contra-indications to driving, such as seizures or homonymous hemianopsia, but may not discuss the implications of these conditions on driving while the patient is acutely ill. Possibly the rehabilitation phase is a more appropriate time to discuss driving because this is when patients attempt to regain their skills to resume their previous lifestyle. Although perceptual and cognitive sta-
routinely assessed during rehabilitation, the tests are not always
tus are
conducted for the purpose of identifying impairments to safe driving. Even when driving ability is specifically assessed, only a small proportion of potentially unsafe drivers will be identified, given that less than 10% of patients with brain injuries receive formal rehabilitation. 16'17 Thus, most patients with brain injuries who return home have not been systematically screened for driving
potential. Once patients return home, most will contact their family physicians. The family physician because of his or her familiarity with the patient, is ideally suited for discussing with pa-
tients their intention to drive.
Role of Physicians We reiterate that specific laws and guidelines require the physician to report patients whose medical conditions may impair their ability to drive.'5'8 Currently, it is unreasonable for the physician to be held responsible for the detection of perceptual and cognitive disorders. Physicians are not prepared, nor trained, to evaluate these subtle deficits during a standard office visit. The full assessment of perceptual and cognitive impairments is a lengthy procedure, requiring the expertise of the psychologist or the occupational therapist. Even among these professionals, there is no consensus on which impairments most affect ability to
drive. There is clearly a need for, at the very least, a screening tool for use in the physician's office that can identify patients who need further testing. Until such a tool is developed, the family physician can contribute by recognizing the possibility of perceptual and cognitive impairments, by exploring the patient's intention to drive, and by directing the patient to specialized centres for the assessment of driving skills and for training. For physicians who wish to have patients with stroke or head injury assessed for driving ability, every province in Canada has at least one driver evaluation program (Table 1). The list was compiled from a survey of Canadian rehabilitation centres and from information provided by Transport Canada. We requested information on the types of assessments ofCAN. FAM. PHYSICIAN Vol. 36: FEBRUARY 1990
fered, the most common system of re- ment usually consists of a visual exferral to the program, and which pro- amination, perceptual and cognitive fessionals most often conduct the as- evaluations, and an on-road driving test. All programs have a procedure sessments. for relaying the results of the assessthat show survey the of results The most often it is a physician who refers ment to the appropriate provincial lipatients for assessment. The assess- censing body. The members of the licensing board will decide, based on the assessment results, either to reTable 1 strict or to revoke the individual's liCentres Conducting cence. Driving Evaluations As health professionals become Alberta more aware of their medical and legal Glenrose Rehabilitation Hospital responsibilities to identify patients in Edmonton who may be unfit to drive, we foresee British Columbia an increased demand for a standard G.F. Strong Rehabilitation Centre and assessment procedure, which would Holy Family Hospital in Vancouver benefit several parties: 1) the patient Gorge Road Hospital (program under who is unsure of his or her ability to review) in Victoria drive; 2) the physician who must leManitoba gally identify those who are unfit to Brandon General Hospital in Brandon Rehabilitation Hospital, Health Science drive; 3) insurance companies who must decide whether to insure indiCentre in Winnipeg viduals after a stroke or head injury; New Brunswick and 4) the community, which must be Forest Hill Rehabilitation Centre protected from unsafe drivers. in Fredericton As we reach the 1990s, preventive Newfoundland medicine will become increasingly L.A. Miller Centre in St. John's important; directing patients for drivNova Scotia ing assessment and retraining will be Nova Scotia Rehabilitation Centre a vital component of this prevention. in Halifax . Ontario Kitchener-Waterloo Hospital in Acknowledgements Kitchener-Waterloo Kingston General Hospital in Kingston We thank Irene Shanefield, MA. March of Dimes (temporarily on hold) for contacting the provincial liMLS, in London boards and collating the regucensing Royal Ottawa Rehabilitation Center in lations from each province and for Ottawa her editorial comments; and Ellen St. Joseph's General Hospital and research assistant, for Abramovitch, George Jeffrey's Children's Treatment contacting the rehabilitation hospitals Centre in Thunder Bay and compiling the information for the The Hugh MacMillan Medical Centre in Toronto table. Prince Edward Island References Queen Elizabeth Hospital in Charlottetown 1. Bardach JL. Psychological factors in the handicapped driver. Arch Phys Med Quebec Jewish Rehabilitation Hospital in Laval Rehabil 1971; 52(7):328-32. Centre de Rehabilitation Constance 2. Luria AR. The working brain: an inLethbridge in Montreal troduction to neuropsychology. New Centre Frangois Charon in Quebec City York: Penguin Books Ltd., 1973. Saskatchewan 3. Walsh KW. Neuropsychology: a cliniWascana Rehabilitation Centre cal approach. Edinburgh, Great Britain: in Regina
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67(2):99-102. 10. Wood-Dauphinee S. The epidemiology of stroke: relevance for physical therapists. Physiotherapy Can 1985; 37:377-86. 11. Bernspang B, Asplund K, Erikson S, Fugl-Meyer AR. Motor and perceptual impairments in acute stroke patients: effects on self-care ability. Stroke 1987; 18:1081-6. 12. Haince S, Bourdages J, Choquette Y. Statistics Med-Echo 1980-81 to 1984-85. Quebec: Ministry of Health and Social Services, Government of Quebec, 1987. 13. Hartunian NS, Smart CN, Thompson MS. The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease, and stroke: a comparative analysis. Am J Public Health 1980; 70:1249-60. 14. Leigh-Smith J, Wade DT, Hewer RL. Driving after a stroke. J R Soc Med 1986; 79(4):200-3. 15. Canadian Medical Association. Physicians' guide to driver examination. Ottawa, Ont.: Canadian Medical Association, 1986. 16. Mayo N, Hendlisz J. Goldberg M, Korner-Bitensky N, Becker R, Coopersmith H. Destinations of stroke patients discharged from Montreal area acute-care hospitals (1984-85). Stroke 1989; 20: 351-6. 17. Ministere de la Sante et des Services sociaux (b). Prix de Journee 1984-85, Service des donnees financieres et operationnelles. Ottawa, Ont: Government de Quebec, Canada, 1989. 18. Coopersmith HG, Korner-Bitensky NA, Mayo NE. Determining medical fitness to drive: physicians' responsibilities in Canada. Can Med Assoc J 1989; 140:375-8.
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