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LDI Curriculum: Behind-the-Wheel Refresher for Older Adults In Fulfillment of the St. Catherine University Occupational Therapy Program Master’s Project Requirement Jordan Wiertzema, Daniel Wackler, Mattea Wieberdink, Patrick Giblin, and Emily Seymour Under the mentorship of Dr. Catherine Sullivan 1 This is a Draft. Do not duplicate Purpose of Curriculum The purpose of this curriculum is to educate licensed driving instructors to help mature- drivers refresh their driving skills. Safe driving requires optimal cognitive, visual, and physical abilities; age-related changes in these functions can threaten driving safety. However, these necessary skills for driving can be maintained or improved through practice. This behind the wheel refresher course curriculum is not intended to replace driving rehabilitation for individuals who have clinical conditions affecting driving that require medical and therapeutic interventions. This version of the curriculum is a draft that will be revised following feedback from stakeholders. So no part of this current curriculum should be reproduced. For information on the status of this curriculum contact Catherine Sullivan, [email protected] or the Masters of Occupational Therapy Program at St. Catherine University. Curriculum Development The approaches that are taught in this curriculum are based on the most current research on how normal age changes affect driving safety, which maneuvers are the riskiest for older adults, and which methods of assessment and interventions are most effective. This content is also based on interviews of various stakeholders, including LDI’s, driving rehabilitation specialists and older drivers. Many recommendations in this presentation rely on a curriculum developed in Australia for licensed driving instructors teaching behind the wheel refresher courses for mature drivers. It is also partly based on the Safe Access to Destinations classroom older driver education curriculum developed in the Occupational Therapy Department at St. Catherine University over the past few years. The complete list of references can be found at the end of this booklet along with additional resources. The reference list of scientific articles us to develop this information is available upon request. 2 This is a Draft. Do not duplicate Table of Contents o Andragogy and Older Adult Education 4 o Reason for Older Driver BTW Refresher Instruction 6 o The Importance of Driving for Health/Well-being 7 o Role of Driver and Vehicle Services, 8 o Roles of OT, CDRS and MD 9 o Normal Age-Related Changes and Impact on Driving 12 o Self-Regulation 22 o Clinical Conditions 25 o Vision and Cognitive Screen 32 o Impact of Eye Diseases on Vision 36 o Medications and Driving 38 o Retraining the Older Driver 42 o Sample Outline of a Behind-the-Wheel Session with an Older Adult 44 o Resources/References 55 3 This is a Draft. Do not duplicate Andragogy and Older Adult Education Andragogy is the method and practice of teaching adult learners. When working with adult drivers, it is important to understand that they learn differently than teenage drivers. Andragogy is shaped by a number of key principles: ○ Collaboration: Adults learn better when they are seen as part of a collaborative effort between teacher and student. ○ Learn by Doing: Adult learners learn best when they are able to practice skills they learn. As such, the behind the wheel refreshers are a natural complement of classroom education for older drivers. ○ Immediate Application of Relevant Information: Adult learners want to learn about things that are relevant and immediately applicable to their daily lives. This concept is closely related to collaboration. Getting input from adult learners about what they want to learn will help ensure that they are learning information pertinent to their lives ○ Self-Motivated: Adults are often more self-motivated in their learning than teens. This can result in greater attentiveness and initiative When teaching older adults, a number of considerations should be taken into account: ○ Older adults are experts at aging. Most of them naturally adapt the way they do things to compensate for the losses of functions due to age. For example, they already self-regulate their driving by avoiding night driving and adjusting their speed to their slower reaction time. Instructors should build on those strategies by reinforcing the effective ones and offering alternatives for those that are counterproductive. ○ Building on past experience vs. letting go of bad habits: It is important to recognize that older drivers have many decades of experience driving that can be capitalized on when refreshing their skills. On the other hand, they may also have developed unsafe habits that will take longer to unlearn. Teaching older adults will be more effective if both the helpful and challenging consequences of experience are taken into account. 4 This is a Draft. Do not duplicate ○ Learning and attention: Changes in cognitive skills that affect driving safety will also affect how they learn. Older adults may need more repetitions before remembering certain rules or directions. Their difficulties with paying attention to more than one thing at a time could make it challenging for them to understand complex instructions while driving in traffic. This curriculum will include ways to adapt teaching strategies to those age-related cognitive changes. ○ Emotions: Age differences in emotional reactions to events will also impact performance on the road and instruction methods. Anxiety is common in older drivers, especially older women. This can cloud judgment and affect the relationship with the driving instructor, On the other hand, some older drivers, especially men, may be over confident. Teaching strategies to address the range of emotional reactions should be developed. ○ Brain training: There are common stereotypes that older adults cannot learn new things and their brain is not plastic. New research in the science of aging had shown that, except in the case of a degenerative disease, the mind stays quite malleable into old age, although it may take more repetitions of errorless trials before the new skill is learned. Strategies and handouts provided in this curriculum build on this new research. Keeping these concepts in mind will help create a better relationship between the LDI and the older drivers and make the learning process more efficient. 5 This is a Draft. Do not duplicate Reasons for Older Driver BTW Refresher Instructions Crash Rate Statistics Teens and older drivers have a higher motor vehicle crash (MVC) rate per mile driven. Because of the frailty of the older body, the risk of death from a MVC also increases with age. Crash Rates per Miles Traveled http://www.nhtsa.gov/people/injury/olddrive/pub/Chapter1.html Both the young adults and older driver population are at higher risks for crashes and are in need of driving instruction and practice implementing or refreshing safe driving skills 6 This is a Draft. Do not duplicate The Importance of Driving for Well-being Driving has many benefits, including o Independence/Freedom o Convenience o Come up with a few examples on your own! o o o Over 90% of the American population relies on driving for community mobility and access to out-of-home activities. Driving cessation has been linked to depression and an overall decrease in well-being in older adults http://www.cambridgecoa.org/about-us There are a number of professionals involved in making sure older adults are safe behind the wheel. These professionals and their roles are described below. 7 This is a Draft. Do not duplicate Role of Driver and Vehicle Services (DVS) How do older adults renew their license? ● All drivers in Minnesota are required to renew their license in person at a DVS office every four years and are also required to take a vision test at that time ● Visual acuity of 20/40 or better, with either one usable eye or with both eyes, with or without corrective lenses. ● Visual field of 105 degrees or greater in the horizontal diameter with either one usable eye or with both eyes. How is the DVS made aware of driving safety issues? ● A letter of concern is written to DVS from either a physician, individual, family, friends or law enforcement ● In Minnesota, family members reporting an unsafe driver are kept anonymous and are legally protected, but neighbors and friends are not. What is the next step after DVS receives information on the issues? ● DVS asks driver to come for an interview – usually seen within 2-3 weeks. ● If concerns arise during the interview, the DVS may request written and/or road test, a vision exam and a doctor’s statement on recommendations about driving privileges. When the doctor requests a professional evaluation by an OT or CDRS, the report of that assessment goes to him rather than the DVS because in Minnesota, the MD is the only health professional with the authority to recommend cancelling or restricting driving privileges to the DVS. ● If the DVS asks the driver to take a behind the wheel test, he or she is given 30 days to comply or have the license revoked. It is during that time interval that the older driver may request a refresher driving course with an LDI to be able to pass the road test Types of Restricted Licenses: ● Daylight only, no freeways, distance allowed, miles per hour, certain roads and/or adaptive equipment ● Specific visual acuity can result in or be a factor in deciding which type of restricted license a person may be issued: ○ 20/50 visual acuity = maximum speed 55 mph, 20/60 = 50 mph, 20/70 = maximum speed 45 mph (with no freeway, expressway or limited highway) 8 This is a Draft. Do not duplicate Generalist Occupational Therapist (OT) Role Older drivers may be referred to Occupational Therapy for driving safety because driving is an instrumental activity of daily living (IADL). Instrumental activities of daily living (IADL) are more complex of daily living than simple self-care. Examples include financial management, meal preparation, medication management, care of pets, child rearing and shopping. Individuals who struggle with one or more areas of IADLs are more likely to also have difficulty with driving. Role of the Generalist OT: Use specific screens or assessments that predict ability to drive safely Provide assessment and training with driving simulator Educate about risks and injury prevention Provide an intervention program to train skills necessary for safer driving (i.e. improve range of motion, visual attention, physical strength and flexibility) Provide options for promoting continued safe driving such as suggesting simple adaptive equipment and teaching compensation techniques Refer client for a comprehensive driving evaluation by a certified driving rehabilitation specialist (CDRS) if needed Counsel client about transition to alternative community mobility options and assists senior in finding those alternatives Since drivers who are seeing occupational therapists for evaluation often have a medication condition, it is unlikely that the OT would refer the driver to behind the wheel refresher courses with an LDI while undergoing OT treatment. However, if the OT does preventive care with well older adults, he or she may recommend both classroom and behind the wheel refresher driving courses. 9 This is a Draft. Do not duplicate Role of Certified Driving Rehabilitation Specialist (CDRS) Clinical Assessment Review of driving history, driving needs, license status, medical history and medications Visual/ perceptual assessment, range of motion, motor strength, coordination, sensation, reaction time; and cognitive assessment On-Road Assessment Assessment of ability to get in/out of car, mobility aid management, vehicle control, adherence to traffic rules and regulations, environmental awareness and interpretation, and consistent use of compensatory strategies. Driver Training and Driving Simulators Off-street training – conducted in safe environments such as empty parking lots On-road training with adaptive driving instruction Driving simulators- used to assess driver readiness or for driver remediation and training in a virtual environment Communication and Recommendations Recommend to driver to return to driving, with or without adaptive driving equipment Communicate with MD to recommend licensing restriction or driving cessation Referrals: o A CDRS in Minnesota cannot make recommendations directly to the DVS, only to the referring MD or patient/family if self-referred o Refer to occupational therapy for training of driving-related functions such as strength, mobility or attention. MD referral is not required to see a CDRS Length and Cost of Comprehensive Driving Assessment with CDRS Approximately 4 hours depending on presenting disabilities and driving needs 3 hours for clinical evaluation; 1 hour for on-road evaluation Cost varies; typically $200 to $400+ for a full assessment In general, Medicare does not reimburse for a comprehensive driving evaluation. May reimburse following an acute medical condition in the context of rehabilitation 10 This is a Draft. Do not duplicate Physician Role How are Older Drivers Referred to Physician? Voluntary referral of patient or by family/caregiver Compulsory referral by licensing office (DVS) or law enforcement officials What is the Physician's Role? Assesses driving-related functional abilities, both physical and cognitive o Health risk assessment/social history questions and gathers additional information. Treat medical conditions underlying driving issues and/or o Refer to OT for IADL assessment, rehabilitation of drivingrelated skills, assistive devices and/or education/counseling. o Refer to Certified Driving Rehabilitation Specialist (CDRS) for comprehensive driving evaluation (not covered by insurance) Recommend specific licensing restrictions to DVS based on own assessment or recommendations by CDRS. For certain conditions such as insulin-dependent diabetes and epilepsy, provide certification of fitness to drive to the DVS as a condition for license renewal In MN, physicians have the authority (but not the obligation) to report drivers who are not fit to drive to DVS. In some states that report is mandatory. 11 This is a Draft. Do not duplicate Normal Age-Related Changes and Impact on Driving Physical Changes Strength Driving impact: Leg strength is important for gas/brake pedal control. Similarly, a moderate amount of handgrip strength is important to control the steering wheel particularly while making sharp turns. LDI Implications: Strength is linked to power. Teach driver to break before it is needed so that does not have to apply such power Reaction Time Driving impact: Fast reaction time is needed for responding appropriately to traffic and traffic signals. LDI Implications: Teach driver to increase following distance and to be aware that faster driving speed means that it will take longer to stop. Encourage participation in racquet sports like tennis or badminton, which are shown to improve reaction time. Apps such as BrainHQ, Drive Focus, and Drivesharp (more detail under cognition) can also help improve reaction time. Range of Motion (ROM) and Driving impact: Neck/trunk flexibility is needed to look flexibility over the shoulder to check traffic. Shoulder flexibility is needed to put on a seat belt, and to control the steering wheel. LDI Implications: Teach how to adapt the mirrors to eliminate blind spots. If this is not enough, provide with panoramic mirrors, or magnifying button mirrors on the outside. If limited motion in the shoulder, provide equipment that makes it easier to buckle the car seat. Encourage involvement in yoga or Tai Chi courses which can improve those two functions, as well as decrease fall risk which has been associated with crash risk 12 This is a Draft. Do not duplicate Endurance Driving impact: Endurance is needed for longer driving trips. However, for some older adults, sitting upright while controlling both the foot pedals and steering wheel can become fatiguing even for shorter trips. LDI Implications: Encourage involvement in exercise classes to improve endurance. Solutions for physical changes: Physical fitness improves strength, flexibility, endurance and brain health. Research has found that people who enrolled in an exercise program had lower risk of crashes than those who did not. Develop a weekly routine that includes: o Strengthening: Focus on your legs (flexion and extension of hip, knee and ankle muscles). o Range of motion: focus on neck and trunk rotation and shoulders o Reaction time: Consider a racquet sport o Cardiovascular health is linked to brain health: Gradually increase to at least 75 minutes per week of aerobic exercise o Balance exercises. Fear of falling can result in reduced activity and decreased fitness (Matter of Balance and Tai Chi are both effective). ***See “Flexibility Fitness Training for Improving Older Driver Performance” handout*** For additional information on physical fitness, please visit the following websites: http://seniordriving.aaa.com/maintain-mobility-independence/keep-your-mindbody-fit/physical-fitness http://www.nia.nih.gov/health/publication/exercise-and-physical-activity-getting-fitlife http://www.mnhealthyaging.org/en/FallsPrevention/MatterBalance.aspx 13 This is a Draft. Do not duplicate Visual Changes Depth perception: ability to judge Driving impact: Judgment of the distance of the distance between the car and approaching cars at intersections and lane other objects (i.e. cars or signs) changes on the road. LDI Implications: Teach the driver to leave plenty of time to make a left turn. Choose intersections with roundabouts, left turn signal or protected left hand turn. Disability glare: inability to see an object due to oversensitivity to a disruptive light. Driving impact: Lower clarity of vision in sunny conditions and greater sensitivity to headlights at night. LDI Implications: Instruct the driver to wear sunglasses when sunny, and to avoid/limit night driving when possible. Difficulty adjusting from bright to dark. Driving impact: Increased blindness from headlights, sunny conditions and contrasting landscapes (i.e. tunnels) LDI Implications: Avoid nighttime driving, chose routes without tunnels if possible. When crossing oncoming traffic at night look down to the line on the pavement marking the edge of the road to avoid being blinded by the oncoming car. Contrast sensitivity: ability to Driving impact: Lower ability to see pedestrians see objects under different lighting and bikers and with reading road signs when conditions. sunny or at night. LDI Implications: Teach the driver to avoid driving at dusk, when raining or other poor visibility conditions. 14 This is a Draft. Do not duplicate Visual Acuity: ability to see clearly (both near and far) Driving impact: Difficulty reading road signs when moving. Dynamic Visual Acuity: ability to see clearly while in motion LDI Implications: Make sure driver is wearing his/her glasses or contacts. Clean windshield. Peripheral vision: ability to see objects to the side of the eyes while driving. Driving impact: Difficulty seeing the whole environment particularly at intersections. Bigger problem when head/neck flexibility also reduced. LDI Implications: Teach scanning strategies with head/neck; recommend wide-view mirrors for blind spot reduction. Visual Solutions: ● Routine eye exams can lead to early diagnosis and treatment of eye diseases. ● Wear sunglasses outdoors to protect from harmful UV rays. ● Wear protective goggles when working with certain tools or playing contact sports to prevent injury. ● Regular exercise helps maintain eye health. ● Enroll in a smoking cessation program as smoking can cause severe damage to the eyes. ● Monitor and control whole body conditions such as high blood pressure and diabetes, as these can cause damage to the eyes. ● Foods rich in nutrients such as vitamin A, C, and E, as well as lutein and zeaxanthin support eye health. ***Resources for Drivers: See nutrition for good vision handout below ***** 15 This is a Draft. Do not duplicate Nutrition to Maintain Good Vision For Safer Driving Vitamin Vitamin A What it does Example of Food Source Allows for light detection, Fish liver oil which helps with night Egg yolk vision Fortified milk Helps prevent Xerophalmia Butter (dry eye) and Yellow/orange fruits and Keratomalacia (cornea vegetables damage) Dark green leafy vegetables Vitamin C Antioxidant May slow progression of eye problems and diseases Citrus fruits Cantaloupe Green pepper Tomato juice Strawberries Broccoli Vitamin E Antioxidant May slow progression of eye problems and diseases Almonds Sunflower seeds Safflower oil Peanuts Peanut butter Lutein and Zeaxanthin Help fight cataracts and other eye diseases They are the only carotenoids (organic pigments) found in the macula Kale Spinach Broccoli Peas Orange pepper Persimmons Tangerines 16 This is a Draft. Do not duplicate Other Senses Hearing Signs include not reacting to instructions, asking to repeat instruction or talk louder. Sometimes one ear is more affected than the other Driving impact: Hearing impairment alone is not considered individually predictive of increased MVC. Impairment can be overcome the by relying more on vision. However, when a person has both vision and hearing impairment together, the combined effect is increased risk of MVC than vision or hearing alone. Implications for LDI: Instruct to wear hearing aids when driving. Make sure they are working properly. Stop the car when providing instructions to maximize comprehension and learning. Vestibular system – important for balance and coordinating movement. Signs of impairment include dizziness (vertigo), loss of balance. Driving Impact: People who are considered a fall risk or have recently fallen are also at an increased risk for MVC. Touch. Reduced sense of touch accompanies certain medical conditions such as diabetes. One sign is the wearing of large, soft footwear sometimes provided to avoid foot injuries. Driving Impact: Losses in the ability to feel steering wheel, brake and gas pedal can affect driving safety. This is most significant when the loss of sensation is in the hands or feet, which has implications for jerky and unsafe driving maneuvers. Implications for LDI: If vestibular system is affected, it could impact the control of the car following sharp turns. Teach to reduce speed in places such as highway entrances. Recommend fall prevention programs focusing on improving balance and core/lower body strength; such courses have been shown to also improve driving safety (Pilates, exercise programs etc.) Implication for LDI. If a person has a condition such as diabetes that impacts feeling in the legs, refer to a CDRS that can determine if hand controls could be helpful. Shoes with a thin sole can make it easier to judge the amount of pressure applied to the pedals. 17 This is a Draft. Do not duplicate Potential ways to overcome hearing loss ● Eliminating background noise in the car will help increase the focus on important sounds. ● Alerting devices that use visual cues may be beneficial such as amplifiers or greater visual cues for gas or turn signal reminders. Tips on Preventing Hearing Loss ● Routine hearing checks are suggested if an individual is often exposed to loud noise or is experiencing symptoms of hearing damage. ● Wear ear protection when exposed to loud noise. ● Take breaks from loud noise if possible. ● Listen to music at a lower volume setting. Tips on Preventing Sensation Loss Monitor and control body conditions that can cause nerve damage such as diabetes. Avoid exposure to harmful toxins. Avoid excessive alcohol intake. Vitamins B and E are important for nerve health. Vitamin supplements may help prevent sensation loss. 18 This is a Draft. Do not duplicate Cognitive Changes Decrease in fluid intelligence. Fluid intelligence: general ability to think abstractly, reason, identify patterns, solve problems, and discern relationships. Decrease in working memory Working memory: storing and managing information required to carry out complex cognitive tasks such as learning, reasoning, and comprehension. Driving impact: Decreased ability to problem solve while driving such as finding a detour when initial route is blocked. LDI Implications: Drive in familiar environments when teaching new skills. Gradually introduce more complex road environments. Driving impact: Decreased situational awareness for surrounding traffic. Problems with decision making involving complex situations. LDI Implications: Avoid giving instructions at the same time as driving. Avoid complex, high traffic situations. Decrease in selective attention. Driving impact: Decreased ability to ignore irrelevant details such billboards or music on Selective attention: the ability to focus the radio while driving. on a particular stimuli for a period of time while simultaneously ignoring LDI Implications: Reduce distractions in the irrelevant information car. Avoid giving instructions at the same time as driving. Introduce complex situations gradually. Recommend use of software to train attention. Decrease in divided attention. Divided attention: the ability to focus on multiple stimuli for a period of time Driving impact: Decreased ability to pay attention to important stimuli such as other vehicles, the speed limit, and signaling while merging into traffic. LDI Implications: Reduce distractions in the car. Avoid giving instructions at the same time as driving. Introduce complex situations gradually. Recommend use of software to train attention. 19 This is a Draft. Do not duplicate Decrease in processing speed. Driving impact: Decreased ability to interpret visual stimuli and react fast enough. Processing Speed: the time it takes a Examples include processing and person to interpret and react to stimuli responding to traffic lights, pedestrians, and other vehicles. LDI Implications: Recommend training with computer games that train speed of information processing (i.e. Wii fit). Practice reaction time in safe driving environments. Cognitive Solutions: Ways to Improve Attention and Memory: Word puzzles (e.g. Sudoku, word finds) Visual search games (e.g. where’s Waldo?) Connect the dots Mazes Memory games Reading Getting enough sleep Physical Exercise Ways to Train Speed of Processing: Playing catch or softball Racquet sports like ping pong or badminton Wii fit or Wii sports *** Resources for Drivers: See Train Your Brain handout below *** 20 This is a Draft. Do not duplicate Train Your Brain Drive Focus Drive Focus is an app designed by Drive Fit Inc. for individuals to practice visual search skills for driving. It trains individuals to better notice, react to, and identify critical items on the roadway (pedestrians, constructions signs, brake lights, etc.) Details: o iPad driver training app with interactive videos o Designed for both novice and experienced drivers o Used to accompany behind-the-wheel training o Measures attention, judgment, and reaction speed o Available for purchase ($9.99) at http://drivefit.org/ brainHQ BrainHQ is a brain-training system by Posit Science to assist individuals in improving attention, memory, brain speed, people skills, navigation, and intelligence. Details: o Online exercises that effectively address cognitive issues related to healthy aging o Provides personalized brain training o Offers suggested activities each month to keep your brain fit o Allows you to track progress over time o Sign up for free brain exercises at http://www.brainhq.com/ 21 This is a Draft. Do not duplicate Drivesharp Drivesharp is a software program designed by AAA Foundation for Traffic Safety and Posit Science. It is clinically shown to help drivers see more, react faster, and cut crash risk by up to 50%. Details: o Computer program designed for middle age and older drivers o Train your brain while traveling to national parks across the USA o To arrive at your destinations, you have to complete brain training exercises that improve visual processing skills essential to safe driving o Completion of program may result in up to a 4.7% discount on auto insurance for qualified insureds o Drivesharp is available at a special AAA price of $49 for qualified AAA auto club members. o Purchase Drivesharp software at https://www.drivesharp.com/ 22 This is a Draft. Do not duplicate Self- Regulation Self-regulation strategies behind the wheel are changes a person makes to his/her driving habits in order to be safe. Self-regulation techniques that older adults use should be encouraged if they are effective. Those techniques can also inform the driving instructor about areas of concern for the older driver. Think about it! What are some self-regulation techniques you have seen or heard of? 23 This is a Draft. Do not duplicate Common Self-Regulation Strategies ● ● ● ● ● ● ● ● ● ● ● ● Avoid driving at night Avoid rush hour traffic & busy streets Avoid driving in inclement weather Avoid left turns (turn right 3 times instead) Take short distance trips Take familiar routes Plan trips in advance Drive without passengers Cut out excess distractions Avoid highway driving Drive at speeds that are comfortable Follow the car in front of you at a greater distance to allow for increased stop time *Note- these helpful self-regulation strategies should not be mistaken for compensation techniques that older adults use when their driving skills are failing. Some examples of compensatory techniques include riding the break, using a “copilot”, and driving at inappropriate speeds (most often too slow). http://ottawakent.com/tag/safety-on-the-road-2/page/4/ ● One important aspect of self-regulation is knowing about any medical conditions that may impact driving. While self-regulation techniques may be useful for some, those with progressive diseases may not be able to drive safely using those techniques alone. ● It is very important for the LDI to refer the driver to a certified driving rehabilitation specialist if clinical conditions interfere with driving safety. 24 This is a Draft. Do not duplicate Clinical Conditions Introduction ● There are some medical conditions that are more common for older adults to experience than others. ● Diagnoses like arthritis, cataracts, and stroke (post rehabilitation), may affect driving, but do not usually require close medical attention as they don’t evolve. ○ Unless the clinical condition is significantly affecting their ability to drive, individuals with conditions like these can be taken behind the wheel for a refresher course. ● Other diagnoses like Parkinson’s disease, Alzheimer’s disease, glaucoma and macular degeneration are progressive diseases that will require close medical attention and regular reassessment to determine fitness to drive. ○ Older adults with these conditions should be referred to a CDRS. ● Patients with diabetes are treated different by the DVS depending on whether or not the patient is dependent on insulin. Patients with insulin-dependent diabetes need a note by the MD at renewal time indicating if they are still fit to drive. These drivers should receive regular check-ups on the progression of their disease. Diabetes not controlled by insulin is less severe and could benefit from LDI refresher courses. ● Medications can also affect a person’s ability to drive safely. Many older drivers take medication so it is important for LDI’s as well as the older driver to be aware of potential side effects of those medication. ● For the above reasons, it is recommended that the LDI ask the driver if he or she has a progressive medical condition that could impact their driving safety. If the answer is affirmative, then they should be given the contact information for a Certified Driving Rehabilitation Specialist (see end of this document) 25 This is a Draft. Do not duplicate Arthritis Facts ● Arthritis is a common progressive disease that affects roughly 25% of older adults aged 65 or older. ● Symptoms include joint tenderness, movement limitations, compromised strength, ROM, and endurance, fatigue, stiffness, and pain. ● Arthritis increases a person’s risk for deformities, disability, and compromised functional abilities. Impact on Driving ● Having arthritis can make older adults’ joints swollen and stiff, which can limit how far they can bend or move their shoulders, hands, head and neck. This can make it harder to: ○ grasp or turn the steering wheel ■ Provide handout on exercises to improve muscle strength and range of motion ○ apply the brake and gas pedals ■ Instruct them to leave extra room between themselves and what is in front of them so that they have time to anticipate applying the break ○ start the ignition or vehicle features ■ Recommend adapted key holders ○ put on their safety belt or look over their shoulder to check your blind spot. ■ Recommend adapted safety belt http://www.arthritissupplies.com/grips-adaptersfeatures holders.htmlimprove range of motion ■ Provide handout on exercises to ● If arthritis affects their hips, knees, ankles or feet, they also may have difficulty getting in and out of their car. ○ Recommend a leg lifter ○ Provide handout on exercises to improve muscle strength and range of motion ● If they take medicine to treat their arthritis, it may cause drowsiness. ○ Recommend the Rx review website If arthritis is significantly impacts their ability to drive, a referral to a CDRS may be warranted. 26 This is a Draft. Do not duplicate Diabetes Diabetes Facts ● In Minnesota, it is required by law that drivers with insulin-dependent diabetes submit a written statement within 30 days of diagnosis from his/her physician indicating whether or not the diagnosis interferes with his/her ability to drive safely. ● Diabetes affects nearly 27% of adults over age 65 and is characterized by the insufficient production of insulin which results in the inability to correctly metabolize glucose. ● Diabetes can result in limb amputation and sensation and vision impairments such as cataracts, glaucoma, and diabetic retinopathy. ● Diabetes can be managed through maintaining a healthy lifestyle through a wellbalanced diet, regular exercise, and sometimes taking drugs like insulin. ● The key to preventing diabetes-related eye problems is good control of blood glucose levels, good blood pressure control and good eye care. A yearly exam with an eye care professional is essential. Impact on Driving ● Diabetes can make glucose (sugar) levels too high or too low and make you feel ○ Sleep or drowsy ○ Confused ○ Have blurred vision ○ Lose consciousness ● Over time, diabetes may cause nerve damage in hands, leg, feet or eyes which can impact driving. ● Individuals with complications of diabetes were found to have longer response time, breaking difficulties, compromised driving behaviors, and higher rates of accidents. ● Discuss with the driver the importance of carrying their medication and blood glucose meter as well as having snacks in the car. ● If their blood sugar is low, have them eat a snack, wait fifteen minutes, check glucose level again, and drive after a safe level is reached. ● To increase driver confidence, recommend that they drive with a friend, family member, or loved one. ● Consider alternative transportation options if no longer desire to drive. ● If an individual has insulin-dependent diabetes, they would likely benefit from a referral to a CDRS ● Those with medication dependent diabetes can be taken behind the wheel as long as their condition is not significantly impacting their ability to drive. 27 This is a Draft. Do not duplicate Stroke Stroke Facts ● Also known as a cerebral vascular accident (CVA). ● The most common type of stroke is an ischemic stroke, where an artery becomes blocked and can no longer supply blood to the brain. ● In a hemorrhagic stroke, an artery of the brain bursts and brain cells in that area. ● Stroke is a leading cause of mortality and long-term severe disability in the US ● Acute symptoms of a stroke may be unexpected numbness on one side of the body, difficulty speaking, problems understanding others, a lack of balance, an intense headache, and vision issues. ○ If these symptoms are occurring, seek medical attention immediately. ● A stroke is not a progressive disease, but will usually have symptoms that last a lifetime which are called residual symptoms. If the stroke caused left sided weakness, you may see the following residual symptoms: ○ Memory issues ○ Impulsive behaviors ○ Hemi-neglect, where individuals are unable to pay attention to the left half of their visual field ● General residual symptoms of a stroke that result in right sided weakness can include: ○ Problems with memory ○ Problem understanding directions ○ Problems expressing oneself (problems in grammar, fluency etc.) ○ Reading and writing difficulties ○ Cautious behavior Impact on Driving ● Most individuals who have had a stroke will undergo rehabilitation and get medical clearance to drive. ○ Be sure that any older adults who have had a stroke have been cleared to drive before you take them behind the wheel. ○ Because a stroke is not progressive after it occurs, patients are not generally closely followed by an MD and could practice their driving skills with you as LDI. ● The symptoms and impact on driving of a stroke will vary greatly depending on the location and severity of the stroke (see table below). ● If symptoms of stroke significantly interfere with an individual's ability to drive, the condition is progressive, or they require complex adaptive equipment, refer them to a CDRS 28 This is a Draft. Do not duplicate Parkinson’s Disease Facts ● Parkinson's disease (PD) is a progressive movement disorder that affects the central nervous system. ● Around 1% of the senior population is diagnosed with PD. ● Motor symptoms often experienced by those with PD include: ○ Tremors, or involuntary shaking movements, while at rest (often in their hands) ○ Rigidity, where the person's muscles become stiff and oppose movement ○ Bradykinesia, or slowness of movement ○ Postural instability, where balance is compromised ● Cognitive symptoms are also very common in PD and can include: ○ Executive functioning problems including the ability to solve problems, start and complete tasks, and multitasking ○ Issues with memory, attention, processing visual information, and slowed thinking Impact on Driving ● Both the motor and cognitive symptoms related to PD can impact driving ability (see table below). ● Due to the disease’s progressive nature, older adults with PD should be referred to a CDRS for a driving evaluation. 29 This is a Draft. Do not duplicate Mild Cognitive Impairment (MCI) Facts ● Mild cognitive impairment (MCI) is a term used to describe a cognitive disorder that affects a person’s memory and reasoning ability. ● MCI symptoms can improve, stay the same, or get worse depending on the cause. If it is due to dementia (i.e. Alzheimer’s disease), symptoms will get worse as the disease progresses. ● New diagnostic criteria includes MCI as a part of what is known as “Mild Neurocognitive Disorder.” ○ The term Mild Neurocognitive Disorder also includes the early stage of dementia ● MCI is believed to affect ten to twenty percent of people over the age of 65. ● Symptoms of MCI can include forgetting recent events and difficulties with attention, judgment, and visual processing. ● They often are difficult to distinguish from normal age changes and many people with MCI go undiagnosed for years. ● It is possible, or even likely, that drivers will MCI will be on your caseload as driving instructors. If you notice memory and attention issues that are mild, it is fine to refresh their driving skills. However, if those problems are significant, include poor judgment and interfere safety, they need to be referred to a driving rehabilitation specialist (see dementia information below). ● Below you will find an observation tool that can help you determine possible memory problems. ● You can also recommend that they use the self-assessment tools such as the SAFER mentioned elsewhere in this curriculum. 30 This is a Draft. Do not duplicate Dementia and Driving Dementia is not a particular disease. It is the deterioration in cognitive functioning that renders a person unable to remember, think and plan effectively in everyday life. Dementia is also called neurocognitive disorder. There are many types of neurocognitive disorders. The most common type of dementia is Alzheimer’s disease. Alzheimer’s Disease (AD) ● ● ● ● More than 5 million people in the United States have AD About 1/8th of people over 65 have Alzheimer’s Disease Almost 1/4th of people over 85 have the disease. The impact of the disease on driving depends on the stage. Stages of Alzheimer’s Disease and Link to Driving Mild (Early Stage) The individual is generally still independent but has difficulty with usual things like word finding, misplacing objects, remembering new information, and taking longer to accomplish everyday tasks. Driving is usually still possible during this stage but the driver should get used to other modes of transportation and have a plan for the driving cessation process. Moderate (Mid-Stage) Individuals in this stage need a higher level of care from others and have issues expressing themselves through language and completing simple tasks. Symptoms can include forgetting important parts of their personal history, increased confusion about their surroundings, wandering/getting lost, impulsive behavior, mood and personality changes, delusions and hallucinations. Driving should be discontinued at this stage. Severe (Late-Stage) During the late stage, severe Alzheimer's disease, individuals need 24-hour care. Most individuals have lost their ability to communicate or respond to their surroundings, and, eventually, can no longer control their physical movements. No driving is safe during this stage. 31 This is a Draft. Do not duplicate Drivers with Dementia ● Drivers with dementia have nearly double the crash risk of others. ● Higher risk of becoming lost is linked to a significant risk of death. ● Driving is an over-learned skill: in good conditions, the driver with dementia may appear to be a competent and safe driver. ● Dementia causes delayed reaction time and impaired ability to process complex information. ● Dementia is linked to lack of insight about driving risk and abilities. ● 25% continue to drive after a doctor recommends they stop. Recommendations Following the diagnosis of dementia, it is recommended that drivers use an advanced directive to give caregivers permission to take away the keys if driving becomes unsafe. (See Alzheimer’s Association website in “additional resources”) Signs Driving Retirement Should Occur ● Difficulty maintaining lane position ● Confusion at exits ● Recent traffic tickets or warnings ● Getting lost in familiar places ● Repeated accidents ● Failure to make stops ● Confusing brake and gas pedals ● Stopping in traffic for no apparent reason The following handout (adapted from Dr. Tom Meuser’s Youtube video at UMSL) could be helpful to screen for both vision and cognitive problems. 32 This is a Draft. Do not duplicate Vision and Cognition Screen Please Circle 1. Why are you here today? Correct Incorrect 2. Do you know where we are right now? Correct Incorrect Ask for his/her license and check it for accuracy in response to the following questions: 3. Please state your full name for me. Correct Incorrect 4. Please state your full address. Correct Incorrect Write down license number. Give back license and ask him/her to read license number: 5. What is your license number? Correct Incorrect 6.a. What is the date today? (Month and day) b. Year? c. Day of the week? 7.a. What is the make and model of your car? b. Year? (can look at insurance card if needed) Correct Correct Incorrect Incorrect Correct Incorrect Correct Incorrect Correct Incorrect 8. I’m now going to ask you to operate some vehicle controls without hesitation. (Correct = no hesitation and correct operation. Incorrect = hesitation and/or incorrect operation) a. Headlights. Correct Incorrect b. High beams. Correct Incorrect b. Windshield wipers. Correct Incorrect c. Front defroster. Correct Incorrect 9. I’m now going to point to some objects in the car and I would like you to name them (Point to the following objects and indicate if the individual correctly identifies the objects) a. Steering wheel. Correct Incorrect b. Glove compartment. Correct Incorrect c. Rearview mirror. Correct Incorrect d. Windshield. Correct Incorrect 10. Ask driver to read from an external sign. Able to read it? Yes No *** IF MULTIPLE INCORRECT ANSWERS, THERE MAY BE VISUAL OR COGNITIVE ISSUES AFFECTING SAFETY. GETTING ASSESSED BY A CDRS WOULD BE WARRANTED*** 33 This is a Draft. Do not duplicate 34 This is a Draft. Do not duplicate 35 This is a Draft. Do not duplicate 36 This is a Draft. Do not duplicate 37 This is a Draft. Do not duplicate Medications and Driving The majority of older adults take one or more prescription or over the counter medications a day. Common medications used by older adults include medications to address difficulties with: pain, allergies, sleep, blood pressure, depression, diabetes, seizures, and muscle spasms. Many older adults are unaware of potential side effects that medications may have on driving. Both medication and characteristics of diseases and disorders can increase motor vehicle crash risks in older adults. Taking a combination of medications may increase risk for motor vehicle accidents. It is important to observe possible side effects of medications (listed below) when taking older drivers behind the wheel to determine if there are any red flags that may require a referral to a driving rehabilitation specialist (CDRS) Common medications that may impair driving: Medication Type: Common Drug Names: Side Effects: Pain medications codeine, hydrocodone may result in sleepiness and slowed reaction time Allergy medications Benadryl may result in sleepiness and slowed reaction time, dizziness 38 This is a Draft. Do not duplicate Sleeping medications Ambien, Sonata may result in sleepiness and slowed reaction time Blood pressure medications Lisinopril may result in low blood pressure, dizziness Antidepressants Zoloft, citalopram may result in sleepiness and slowed reaction time, dizziness Anti-diabetic drugs metformin, glyburide may result in low blood sugar, dizziness Seizure medications Tegretol, phenytoin may result in moving difficulties, dizziness, sleepiness and slowed reaction time Muscle relaxants cyclobenzaprine may result in dizziness, sleepiness and slowed reaction time After the first session, you can give your clients the following handout regarding medications. Encourage them to visit the Roadwise Rx website to find out how any medications they may be taking could affect their driving safety. *** Resources for older drivers: See 2-page Medication Handout *** 39 This is a Draft. Do not duplicate Medication Handout It is a good idea to: ● Keep an active list of medications. ● Create a dosing schedule and carry your next dosage with you if you will be out of the house. ● Use the same pharmacy every time & ask your pharmacist questions about over the counter medications. ● Ask your doctor or pharmacist how medications will affect driving and don’t drive until you know how a medication will affect you. ● Avoid driving if you feel dizzy, sedated, or have blurred vision. ● Make alternative transportation arrangement with friends or public transit while using potentially driving impairment medications. Notes: 40 This is a Draft. Do not duplicate A tool for understanding how Medications may affect you and your driving. Medications have both intended and unintended effects on the body. o These effects change based on the other medications that someone is taking, the foods that someone eats, body weight, and metabolic rate. Medications can also impact your ability to safely drive. Roadwise Rx is an online tool designed to help you learn more about your medications and how they may affect your driving. Any information that you enter in this tool is completely confidential and cannot be viewed by any other party. To access Roadwise Rx go to http://www.roadwiserx.com/index.aspx o Begin typing the name of a medication that you are currently taking and then select it from the list. o Once you have entered all your medications, both prescribed and over-the counter, click "View Results." 41 This is a Draft. Do not duplicate Retraining the Older Driver Assessments Before starting the behind the wheel process, a self-assessment can be taken by the driver to identify specific driving areas of need that can be addressed by the LDI. The Driving Decisions Workbook was created by the University of Michigan and provides direct feedback for the following areas: on the road driving, vision, cognition, mobility, and health. A free PDF version of the Driving Decisions Workbook can be found at: https://deepblue.lib.umich.edu/handle/2027.42/1321. Sample Page of the Driving Decisions Workbook A computerized later version of the above self-assessment is called the Self-Awareness and Feedback for Responsible Driving (SAFER) and takes about 15-30 minutes to complete. It provides the test-taker with a list of possible driving health concerns, specific driving skills impacted, and recommendations and safety tips for action. The SAFER self-assessment can be found at: http://www.um saferdriving.org/firstPage.php ***We recommend that drivers take this self-assessment and bring a print out of the results to the first behind-the-wheel refresher session. *** 42 This is a Draft. Do not duplicate Starting the Behind the Wheel Process As with younger drivers, behind the wheel instruction time with older adults should start with more basic aspects of driving and grow more complex over the course of the session. Along each step of the process, instructors should communicate next steps with the driver and ask them if they feel comfortable progressing onto a more challenging driving activity (e.g. rural streets onto a county road). However, it is most important to use your judgement about whether or not an older driver is capable to safely handle more complex driving scenarios. It is also important to keep in mind some of the previously discussed andragogy principles when working with older adults. Since adults learn differently than teenagers, it is important to keep in mind how they learn when working with them. Some of examples of how to incorporate these principles during your training include: ● Asking if there are any driving skills the older adult specifically wants to work on during your time together. This will create buy in from the older adult, help establish rapport, and help keep the driver engaged during the session. ● Determine the lesson length they feel the most comfortable with. Many older adults fatigue more easily so two 1-hour lessons may be more conducive to learning than one two-hour lesson. ● Starting with many prompts and a lot of structure provided by LDI, and gradually reducing over time ● Provide opportunities for older adult drivers to practice a skill several times until the driver has proven he has it down. It is easier for older adults to learn by doing, which allows them to tap into their procedural or muscle memory. Provide opportunities for drivers to talk through their actions right after having handled complex situations (intersections/roundabouts) so they can learn from it when it is still fresh in their memory. 43 This is a Draft. Do not duplicate Most importantly, keep in mind that providing feedback/directions while an older adult is driving can tax their divided attention skills and can potentially lead to unsafe driving. Divided attention is focusing on more than one aspect of the environment at a time while executing more than one action at a time. Teenagers can do this very well, but older adults struggle with this and it is a main reason why older adults struggle with driving in general. Therefore, feedback/instruction is best given: ● Before a task requiring high divided attention (intersection) ● After a task requiring high divided attention ● When a driver is pulled off on the side of the road/parked In general, try to keep directions short and focused, trying not to give more than 3 steps in a single direction. If an older adult seems to be having trouble following directions, reduce them to two or one step directions. 44 This is a Draft. Do not duplicate Sample Outline of a One-Hour Behind-the-Wheel Session with an Older Adult 0-10 minutes Parking Lot Check: Introductions: Spend the first few minutes getting to know your driver by asking them about their driving experience and the reason he/she came to see you today. Look through the SAFER information or other selfassessment results if the driver has brought it. This will help you establish some rapport with the driver and give you initial insights into what areas he/she needs or wants to work on. Eye glasses check: Check the license to see if it indicates the driver needs to wear corrective lenses while driving. If it does, make sure the driver has those glasses/contacts before the driving begins. Vision, cognitive and physical check: In order to check for potential memory and cognitive losses, ask them to complete a brief cognitive and vision screen (see page 33 of this curriculum for a suggestion). Instead of looking at a sign when conducting the brief vision screen, stand 10 feet in front of the car and holding up one to five fingers. Ask to driver to sit with their hands on the wheel as if they were driving and call out each number as you hold it up. For the physical check, ask the driver to do the following. Ideally the LDI should be trained as CarFit technician and be able to identify problem areas and educate the driver on how to fix them. ● Put on their seatbelt, to see difficulty with shoulder movement. ● Step alternatively on the gas and brake pedals, to see efficiency of movement and correct distance from pedal. ● Turn the car on/off to assess fine motor skills. ● Observe ability to turn neck to look at you over the shoulder if you are not in the side-view mirror, to test neck mobility and need for mirror adjustment to eliminate the blind spot. i.e. CarFit protocol. 45 This is a Draft. Do not duplicate If they are showing hesitations, or confusion in responding to your requests and performing those tasks, make a note of it, as it could indicate problems affecting driving safety However, keep in mind that using an unfamiliar car and/or nervousness about the session could impact performance on this simple test. The parking lot session is also a good opportunity to check and teach the river about the importance of a clean windshield and regular car check-ups. 10-20 minutes: Basic maneuvers: Have the driver practice basic moves in the parking lot such as driving forward, backing up, turning and getting in and out of parking spaces. Use this information to anticipate whether or not the driver will be able to navigate a low traffic road safely. Things to look for during this time: Backing up - Is the driver using only the mirrors to look back? When turning trunk and neck, is there enough rotation to get a good sight line out of the back of the car? o Older adults may only use their mirrors due to a loss of flexibility/strength in the neck and torso Turning - Is the driver able to grip the wheel tight enough to complete these turns at a reasonable speed? o Older drivers may suffer from arthritis in their hands which could impact their grip on the wheel o Or shoulder pain can impact where an older driver holds the wheel while turning the car. Pain holding the top of the wheel, or crossing midline can affect ability to control the vehicle. Driving Straight - Is the driver able drive the car in a straight line when moving forward and backward? 46 This is a Draft. Do not duplicate o Research has shown that older drivers have difficulty maintaining lanes. If they struggle in this environment, bringing them out on a road with multiple lanes may be unsafe 20-35 Minutes: Side Road: Unless the parking lot maneuvers reveal significant difficulties, take the older driver out onto a low traffic road, such as in a residential area or any area where the speed limit is relatively low (25-35 mph) and both pedestrian and vehicle traffic is minimal. Have the older driver attempt the following maneuvers: 4 way stop intersection - Does the driver understand how the four way stop works? Does the driver stop at the appropriate time and in the appropriate place? Does the driver appropriately scan the environment before proceeding? o Visual deficits and attentional deficits are more common as people age. Divided attention in particular decreases with age. This can significantly impact a driver’s ability to safely manage intersections. Stop and right turn at intersection with larger road - Is the driver checking both ways before he turns right at the intersection? Is the driver able to safely judge the distance of traffic coming from the driver side? Is he checking for pedestrians and bikers on the passenger side? o Intersections are one of the areas where older drivers are most susceptible to getting into crashes. One of the main reasons for this is that older drivers have a hard time judging safe gaps in traffic in which to enter. Another contributing factor is that older adults are less able to attend to information in their peripheral field of view than younger drivers Suggestion for Entering Traffic Safely: Instruct the older driver to be extra cautious when judging gaps in traffic, making sure to give themselves enough space to enter 47 This is a Draft. Do not duplicate safely. Better to be patient and safe than rush and be unsafe! Suggestion for Reduced Peripheral Field of View: Instruct the driver to completely rotate their head to check oncoming traffic. Give them to goal of trying to touch their chin to their shoulder when they check. If neck flexibility is an issue, instruct them to lean forward and rotate their entire trunk in order safely check for oncoming traffic. Stop and left turn at intersection with road without stop: Is the driver checking both ways before he turns right at the intersection? Is the driver able to safely judge the distance of traffic coming from the driver and passenger side? Is he checking for pedestrians and bikers? o See explanation as above relating to problems with peripheral vision and judging of gaps in traffic. This difficulty becomes significantly worse when traffic is over 40 mph. By testing an older driver’s ability to manage intersections in lower speed environment, you can gage whether or not it is safe for the driver to move on to higher speed and higher congestion environments. 35-50 Minutes: Take the older driver to a higher traffic area, such as on county roads or major arterial roads. Try to access areas that require more demands on the driver’s attention, such as stoplights with potential pedestrian crossings, areas where traffic is merging onto the road, and roundabouts. Have the driver do the following maneuvers: Protected left turn: Turn left at an intersection with a stop light that has a protected left turn with a dedicated light signal and a dedicated left turn lane. Does the driver understand what the arrow means? Does the driver proceed to turn at the correct time? 48 This is a Draft. Do not duplicate Unprotected left turn: Turn left at an intersection with a stop light without a protected left turn with a dedicated light signal. Does the driver know how to position their car in the intersection to prepare to turn left? Does the driver turn left at a time that is safe for him/her and other drivers? Is he/she proceeding to the correct lane when he/she completes the turn? o Turning left at a stoplight without a green arrow has been shown to be another common area for crashes among older adult drivers. This is due in part to the difficulty older drivers have with judging speed, safe gaps in traffic and potential issues with depth perception. All of these factors can be made worse by trying to managing them in the complex environment of an intersection that requires strong divided attention skills. For this reason, it is best to have the driver attempt to complete a left turn at a light with a protected left turn with a dedicated light signal and a dedicated left turn lane arrow before proceeding on to an intersection without one. Suggestion for Completing Left Hand Turns Safely #1: Instruct the older driver to be extra cautious when judging gaps in traffic, making sure to give enough space to enter safely. Better to be patient and safe than rush and be unsafe! Suggestion for Completing Left Hand Turns Safely #2: If drivers admit this is a problem for them, a self-regulation technique of finding alternative routes that avoid these challenging turns may be appropriate Lane change: Have the driver go on an arterial road or county road that has two lanes of traffic going in both directions. Have the driver change lanes at least one time. Can the driver maintain the appropriate speed? Can the driver maintain their position in their lane? Does the driver appropriately used mirrors and turn his/her head to check traffic? o Maintaining lane positions and changing lanes are two other common reasons for crashes among this population. Slower 49 This is a Draft. Do not duplicate response time, potential physical inability to check mirrors and blind spots correctly and a smaller peripheral field of view are just some of the contributing factors to this issue. Suggestion for Changing Lanes Safely: See parking lot suggestion for following protocol to eliminate blind spots. This should be done before taking the older adult on a major artery where lane change will be needed. Another option is to suggest they purchase an extendable wide angle rearview mirror and/or a convex blind spot mirror Roundabout: Have the driver navigate either a single lane or multilane roundabout. Before having the driver do this, ask the driver if he has any familiarity with roundabouts. Despite their increasing presence in Minnesota, many drivers both young and old do not know how to navigate these intersections. If the driver is unfamiliar, it might be appropriate to either pull over and explain how one works, or avoid this part of the session and train the driver on this during any potential classroom time you may have with the driver - particularly how to respond to a yield sign o Along with the unfamiliarity of roundabouts, they also require merging into traffic which is a common problem for older drivers. These two factors combine to make roundabouts problematic for older drivers. However, the silver lining is that roundabouts reduce overall crashes and fatal crashes significantly compared to traditional intersections, especially for older drivers. 50 This is a Draft. Do not duplicate Resources for Educating Drivers on Roundabouts: Youtube MnDOT Video: https://www.youtube.com/watch?v=BbfPebLjNec How to navigate a multi lane roundabout: http://www.wsdot.wa.gov/safety/roundabouts/ 51 This is a Draft. Do not duplicate Single Lane Roundabout vs. Multi lane: http://safety.fhwa.dot.gov/intersection/innovative/roundabouts/fhwasa10006/ 50-60 Minutes: If you and the driver feel comfortable, take the driver onto the highway. It is possible the driver may already be avoiding highways. If this is the case, and the driver feels confident that he can get where he wants and accomplish what he needs to without using them, then omit this section. ● Highway merging: Have the driver merge onto the highway. Does the driver accelerate appropriately to match the speed of highway traffic? ● Highway lane change: Have the driver maintain their lane and then change their lane at least once. Does the driver feel comfortable doing this maneuver at this speed? Is the driver checking his blind spots before changing lanes? Does the driver maintain the appropriate speed? 52 This is a Draft. Do not duplicate A checklist of Problematic Maneuvers/Situations for Older Drivers and your recommendations: ● Backing up ● Yielding to oncoming traffic in right turns ● Yielding to oncoming traffic in left turns ● Maintaining lane position ● Changing lanes ● Highway merging ● Navigating roundabouts ● Other: Keep in mind that a majority of these have to deal with navigating intersections. Therefore, it would always be best to start with basic intersections (Stop signs, 4 ways stops) before moving on more complex intersections. 53 This is a Draft. Do not duplicate References Brain HQ. (2016). Brain training that works. Retrieved from http://www.brainhq.com/ Drive Fit. (2016). Brain training for driving. Retrieved from http://drivefit.org/ Drivesharp. (2016). See more, focus better, and react faster. Retrieved from https://www.drivesharp.com/ Eby, D. W. (2012). Older driver self-screening and functional assessment [PowerPoint] Homesley, S. &Reshel, N. (n.d.). Nutrition and vision: Teaching you how to eat right for your eyesight. [Brochure]. San Diego State University: n.p. Meuser, Tom. Univeristy of Missouri in St. Louis Driver Examiner Training video https://umsl.mediaspace.kaltura.com/media/Driving+Test+with+MO+State+Highw ay+Patrol+Examiner+++Woman+with+Vision+Loss/0_my0ht6c1 NRMA-ACT Road Safety Trust (2001) Teaching Older Drivers: A Handbook for Driving Instructors. La Trobe University, Tasmania, Australia St. Catherine University MAOT (2015) Safe Access to Destination Curriculum. Vision Eye Institute (n.d.). Couple Driving [digital image]. Retrieved from http://www.visioneyeinstitute.com.au/page/14/?page_id=0 Additional Resources AAA: http://seniordriving.aaa.com/ National Highway Traffic Safety Administration. http://www.nhtsa.gov/Senior-Drivers Alzheimer’s Association Dementia and Driving Resource Center http://www.alz.org/care/alzheimers-dementia-and-driving.asp Hartford driving safety guides. https://www.thehartford.com/resources/maturemarket-excellence/publications-on-aging For Referrals To find a Driving Rehabilitation Specialist near you, look at the following website: http://www.aota.org/olderdriver 54 This is a Draft. Do not duplicate