The Occupational Therapy PowerPoint Presentation

The Occupational Therapy PowerPoint Presentation

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Pre-Driving Clinical Assessment. Judith Joseph, OTR, MA, CDRS. jajoseph@houstonmethodist.org. TOTA MCC. November 6, 2014. Objectives. Develop an occupational profile that addresses the client’s driving needs.. ID: 526615

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Slide1

The Occupational Therapy Pre-Driving Clinical Assessment

Judith Joseph, OTR, MA, CDRS

jajoseph@houstonmethodist.org

TOTA MCC

November 6, 2014

Slide2

Objectives

Develop an occupational profile that addresses the client’s driving needs.

Select specific evidence-based assessments and assessment methods to assist in determining driving readiness.

Using the information gathered from the occupational profile, assessments, and goals determine the need to refer client’s to the DRS.

Gain knowledge in the laws and agencies in the state of Texas that determine driving fitness to assist OT practitioners in establishing treatment plans and goals.

Slide3

About the speaker

Introduced to clinical driving evaluations in 1987

Attended my first ADED conference in 1989?

Developed a pre-driving clinical screen and evaluation in 2010

Passed CDRS exam August 2013

Slide4

“So, what are you going to do about driving?”

Slide5

Why should occupational therapist evaluate fitness to drive?

Slide6

Things to consider

There are 20 million drivers in the U.S. 70 and older.

Every year, more than 

795,000 people

 in the United States have a stroke.

400,000 individuals estimated to have

MS.

Approximately 60,000 Americans are diagnosed with Parkinson's disease each year, and this number does not reflect the thousands of cases that go undetected

.

One in four adults−approximately 61.5 million

Americans−

experiences mental illness in a given

year

Approximately two million Americans have mild low vision which affects driving and reading.

Slide7

Why Should OT evaluate fitness to drive?

Because driving is an instrumental activity of daily living within the domain of occupational therapy practice. practitioners should be able to accurately determine who is a safe driver, who is at risk for unsafe driving, and who needs further evaluation by a driving rehabilitation specialist (DRS).

AOTA Driving and Community Mobility

Slide8

Occupational Therapy Roles

Generalist: general knowledge and understanding of performance and processing skills related to driving.Advanced Training: Further education to evaluate the integration of sub-skills associated with driving and provide specific sub-skill trainingSpecialized Training: Received specialized education, examination, and/or certification.

University of Florida

Slide9

What is in our domain of practice?

Musculoskeletal disorders

Neurological impairments

Cognitive impairment

Memory disorders

Visual impairments

Perceptual impairments

Mobility

Mental impairment

Slide10

Consider the diagnosis and resulting impairment

Slide11

Medical condition examples

Diagnosis/condition

Sleep apneaTBICVA Dementia/Alzheimer’s MS

Impairment Risk

Impaired arousal, responsiveness, daytime sleepinessAttention, orientation, visual fieldVisual, cog, motor, visual fieldExecutive functionsMuscle weakness, sensory loss, fatigue, cognitive or perceptual deficits, symptoms of optic neuritis

Sherrilene Classen, Miriam Monahan ADED Conference 2013

Slide12

Let’s Start with the law!

Texas MAB

Slide13

Texas Medical Advisory Board (MAB)

The Texas Medical Advisory Board (MAB) for Driver Licensing was established in 1970 to advise

the

Texas Department of Public Safety (DPS) in the licensing of persons having medical limitations

which

might adversely affect driving.

Guidelines established using the following:

AMA Physician’s Guide for Determining Driver Limitation

Driver Fitness Medical Guidelines (NHTSA)

The American Association of Motor Vehicle Administrators

Slide14

Texas Medical Advisory Board/DPS

The ultimate goal is to allow all who can drive safely to do so and to continue to reduce the number and severity of motor vehicle accidents in

Texas

Slide15

Functional Ability Profiles

General DebilityCardiovascular diseaseSyncopeNeurological DisordersPsychiatric DisordersExcessive Alcohol use/abuseDrug use/abuseMetabolic DiseasesMusculoskeletal DefectsEye Defects

Aging

Recurrent syncope

CVA, Seizures, Dementia

MS, Parkinson's, Peripheral neuropathy

PTSD

DM

CP, MD

Diplopia, Peripheral vision

Visual acuity

Slide16

Where do I start?

Slide17

The Association For Driver Rehabilitation Specialists (ADED)

Slide18

ADED Mission Statement

Promoting excellence in the field of driver rehabilitation in support of safe, independent community mobility

Slide19

ADED Best Practices For The Delivery of Driver Rehabilitation Services

Section 1: Interview/Medical HistorySection 2: Clinical Visual AssessmentSection 3: Clinical Physical AssessmentSection 4: Clinical Cognitive Assessment

www.ADED.net

Slide20

Interview/Medical History

History of Present Illness

Past Medical History

Determine medical consent

Review current medications (side effects)

Assess communication status

Review driving history

License status

Driving goals

Vehicle availability

Slide21

Clinical Visual Assessment

ADED recommendation

Visual historyVisual acuity Field of visionOther visual skills

Possible Deficits

Cataracts, glaucoma, HH, etc.

Feinbloom

eye chart,

BiVaba

, Snellen

Scatomos

, HH

Visual short term memory, figure ground, form constancy, visual discrimination, visual scanning skills, High/Low contrast sensitivity

Slide22

Visual Assessments and Observations

Assessments

biVABA Brain Injury Visual Assessment Battery for Adults The cover test UFOV Useful Field of ViewDynavisionMotor Free Visual Perception Test (MFVPT)Clock drawing testTrails B Pursuits and Saccades

Observations

Bumping into walls, furniture, etc.

nystagmus

Head tilting or position

squinting

Position of test paper

Visual scanning efficiency

Slide23

Clinical Physical Assessment

Range of MotionStrengthGrip strengthPrehension statusSensationProprioceptionCoordination (rapid pace walk)Muscle tone (MAS)

Mobility status (TUG)

Balance (Berg,

Teniti

,)

Orthotic devices

Mobility aids

Transfer skills

Reaction times (

Dynavision

)

Slide24

Clinical Cognitive Assessment

Mini Mental State Exam (MMSE)

Short Blessed Test

Clinical Dementia Rating Scale

Montreal Cognitive Assessment (

MoCA

)

Maze Navigation Test

Single Digit Modality Test (SDMT)

Assessment of Motor Processing Skills (AMPS)

Slide25

Case Study 1: CVA

76 y/o male with R MCA infarct, s/p thrombectomy, left hemiparesis, DM-2, HTN, BPH, small tear in left supraspinatus.

+ multiple falls

Poly pharmacy

Wants to run errands and drive to any appointments

h/o getting lost while driving when blood sugar is uncontrolled

Backed into parked car in grocery store parking lot

Totaled a vehicle 6-7 years ago

Has not driven since onset of stroke

Slide26

Case Study 1 continued: CVA test results

Impaired left peripheral vision

+nystagmus

Rapid pace walk= 10 sec.

Impaired head/neck flexibility

Visual closure, mild impairment

Trail Making B Test- 111sec.

UFOV- unable to complete. Could not see 2

nd

vehicle

Short Blessed=2

Multiple angry outburst during testing

Slide27

Case Study 1: recommendations

Referred to U of H low vision clinic by Neuro-ophthalmologist

Complete program at U of H prior to attempting to drive or being referred to CDRS for BWT only after being cleared by Ophthalmologist

Consider driving cessation

Slide28

Case Study 2: Parkinson’s Disease

91 y/o male with h/o Parkinson’s Disease, loss of balance, peripheral neuropathy, spinal stenosis, lumbar laminectomy

+ multiple falls

Using walker with seat

Last eye exam 2-3 years ago

History of falling asleep spontaneously

“minor” accident in parking lot when he could not stop in time when another vehicle pulled out in front of him causing a rear end collision

Totaled a car 3

yrs

ago when he backed out of the driveway

Wants to cont. driving without restrictions

Slide29

Case Study 2: Test results

High low contrast sensitivity intact

+nystagmus

Failed cover test

Bells Test 3:57 sec.

Trails B test 161 sec.

Right ankle strength 2/5, hip/knee strength 3/5

Limited head/neck flexibility

Unable to locate 50% items on UFOV

Fell asleep during testing

Rapid pace walk= 36 sec.

Scored 100% on sign recognition, map reading (items 14-24 on MFVPT)

Slide30

Case Study 2: Recommendations

Patient should not resume driving without a BWT.

High risk for having a crash

Consider driving cessation

Slide31

Case Study 3: Left Hip fracture

82 y/o female with dx of left hip

fx

Has trouble looking over her shoulder, difficulty backing up, and has gotten lost while driving

Wants to be able to drive to the store, etc. She does not plan on driving on the freeway or at night.

She has not driven in 6 months since hip surgery

Slide32

Case Study 3: Test Results

Mild impairment of low contrast vision

Mild impairment of working memory

Impaired visual closure

Trails Making B test: 353 seconds

Impaired visual processing speed

Impaired UFOV

Rapid pace walk- 17 seconds

No errors on clock drawing test

Impaired head/neck flexibility

Slide33

Case Study 3: Recommendations

Further assessment through BWT

Referral to optometrist

Slide34

Case Study 4: MS

57 y/o female diagnosed with MS. Referred due to recent black out.

h/o ventricular tachycardia, osteoporosis, cataracts, severe scoliosis

+ falls

Wears built up right shoe for leg length discrepancy and R AFO

Gets lost while driving, trouble finding and reading signs in time to respond, feeling tired after driving, had “near misses”, bothered by head light glare, trouble looking over shoulder when backing up.

Recently hit a pole at the drive through bank and backed into trash cans at the end of her driveway.

Slide35

Case Study 4: Test Results

Impaired visual acuity20/50 in left eye

High low contrast intact

No deficits noted with visual closure

Trials Making B test 73 seconds

Mild deficit with visual processing speed on UFOV

Mild deficit with working memory

No errors on clock drawing test

Rapid pace walk 5.8 seconds

Right shoulder flex limited to 90

Limited head/neck flexibility

3+/5 strength in

Bil

hips, and ankles

Became fatigued during test

Slide36

Case Study 4: Recommendations

Begin to seek alternative transportation if deficits worsen

Use power chair instead of RW for appointments to conserve energy

Do not drive on unfamiliar trips

Do not drive when fatigued

Consult with MD

Referral to PT

Referral to CDRS for BWT

Slide37

Case Study 5: Impaired memory

73 year old female with dx of impaired memory.

Cataract removal

Currently driving

Unable to recall last eye exam

Had one speeding ticket

Wears a hearing aid (not wearing during exam)

No falls

Admits to getting lost while driving, feels others drive too fast, being stressed out by driving, difficulty at busy intersections, friends will no longer ride with her.

Slide38

Case Study 5: Test Results

20/25 binocular vision

Impaired horizontal fixation to right

Bells Test: 1:54, 3 errors

Rapid pace walk- 6 seconds

Scored 14 on the Short Blessed

Trials Making B Test 194 seconds

Intact visual closure, visual processing speed showed mild deficit

Slide39

Case Study 5: Recommendations

Driving should be restricted at best to her immediate neighborhood, however without being able to control what happens such as weather conditions, and changes in traffic volumes driving cessation may need to be considered. If family insist on pt. continuing to drive a referral to CDRS for BWT should be completed.

Slide40

I am not the decider!

Slide41

QUESTIONS?????


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