Cognitive explanations of learning and approaches to teaching
Teaching Cognitive Assessment - Duke University
Transcript of Teaching Cognitive Assessment - Duke University
DeprescribingJessica Visco, PharmD, CGP
SeniorPharmAssist
August 24, 2016
Deprescribing
Jessica Visco, PharmD,
CGP
SeniorPharmAssist
Webinar #1Webinar #14
Keys To Safe Driving and Community Mobiity
Laura Juel OTR/L, CDRS
Julia Gamble MPH, NP
Disclosures No commercial support has influenced the planning of the
educational objectives and content of the activity. Any
commercial support will be used for events that are not CE
related.
There is no endorsement of any product by DUHS
associated with the session.
No influential financial relationships have been disclosed by
planners or presenters which would influence the planning of
the activity. If any arise, an announcement will be made at
the beginning of the session.
This program is supported by a Geriatric Workforce
Enhancement Program (GWEP) grant (U1QHP28708) from
the U.S. Bureau of Health Professions Health Resources and
Services Administration (HRSA).
Objectives
Identify 3 age related changes that may
impact driver safety.
Identify 3 potential ‘red flags’ in the clinic.
Provide an overview of the NC DMV
Medical Program and the medically at risk
driver.
Identify Durham, NC options for
transportation on buses or vans
Statistics
By 2030, drivers over the age of
70 are expected to triple.
In 2015 there were 6,165 people 65
and older killed in traffic crashes
in the United States,
18% of all traffic fatalities.
Older drivers are more
disproportionate to be involved in
fatal crashes (per miles driven)
Fatality rate for age 85 and older is
9x as high as 25-69 age range
NHTSA, 2017
Driving
Cars are viewed as physical
extensions of ourselves.
The ability to drive safely can be
challenged by changes in our
physical, emotional, and/or
mental conditions.
The ultimate instrumental activity of daily living, requiring
the integration of high-level cognition,
vision and motor function
Driving is a complex skill.
Driving represents freedom, control and
independence.
The Driving Task
Changes in body and mind can
impact driving abilities in
three functional areas;
See traffic and road conditions
Recognize these images, process them,
and decide how to react
Perform the physical movements required to
control the vehicle
Vision
Driving Implications:
Ability to see other vehicles,
traffic signals and signs,
lane markings, road
conditions, and pedestrians
Age-related changes in visual function;
particularly reductions in visual acuity, contrast
sensitivity and visual field loss have been
associated with driving ability and crash risk in
older adults
90% of information for driving comes in through the eyes
Wood, 2013
Common Eye Diseases
Cataracts- clouding of the eye lens making it difficult
to see clearly, halos around lights
Glaucoma- damage of optic nerve due to high
pressures. Early- peripheral vision loss, as disease
progresses- invades central field of vision
Macular Degeneration- deterioration to the retina
resulting in decreased central vision
Diabetic Retinopathy- damage to the blood vessels
in eye resulting in patchy or blurred vision, difficulty
seeing at night
Physical Abilities
Driving Implications:
Ability to get in/out of car
Ability to manage assistive
device
Ability to navigate parking
lots/streets at destination
Ability to perform physical
movements to control
vehicle (look over shoulder, turn
wheel, operate pedals)
Strength, flexibility, gross and fine motor control,
reaction time
‘Low Tech’ Adaptations
panoramic mirror
blind spot mirror
wedged seat cushion
Handy Bar deviceSeat belt grabber
Cognition
Driving Implications:
Ability to recognize traffic conditions and
destinations
Ability to process the
information and make
appropriate decisions
in a timely manner
Ability to understand and operate own vehicle
Memory, attention, recognition, reaction times,
problem solving and judgment
Red FlagsNot one test can accurately predict crash risk
MMSE < 24 strong predictor of crash risk
Montreal Cognitive Assessment (MoCA) more sensitive to
identify cognitive decline, < 23 = crash risk
Requires assistance with daily tasks; medication
management, meal preparation, managing finances.
Family members will not ride with them/gets lost in familiar
areas.
Other clinical factors associated with greater MVC risk;
depression, falls within the previous year, sleep apnea, and
lower baseline systolic blood pressure. Joseph et al, 2014
Medication Side Effects
Antidepressants, antihistamines:
blurred vision, drowsiness, motor
coordination
High blood pressure medications: impair driver’s
response by causing dizziness, fatigue, confusion
and/or sedation
Pain Killers and non-steroidal anti inflammatory drugs:
may cause confusion that results in dangerously
slow reaction times.
**Risk for medication side effects and interactions
increases with the number of medications taken
Things to Consider
Will this persons condition worsen over time?
Will medical attention improve their
situation? (eye exam, medications)
Medications (side effects)
Do they have the capability to
learn and follow through with
restrictions if needed.
ie: no highway driving
The Conversation
Discuss recommendations with client,
document discussion in the medical chart.
If they continue to drive against medical
advice then discuss with client that you will
report to DMV.
Ask early and frequently about plans… living situation, family
support, driver retirement- average person will outlive their
ability to drive by 7-10 yrs.
Driving cessation can negatively impact older adults’ health
and well-being
Wood et al. 2013
NC General Statue
Statue 20-9.1 (2016), after consultation with the client,
a physician, psychologist or medical provider may
disclose information of a persons physical or mental
disability or disease to be used “only for the purpose of
determining the qualifications of the patient to operate
a motor vehicle”.
The specific information provided to
NC DMV would be limited to
the client’s name, address, date of
birth and diagnosis.
DMV Medical Review Program
DMV is the official licensing agency
Medical Review provides oversight for
persons with medical or
psychological issues
Persons can be entered into this program
by medical providers, family members,
police, or local DMV offices
If you are not confident about completing a patients DMV
medical paperwork, a referral for a clinical driving evaluation
can provide some objective data to determine medical fitness to
drive.
NC DMV Restrictions
Corrective lenses
Daylight-driving only
Mandatory reporting for seizures
Seizure free 6 months on medication/1 year off
Homonymous hemianopsia- absolutely no driving
Limiting driving to speeds less than 45 mph speed and
prohibiting interstate driving
Limiting driving to/from places; work, doctor, church,
grocery store
Limiting driving within a specified radius of home
Duke Driving Program
Behind the wheel test may be
recommended based on outcome of
clinical evaluation ($150)
Provides some objective data related
to crash risk
2-2.5 hour clinical evaluation performed by an
Occupational Therapist- Driver Rehab Specialist
Comprehensive evaluation of physical abilities,
vision, thinking skills and reaction times
$200 fee for clinical driving evaluation
Community Mobility
GO Durham serves greater Durham with
connections to other cities in the Triangle
Regional call center provides trip planning and
up to the minute arrival time information – call
919.485.RIDE (7433)
Travel Training presentations are available
from Go Durham staff
Community Mobility
• Seniors (65 years and up) ride free on GO
Durham
• GO Durham cards are issued without a waiting
period
• ID cards issued at Durham Station
• Monday-Friday; 8:30–11 a.m. & 12:30-4:30 p.m.,
excluding holidays.
• Bring proof of age and/or your Medicare card
Community Mobility
Van Service Overview
Criteria to ride
How to apply
What is included in the service
How long can it be used
What is the cost
Who is the contact?
Other info?
Criteria to Ride
Medicaid Transportation • Medicaid, Durham County resident
GoDurham ACCESS • Disability which prevents use of fixed-route bus service
– Application & in-office evaluation required
Durham County ACCESS • Various Criteria (funding dependent)
– Can be job-related, location-bound
or health-related
Lincoln Community
Health Center Vans
• Lincoln Community Health Center
patients only
How Do I Apply
Medicaid Transportation • Apply via phone
• 5-20 minutes of questions
• Notification (approval/denial) immediate
GoDurham ACCESS • Download, complete and mail application
– 21-day approval timeline; notified via
phone call
– May be able to scan/email
Durham County ACCESS • Complete application
– Approval timeline varies; notified via
phone call
– Fax/email/drop off
Lincoln Community
Health Center Vans• No Application
– Call to schedule service
What is Included?
Medicaid Transportation • Van service to and from appointments
• Only billable Medicaid appointments
GoDurham ACCESS • Any type of trip
– Medical, mental health, substance
abuse, employment, education
– Leisure/Recreation
Durham County ACCESS • Any type of trip
– Medical, mental health, substance abuse,
employment, education
– Leisure/Recreation
Lincoln Community
Health Center Vans
• Medical trips to a Lincoln Clinic
– Specialist medical visit ordered/referred
by Lincoln providers are also covered
How Long Can I Use It
Medicaid Transportation • As Long as Medicaid is active
GoDurham ACCESS • Recertification requested occasionally
Durham County ACCESS • Varies, typically 1-3 months
– May need to recertify
Lincoln Community
Health Center Vans
• Indefinite
What Does it Cost?
Medicaid Transportation • No Cost
• Covered by Medicaid
GoDurham ACCESS • $2 one-way trip (cash fare)
– Ticket books available for $17
(ten tickets)
Durham County ACCESS • No Cost
Lincoln Community
Health Center Vans
• No Cost
How Do I Schedule a Trip
Medicaid Transportation • Call Transportation Line: 919.560.8607
• Get approval, schedule recurring trips
• Call authorized van service
GoDurham ACCESS • Call: 919.560.1551
– Can book recurring trips
– Dispatch Option 1, Reservations Option
2, Cancellations Option 3
Durham County ACCESS • Call: 919.560.1551
– Can book recurring trips
– Dispatch Option 1, Reservations Option
2, Cancellations Option 3
Lincoln Community
Health Center Vans
• Call: 919.956.4000
• At least 3 days before trip
Who Is My Contact
Medicaid Transportation • Processing Unit Assistant Supervisor
• Medicaid Transportation (919.560.8607)
• Lisa Webb 919.560.1840
GoDurham ACCESS • GoDurham ADA Specialist
• Tammy Pettiford
• (919.560.1555 x 36303)
Durham County ACCESS • Durham County Cooperative Extension
– Toni Glover [email protected];
919.560.0520
– Linda Thomas-Wallace
[email protected]; 919.560.8757
Lincoln Community
Health Center Vans
Other Information
Medicaid Transportation • Must have updated address before scheduling trip, if client moves
• No wheelchair support on one pre-approved van service
• Bus tickets are an option.
GoDurham ACCESS • Service to all areas of the City and areas of
the County within ¾ miles of bus stop
• Taxi option which allows same day
scheduling ($21 = $51 trip)
Durham County ACCESS • Best for short-term usage
(funding can run out)
Lincoln Community
Health Center Vans
What Makes it Different
Medicaid Transportation • Multiple steps to schedule• Wait time on either end of trip• Lack of Flexibility
GoDurham ACCESS
• Lack of flexibility
• Wait time on either end of trip
• Requires pre-scheduling
• More costly than discount bus pass
Durham County ACCESS• Lack of flexibility
• Wait time on either end of trip
Lincoln Community
Health Center Vans
• Lack of flexibility
• Wait time on either end of trip
Clinical Resources
FREE- Marketing material for conversations with older
drivers- https://www.thehartford.com/resources/mature-
market-excellence/family-conversations-with-older-drivers
Clinicians Guide to Counseling Older Drivers
https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/812228_clinicia
nsguidetoolderdrivers.pdf
NC General Statute
https://www.ncleg.net/Enactedlegislation/Statutes/PDF/BySect
ion/Chapter_20/GS_20-91.pdf
DMV Medical Review Program (guidelines, forms, restrictions)
https://www.ncdot.gov/dmv/driver/medical/
Wood, Joanne M. Evaluation of screening tests for predicting older driver
performance and safety assessed by an on-road test. Accident Analysis
and Prevention Jan 2013; 50: 1161-1168.
NHTSA/US Department of Transportation, Traffic Safety Facts, 2017.
https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/documents/2015_traffic_sa
fety_fact_sheet_older_population.pdf. Accessed 4/16/2018.
Philip, Joseph G, O’Donnell, Martin. Et al. The mini mental state
examination, clinical factors, and motor vehicle crash risk. Journal of
American Geriatric Society 2014; 62: 1419-1426.
Laycock, Keith. Driver assessment: Uncertainties inherent in current
methods. BC Medical Journal 2011; 53: 74-78.
References
Duke Driving Program
Laura Juel OTR/L, CDRS
Outpatient Occupational Therapy
Lenox Baker Children’s Hospital
3000 Erwin Road
Durham, NC 27705
Appointments: 919 684-2445
Duke Outpatient Clinic
General Internal Medicine
Julia Gamble MPH, NP
Continuing Education Credits
1 hour of CE credit is being offered for this webinar.
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