Assessment Group:
Discussion and Unresolved
Issues
An assessment flow
Why?: Identify drivers with
functional changes that may
compromise personal or public
health or safety
Why?: Identify
individuals who may
benefit from prevention,
education, remediation
Who?: Many different sources of screening and referral (self, family,
law enforcement, DMV, other agencies, health care professionals,
driver rehabilitation specialists, driver educators, community-based
agencies and groups, etc, etc)
What?: Tier One: Brief screening of
cognitive, motor, sensory and
health/medication functions. The form of
Tier 1, and its next steps, are contingent
on who does the assessment.
An assessment flow
What?: Tier One: Brief screening of
cognitive, motor, sensory and
health/medication functions. The form of
Tier 1, and its next steps, are contingent
on who does the assessment.
What?: Tier Two: In-depth assessment of
cognitive, motor, sensory and
health/medication functions,
personality/motivation/awareness. The
next steps, are contingent on who does the
assessment. Often done with Tier 3.
What?: Tier Three: Behind the wheel
assessment
At each tier, there
should be
appropriate
referrals
Candidate measures
The domains that follow in red come from the NHTSA/AAMVA
recommendations
A goal is that a battery should be evidence-based (with regard to
its predictiveness of driving performance, which could
include crashes, on-the-road driving errors, or other
performance measures).
There are alternative pathways.
1. One approach focuses less on specific domains, but tries to
include a battery which—in combination—maximizes
predictive salience.
2. A second approach tries to represent multiple domains.
This will be more useful for making rehabilitation
recommendations and identifying the sources of problems.
The two approaches are not mutually exclusive.
Tier 2 Candidates:
Cognition
Domain
Candidate
measures
Notes
Mental Status
• Mini-Mental Status
Examination
• Telephone
Interview for
Cognitive Status
Does it make sense to
separately predict driving
for demented and nondemented elders?
Where does MCI fit in?
TICS has wonderful
advantages, including
phone plus better
memory than MMSE.
Divided
Attention
• Trails A & B
Trails is widely used, and
• Useful Field of View AMA recommended;
UFOV is predictive and
trainable, but equipment
intensive.
Tier 2 Candidates:
Cognition
Domain
Candidate
measures
Notes
Perceptual
Speed/Visual
Search
• Letter
Cancellation Task
• Digit Symbol
Substitution Task
•Trails
Does this add anything
beyond the speeded
Divided Attention Tasks?
Reaction Time
• Complex Reaction
Time (e.g., Doron
There is no shortage of
CRT tasks. Again, these
generally require a
computer; Doron is
driving stimulus-specific.
Is a simulator (not
portable) a better choice?
Tier 2 Candidates:
Cognition
Domain
Candidate
measures
Notes
Judgment/
Decision
Making
• RoadSmart
Judgment Test
•Driver risk inventory
We have not seen this
measure, but it is
referenced, and raises
the intriguing prospect
of domain-specific
reasoning.
Is there room for basic
reasoning measures
here, like Inductive
Reasoning?
Episodic
Memory
• Hopkins Verbal
Learning Test
• Telephone Interview
for Cognitive Status
TICS phone-admin., but
picks up memory well;
is this really a screen
for impairment?
Tier 2 Candidates:
Cognition
Domain
Candidate
measures
Working Memory • Digit Span Task
•(consider also
Delayed Memory)
Driving
Knowledge
• Rules of the
Road Test
• Traffic Signs
Test
Notes
Again, does this add
anything meaningful
beyond divided
attention tasks? Are
better working memory
tasks to be used?
Cognitive science tells
us that in expert
domains, the best
predictor of
performance is domainspecific knowledge; this
is also an assumption
of state-level licensing
programs
Tier 2 Candidates:
Cognition
Domain
Candidate
measures
Notes
Spatial ability
Block Design
MVPT (horizontal)
Is this too domaingeneral? Is a
specific map-reading
task more
meaningful?
Visualization of
missing
information
Visual closure
subtest of MVPT
Taps into ability to
generate
expectancies about
impending visual
threats?
Complexity/situation awareness
(not a domain. .
belongs in the
flow elsewhere)
DriveABLE
Are these the Tier 1
measures?
CA/
MD(Grimps+UFOV
2) Model
Tier 2 Candidates: Sensory
Domain
Candidate
measures
Proprioception • Foot tap time
• Simulator?
•Brake reaction
time
Notes
Face validity with moving
foot from gas to break pedal
Cutaneous
sensation
(pressure on
sole of foot)
• Semmes
Weinstein?
•Pressure and
localization
sensation test?
Evidence?
Pain
• Jette
• McGill
• VAS
Association with back pain
and vehicle crashes
Disability specific pain
(Arthritis)
Tier 2 Candidates: Sensory –
Vision
Domain
Candidate
measures
Notes
Oculomotor
Control
• Manual
assessment
Subjective
Typically an issue in
neurologically involved
drivers, not older adults
Visual Fields
• Perimetry testing
with Humphrey or
Goldmann;
•Confrontational
field testing may
be sufficient
Identifies blind spots and
other visual field
disturbances but does not
indicate an impact on driving
or if driver compensates
Visual Acuity
• Wall charts
•Automated
testing machines
Identifies ability to visually
decipher the environment
Determines if driver meets
state vision guidelines
Tier 2 Candidates: Sensory –
Vision
Domain
Candidate
measures
Notes
Depth /
Stereopsis (For
the newly
monocular)
• Optec
• Keystone
•Porto Clinic
• Stereo Fly
Stereopsis is a binocular skill;
can’t measure monocular drivers
In most vision testing machines
Connection to crashes?
Color
Recognition
• Optec
• Keystone
• Porto Clinic
Included in most vision testing
machines
Connection to crashes?
Contrast
Sensitivity
• F.A.C.T.
• Pelli – Robson Chart
• Regan Low Contrast
•Letter Acuity Chart
• Vision batteries
Linked to driving performance and
crashes
Tier 2 Candidates: Sensory – Visual
Motor
Domain
Visual Motor
Candidate
measures
• Test of Visual
Motor Skills
(TVMS-R)
• Bender VisualMotor
Gestalt Test
• Rey-Osterrieth
Complex Figure
Test
Notes
Evidence linking
assessment
performance to driving
performance?
Tier 2 Candidates: Motor
Domain
Range of
motion
Candidate
measures
• Knee flexion
• Cervical rotation,
flexion, extension,
lateral bend (headneck flexibility)
• Trunk rotation
• dorsiflexion
• Upper extremity
Strength (Leg • Grip
strength
• Pinch?
especially)
• Manual muscle
testing
Notes
Limited L knee flexion
associated with adverse
events.
Limited evidence of
correlation with driving
performance for cervical,
UE and trunk ROM.
Older impaired drivers >
risk at T-intersections
Functional grasp
association with crash
involvement.
Which muscle groups?
Tier 2 Candidates: Motor
Domain
Gross
Mobility
Candidate
measures
• Rapid Pace Walk
• Get up and go test
• Number of blocks
walked
• Foot abnormalities
•Fall history
Notes
Association with falls and
vehicles crashes; Adverse
driving events and
distance walked
Redundancy with balance
and proprioception
assessment?
Tier 2 Candidates:
Sensorimotor
Domain
Balance
(dizziness)
Candidate
measures
• Romberg
• Berg Balance
Scale
• Tandem Stand
• Side-to-side
stand
• Single leg stand
• Smart Equitest
•Sitting balance
Reaction Time • Foot reaction
time (brake) Doron?
Notes
Complete Romberg or
segments?
Association with weighted
error score for tandem
stand.
History of falls associated
with vehicle crashes
Neurocom Equitest
assessment (Quantify/train
or cost prohibitive)?
Association with increase
vehicle crashes among
women
• Behavior, Personality, Beliefs: Driver Risk
Assessment (risk taking), impulsivity,
empathy, aggression, cautiousness
• Depression
• Mania
Unresolved issue: The Criterion
Problem
• By which criteria should we evaluate the
predictive salience of our battery?
–
–
–
–
–
Accidents?
Simulator?
Field driving tests?
Standardized driving courses?
Subjective driving evaluations?
• Is the more sensible goal the
multidimensional assessment of different
aspects of driving?
Unresolved issue: Measurement
selection
• There is a wide variety of studies
• Few multidimensional studies in which
measures evaluated simultaneously
• Great variation in dependent variables used
across studies
• It seems important to first identify demented
individuals; different prediction equations
likely for non-demented elders; more likely to
predict subtle driving errors
Unresolved issues:
Cognition
• Should we do a gross check for dementia,
and triage such individuals out of further
assessment? Or do we need tests like Clock
Drawing (special Freud scoring), CognitiveLinguistic Quick Test, Boston Naming,
Wechsler Memory Scale, WAIS Picture
Completion
• Some commonly used tests seem redundant
with what we have shown (Stroop, Minnesota
Rate of Manipulation, AARP Reaction Time)
• Interesting dimensions not commonly
studied, including Motor-Free Visual
Perception Test, Unilateral Neglect
Unresolved issues: Sensory
• Is there a better proprioception test for
the lower extremity?
• What amount of pressure is needed for
breaking?
• Should pain assessment be used and if
so, which pain assessment is the most
appropriate?
Unresolved issues: Motor
• Should all ROM measurements be
functional rather than exact?
• Should upper extremity ROM be
tested?
• Should MMT be done on lower
extremity muscle groups (such as knee
extension) and if so, should it be
quantified with hand-held
dynamometry?
• If we were to choose one gross mobility
test only, which is the best?
Unresolved issues:
Sensorimotor
• Should a balance (dizziness) test be
used?
Unresolved issues
• Who is screened? (everyone? just at
risk drivers? just older drivers?)
• Who screens? (what kind of training is
needed?)
• Who pays? (what is the estimated cost,
and what are some possible sources of
funding?)
• What are the legal implications? (what
supportive policy/legislation is needed?)