Parkinson Disease And Driving An Evidence Based Review

Driving With Parkinsons Disease: Exploring Lived Experience

Jeffrey D. Holmes

1School of Occupational Therapy, The University of Western Ontario, London, Canada

2School of Health Studies, The University of Western Ontario, London, Canada

3Health and Rehabilitation Sciences, The University of Western Ontario, London, Canada

Abstract

1. Introduction

Given the implications that driving has for independence, autonomy, and social participation, exploring and understanding the lived experiences of people living with PD is critical to the development of targeted interventions and preemptive driving retirement approaches. Therefore, the purpose of the current secondary data analysis is to explore the lived experiences of people with PD surrounding their fitness to drive.

2. Materials and Methods

2.1. Setting and Context

2.2. Primary Data Set

2.2.1. Participant Recruitment

For the parent study, a convenience sample of participants was recruited via posters displayed within local movement disorder clinics in a midsized Canadian city and from information sessions that were delivered at local PD support groups and regional PD conferences. Individuals were eligible for participation if they were living with idiopathic PD and understood English. Participants were excluded if they experienced cognitive or communication difficulties that impacted their ability to participate in an oral interview or group discussions.

2.2.2. Data Collection

2.3. Secondary Data Analysis

3. Results

3.1. Meaning and Significance of Driving

3.2. Driving Cessation

Learn The Protocol For Your State

Colorado is not a medically mandated state. Its a self-reporting state, which means its up to you to assess whether or not you are fit to drive. With that said, Dittmar says that approximately 75% of the driving assessments she does are direct referrals from doctors.

Once Dittmar has completed a driving assessment, she sends the report to the drivers doctor and it gets linked back to the drivers DMV profile. The recommendations then become connected to a license.

These recommendations must be measurable. For example, some of the restrictions that could be placed on a driver include:

• Can only drive in daylight
• Can only drive within a certain radius of their home
• Can only drive below certain speeds

In some states, the report gets sent to the medical board. Contact the DMV in your state to learn more about how its done where you live.

No Evidence To Support Periodic Driving Reassessment For Parkinson Disease

Although patients with Parkinson disease demonstrate substantial driving impairment, self-reported crash data does not support mandated PD-specific periodic driving reassessment, according to results published in Neurology.

The researchers searched 7 databases through January 2018. They included studies that compared participants with PD with healthy controls on overall driving performance. Data were analyzed using random-effects meta-analysis.

A total of 50 studies that included 5410 participants met the eligibility criteria.

The researchers found that participants with PD had higher odds of on-the-road test failure and simulator crashes compared with healthy controls. Participants with PD had a higher likelihood of simulator crashes . Participants with PD also had worse overall driving ratings compared with controls .

Despite these results, the rate of self-reported, real-life crash involvement did not differ between participants with PD and health controls . After adjusting for differences in age, sex, and driving exposure, the findings remained consistent. Additionally, the researchers did not find a moderating influence of disease severity.

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Ginseng And Ginko Biloba

Ginseng is a plant substance which has been used in Eastern countries for centuries and is proposed to have anti-inflammatory properties, improve fatigue, and improve cognition. Extract from the Ginko tree or Ginko Biloba, have similarly been used for centuries in countries like China and Korea. In addition to containing anti-inflammatory flavanoids and terpinoids, Ginko extract is thought to exhibit important effects on multiple neurotransmitter pathways including acting as an MAO-Inhibitor , and inhibiting reuptake of serotonin, dopamine, and norepinephrine. While neuroprotective effects of these substances have been demonstrated in PD rat models, there are no randomized controlled clinical trials in humans using either ginko or ginseng in this population to guide recommendations.

Tips For People With Parkinsons Disease

If you have early-stage Parkinsonâs disease and hope to continue driving as long as possible, itâs essential to keep up regular exercise that maintains the muscle strength you need to operate a vehicle. Itâs also essential to meet with your doctor and ask them about:

• Medications and other treatment, such as deep brain stimulation, that may treat your symptoms.
• Medication side effects that can interfere with driving safety.
• Referral to a center or specialist who can give you an off-road driving test.

To find a local specialist, contact the Association for Driver Rehabilitation Specialists at 866-672-9466 or visit its website. Your local hospital or rehabilitation center may help you find an occupational therapist who can assess your driving skills. In addition, your stateâs department of motor vehicles may offer driver evaluations.

If you have early-stage Parkinsonâs disease and early-stage or mild dementia — and wish to continue driving — you should seek an immediate evaluation of your driving skills. People with moderate-to-severe dementia should not drive. Some states automatically revoke the licenses of everyone diagnosed with moderate-to-severe dementia.

If you pass a driving evaluation, it doesnât mean that you can continue driving indefinitely. Because symptoms of Parkinsonâs disease and dementia usually worsen over time, itâs important to be re-evaluated every six months and stop driving if you do not pass the test.

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Can I Still Drive With Pd

Most likely yes, in the early stages and if you take medicines that control your symptoms. Staying fit and active helps keep the muscle strength you need to drive. Here are some other options to help you maintain optimal driving safety:

• Eliminate driving distractions. Listening to the radio, talking on a cell phone, eating or drinking while driving all affect concentration and reduce safety.
• Avoid nighttime driving if you have vision changes in reduced light settings.
• Do not drive when you feel fatigued or your medication wearing off.
• Choose familiar, comfortable routes and non-peak driving hours. Consider a GPS system for directions.
• Maintain good posture. Reduce back strain with a lumbar support cushion.
• Do regular neck and trunk stretching exercises to increase mobility when backing up or watching for traffic and other obstacles.
• Consider taking a defensive driving course. AAA, AARP and other agencies offer these classes. It may also lower auto insurance premiums.

How To Ease The Transition

Frank discussions with family members and doctors are often enough to convince people with Parkinsonâs disease to modify their driving. Some people may need additional input from a support group, lawyer, or financial planner to ease the transition.

Some people with Parkinson’s disease can continue driving under strict guidelines, although the long-term goal will still be to eventually stop driving. Guidelines for limited driving may include:

• Drive only on familiar roads
• Limit drives to short trips
• Avoid rush-hour traffic and heavily traveled roads
• Restrict drives to daylight hours during good weather

Itâs important for family and friends to find ways to help their loved one reduce their need to drive. These include arranging for groceries, meals, and prescriptions to be delivered to the home, or for barbers or hairdressers to come to the home.

Itâs also important to help your loved one become accustomed to using alternate methods of transportation, such as:

• Rides from family and friends
• Taxi cabs
• Public buses, trains, and subways
• Walking

Your local Area Agency on Aging can help you find transportation services for a loved one. Eldercare Locator, a service of the U.S. Administration on Aging, can also assist. Its phone number is 800-677-1116,

If your loved one refuses to voluntarily limit or stop driving, despite a demonstrated need to do so, you may need to take more aggressive steps, such as:

• Hiding the car keys

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Satisfaction And Research Participation

97.9% of participants were satisfied or very satisfied with the overall study . More than 90% of participants felt they were accurately assessed, it was easy to participate, and they would recommend participation in virtual studies . A small number had concerns regarding confidentiality and communication , and a small proportion would have preferred in-person visits.

Participants indicated a high level of willingness to participate in future virtual studies. 98.5% were willing to participate in a future observational study with virtual visits, 76.1% in an interventional trial with some virtual visits, and 68.5% in an interventional trial with all virtual visits. More than 50% of participants indicated they were more interested in participating in observational and interventional studies that included virtual visits .

Patient Disease And Driving Characteristics

The patients disease and driving characteristics are summarised in . The mean age was 70 years old and the majority of subjects were male . Most had been referred for assessment by the DVLA , held a full license and drove a manual transmission vehicle . Most participants were only driving in the local area and had been driving in the last 6 days . Equal proportions were driving less than and more than weekly.

Table 1

Patient, disease, driving characteristics and univariable logistic regression ). Data are n , mean , median . OR =odds ratio, CI =95% confidence interval, P =P-value, DVLA =Driver and Vehicle Licensing Agency, GP =General practitioner, Section 88 =Section 88 of Road Traffic Act 1988, PD =Parkinsons disease, RDB =Rookwood Driving Battery.

Predictor variable .

The median disease duration was 7 years . The RDB was the predominant cognitive test used . The average RDB score was 6 . The majority of subjects did not demonstrate a depth of vision nor visual field deficit . The median lowest contrast sensitivity seen was 20% and 71% of subjects passed the glare recovery test. Median response time was 0.60 seconds . The assessment outcome was mostly negative with 63% of participants given a not drive outcome.

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Challenges Opportunities And New Directions

A major challenge regarding wider adoption of these tools may be the phones themselves, since many have been designed and manufactured for users with unimpaired dexterity and steady fine movements of the fingers. Individuals with PD face the same limitations while using a computer keyboard. Such challenges have been eased by the emergence of intelligent personal assistant software. IPA is a software agent that can perform tasks or services for an individual. These tasks or services are based on user input, location awareness, and the ability to access information from a variety of online sources. IPAs have made life easier in general but can be much more beneficial for people who are experiencing impaired motor abilities, such as those with PD.

Examples of such an agent are Apples Siri, Google Home, Google Now, Samsungs S Voice, LG G3s Voice Mate, and BlackBerrys Assistant. Some IPAs adapt to the users individual language and search preferences with continuing use, allowing for individualized results.

Desktop computers with keyboard and mouse are adjustable according to patients needs by using a voice control system. Other adaptive software is available that automatically smoothes the mouse cursor motion to reduce the effects of unsteady or tremulous hands. Additionally, desktop keyboards with oversized keys make typing easier for individuals with Parkinsons disease.

Relationship Between Characteristics And Driving Assessment Outcome

Age, duration license held, overall RDB score, usual driving distance, depth of vision deficit and response time were found to be significantly different between assessment outcome groups. On inclusion of these candidate variables in a backwards stepwise logistic regression, the RDB overall score was found to be the best predictor of driving assessment failure, conditional on the other variables .

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What Is Parkinsons Disease

Parkinsons disease was described by James Parkinson nearly 100 years before Dr. Alois Alzheimer described the dementia later named Alzheimers disease . Called the shaking palsy by Parkinson, PD is diagnosed when a person shows at least two of these three symptoms: slowed movements , muscle rigidity, and tremor . We recognize many other associated signs of PD, including expressionless face, quiet speech, cramped handwriting, shuffling gait, trouble getting out of a chair, and difficulty swallowing. Many of the symptoms of idiopathic Parkinson’s disease result when certain nerve cells that produce dopamine in the brain begin to malfunction and die.

Most cases are called idiopathic, meaning the cause remains unknown, although a small number of cases are linked with poisoning , head trauma, more complex PD-like neurological disorders , or reversible toxic medication effects ,

Systematic Review Of Assessment Tools For Determining Fitness To Drive In Parkinsons Disease Patients

The aim of this study was to perform a systematic review of the four main driving assessment methods and provide the evidence on individual methods for assessing driving ability in PD patients. To address the question of how much evidence we have regarding driving competency in PD, we performed a systematic review by searching MEDLINE, life science journals, Google scholar, and online books using the following key words: driving OR driving safety OR driving ability OR road test OR driving questionnaires OR sleepiness scale OR driving simulator OR naturalistic driving OR car sensor OR reaction time OR driver OR transportation OR automobile OR car OR vehicle OR collision injury OR car accident. Selected articles were required to have the term Parkinsons disease AND any one of the above key words within the title and/or abstract.

Table 3 Summary of studies involving driving assessment tools in patients with Parkinsons disease

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Massage Manual Therapies & Alexander Technique

Anecdotally, PD patients have described transient improvement in stiffness and posture after massage therapy. In observational studies of massage for PD, improvement in gait speed as well as subjective selfconfidence and well-being have been described. Similarly, Japanese massage was associated with improvement in gait speed and shoulder range of motion in an observational study of 10 PD patients. Alexander technique uses hand contact to assess and manipulate changes in muscle activity by addressing the relationship between thought and the resultant muscle activity. Stallibrass et al. published the only RCT of massage and Alexander technique in 93 subjects with PD followed with biweekly sessions for 3 months. Compared with a no intervention group, only the Alexander technique participants improved on self-assessment disability scores and depression ratings. More objective motor assessments were not performed. On the other hand, one study that did look at objective motor outcomes was conducted by Craig et al.. They demonstrated that neuromuscular therapy, a technique similar to massage but which relies on direct compression of trigger points, was more effective than relaxation at improving motor UPDRS scores in 36 PD patients over a 4 week intervention period.

Sample Size And Statistical Methods

We used Cohens kappa coefficient to determine the level of agreement beyond chance between self-reported diagnosis, clinician-determined diagnosis, and diagnostic criteria. We determined that a sample size of 200 participants would provide > 80% power to detect a true kappa value of at least 0.8 assuming the null hypothesis value of kappa to be 0.6, using a significance level of 5%. We explored variation in level of agreement according to self-reported PD duration, temporal proximity from FI baseline to the virtual visit, disease-specific clinical features, and demographic features.

We used descriptive statistics to assess willingness to participate, satisfaction with this study, and willingness to participate in future studies as well as to characterize participants. We used observed percent agreement to determine agreement between PD medications and health history as self-reported in FI and obtained by the study team. We assessed associations between the Geriatric Depression Scale scores from FI and the MDS-UPDRS depression item using Spearman correlation. To explore factors associated with participation, we used logistic regression with enrollment as the outcome variable and age, sex, ethnicity, education, household income, and self-reported disease-duration as predictor variables.

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Relationships Between Cognitive Functions And Driving Behavior In Pd

Most reports have compared PD patients driving performances to those of matched healthy controls. Some studies are conducted on driving simulators, which involve tactical and operational level behaviors other studies use instrumented vehicles in real on-road situations, which involve both of these levels but also strategic level behavior. In this type of experiment, PD patients are always evaluated while on medication, when they are feeling their best.

Art Music & Expressive Therapy

Expressive therapies are commonly used as complementary to conventional treatment of PD, although there is little objective data assessing the benefits of these interventions. Active theater combines movements with stimulation of different sensory pathways and emotions, enforcing socialization through the continuous interaction between performers. In one RCT, the effect of three years of theater therapy was found to delay the need to increase dopaminergic therapy when compared with conventional physiotherapy of the same duration. Further investigations are needed to clearly assess the role of specific forms of theater and other expressive therapies in PD.

Based on the existing data, there is sufficient evidence to support the use of music and dance therapy as safe, non-invasive, and inexpensive interventions for patients with PD. Dance therapy, and tango in particular, has demonstrated efficacy in several high quality trials. Compliance with these interventions is thought to be high due to the enjoyability and social aspect of these practices.

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Theoretical Basis Of Driving Behavior And Its Relevance To Pd

Driving is a complex activity which requires various visual, motor and cognitive abilities. In most driving situations, the driver has to use perception, process information and to make a number of decisions very quickly. In order to understand driving activity better, Michon et al. have distinguished three levels of driving behavior. Strategic level behaviors include actions such as choosing the route and time of travel. Tactical level behaviors involve actions such as adapting following distance and adjusting speed. Operational level behaviors include second-to-second driving behaviors such as maintaining lane position and reacting to obstacles. These operational behaviors are heavily time-pressured. As shown in figure 1, these levels imply several cognitive domains.

Fig. 1

Illustration of Michons model and cognitive functions involved in driving.

The Michons model is relevant to PD. Indeed, literature shows that PD patients have difficulties in these three driving behavior levels. For strategical level, they have difficulties while performing a distraction or navigation task . Regarding tactical level, PD drivers have problems in reversing, negotiating traffic light controlled intersections, adapting driving to changing road conditions or changing lane . As referred to operational level, patients have an increased driving reaction time, a delayed deceleration or difficulties in maintaining a constant lateral position .