Applying Cognitive Assessments to Improve Driving Rehabilitation Interventions & Outcomes SUSAN TOUCHINSKY, OTR/L , SCDCM, CDRS sus ie@adapt ivemobi l i ty.com

ERIN KNOEPFEL MS, CCC-SLP eknoepfel@thebcat .com

ADED 2019 LEXINGTON, KENTUCKY

Conflict of Interest

Erin is employed by Mansbach Health Tools, LLC. And is a licensed BCAT® user

Susie is a licensed BCAT® user

Presentation Goals◦ Driving requires the

coordination of a range of motor, coordination, sensation, vision, and cognitive skills.

◦ Cognition & driving is complex

◦ Our goal is to explore the role of cognition with driving

Learning Objectives

Explore Explore the importance of cognition for the task of driving

Understand Understand OT’s role with cognitive assessment and referral relationships

Learn Learn the key components of the Brief Cognitive Assessment Tool (BCAT®) Approach

Apply Utilize results & apply standardized assessments completed by the referring OT

Understand Understand implications of various cognitive assessment tools for determining fitness to drive for adults

Exploring Cognition

Key Point◦ Cognition is a critical vital sign

◦ It is essential for maintaining an independent lifestyle and is at the center of all experiences.

3 Strong Cognitive Predictors of

Instrumental Activities

Of Daily Living

(Mansbach, et.al, 2012)

Primary Control Center

Attentional Capacity

Contextual/Working Memory

Executive Control Functions

5 Areas of Attention

Focused Shifting Sustained

Selective Divided

Attentional Capacity & DrivingClassen, S., Dickerson, A. E., & Justiss, M. (2012). Occupational Therapy Driving Evaluation: Using Evidence-Based Screening and Assessment Tools. In: M. J. Maguire & E. Schold Davis (eds.), Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan. Bethesda, MD: AOTA Press.Kramer, A. F. & Madden, D. J. (2008). Attention. In: F. I. M. Craik & T. A. Salthouse (eds). The Handbook of Aging and Cognition (pp. 189-249). Hillsdale, NJ: Erlbaum.Madden, D. J., Turkington, T. G., Provenzale, J. M., Hawk, T. C., Hoffman, J. M., & Coleman, R. E. (1997). Selective and divided visual attention: age-related changes in regional cerebral blood flow measured by H2(15)O PET. Human Brain Mapping, 5, 389-409.

Attention Area Driving Demand

Selective Attention Tune out irrelevant objects (billboard messages, lawn ornaments)

Sustained and Focused Attention Attend to critical stimuli (traffic lights, vehicles, pedestrians) while maintaining the task of operation of the vehicle

Divided Attention Most driving maneuvers: changing lanes, modifying speed, turn signals, position relation to other vehicles

Attentional Capacity & AgingClassen, S., Dickerson, A. E., & Justiss, M. (2012). Occupational Therapy Driving Evaluation: Using Evidence-Based Screening and Assessment Tools. In: M. J. Maguire & E. Schold Davis (eds.), Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan. Bethesda, MD: AOTA Press.Kramer, A. F. & Madden, D. J. (2008). Attention. In: F. I. M. Craik & T. A. Salthouse (eds). The Handbook of Aging and Cognition (pp. 189-249). Hillsdale, NJ: Erlbaum.Madden, D. J., Turkington, T. G., Provenzale, J. M., Hawk, T. C., Hoffman, J. M., & Coleman, R. E. (1997). Selective and divided visual attention: age-related changes in regional cerebral blood flow measured by H2(15)O PET. Human Brain Mapping, 5, 389-409.

Attention capacity declines with age divided attention > selective attention

Attention is compromised by distractions cell phones, texting, & passengers

Driving may maximize driving safety

Contextual/Working Memory

• A cognitive “workspace” that allows us to temporarily store information we hear, see or feel in order to do something with

• Working memory typically lasts for 15 to 30 seconds

The ability to mentally hold and manipulate information over a

short period of time

• Phonological (sound)

• Visuo-spatial (visual)

Two dominant domains of working

memory:

Contextual/Working Memory & Driving

Barco, P., Stav, W., Arnold, R., & Carr, D.B. (2012). Cognition: A vital component to driving and community mobility. In: M. J. Maguire & E. Schold Davis (eds.), Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan. Bethesda, MD: AOTA Press.

Goetz, C. G. (1999). Textbook of Clinical Neurology, 1st ed. Philadelphia: W. B. Saunders Company.

Levy, L.L. (2005). Cognitive aging in perspective: Information processing, cognition, and memory. In: N. Katz (Ed.), Cognitive and Occupation Across the Lifespan: Models for Intervention in Occupational Therapy, 2nd ed (pp. 305-325). Bethesda, MD: AOTA Press.

Retain Retain certain information while processing new or unique information (driving in a school zone)

Obey Obey traffic rules and regulations

Recall Recall the steps to operate the vehicle

Navigate Navigate to the destination

Remember Remember their destination

Contextual/Working Memory & Aging

40% of people over age 65 experience some form of memory loss

Neurophysiology and aging:◦ Brain loses cells that are essential in

encoding and retrieval processes of memory

◦ Overall brain weight decreases

◦ Cell loss causing the connections between synapses to weaken

◦ Hippocampus loses 5% of its neurons every decade, with 20-30% being lost by 80 years of age

Contextual/Working Memory & Aging

Aging adults demonstrate the following changes with memory:◦ More difficulty learning new things

◦ Retrieving old information

◦ Multitasking

◦ Reduced auditory processing speed and amount of information

Executive Control FunctionIn: N. Katz (Ed.), Cognitive and Occupation Across the Lifespan: Models for Intervention in Occupational Therapy, 2nd ed (pp. 305-325). Bethesda, MD: AOTA Press.Elliot, R. (2003). Executive functioning and their disorders. British Medical Bulletin, 65, 49-59. https://doi.org/10.1093/bmb/65.1.49.Barkley, R. A. (2012). Executive Functions: What They Are, How They Work, and Why They Evolved. New York: Guilford Publications, Inc.Rizzo, M. & Kellison, I. L. (2010). The brain on the road. In T.D.M.I. Grant (Ed.) Neuropyschology of Everyday Functioning (pp. 168-208). New York: Guilford Press.

THE COORDINATION OF SEVERAL COGNITIVE FUNCTIONS

NECESSARY TO ACHIEVE A GOAL

TASK INITIATION, MAINTENANCE AND DISCONTINUATION

EXECUTIVE PROCESSES OCCUR IN THE FRONTAL LOBE OF THE

BRAIN

Executive Control FunctionLevy, L.L. (2005). Cognitive aging in perspective: Information processing, cognition, and memory. In: N. Katz (Ed.), Cognitive and Occupation Across the Lifespan: Models for Intervention in Occupational Therapy, 2nd ed (pp. 305-325). Bethesda, MD: AOTA Press.Elliot, R. (2003). Executive functioning and their disorders. British Medical Bulletin, 65, 49-59. https://doi.org/10.1093/bmb/65.1.49.Barkley, R. A. (2012). Executive Functions: What They Are, How They Work, and Why They Evolved. New York: Guilford Publications, Inc.Rizzo, M. & Kellison, I. L. (2010). The brain on the road. In T.D.M.I. Grant (Ed.) Neuropyschology of Everyday Functioning (pp. 168-208). New York: Guilford Press.

Problem solving

ReasoningPractical

Judgment

Abstraction Set-shifting

Executive Control Functions & Driving

Making decisions to stop at a red light

Knowing what to do when the light is green, but a pedestrian is crossing the street

The ability to drive in unfamiliar routes without a problem

Driving the speed limit in construction zone due to safety of workers

Adjusting the route when exiting at the wrong location

Executive Control Function & Aging

Capacity for logic declines with aging

Most problems with ECF is related to impairment with working memory and processing

The information isn’t even making it to the frontal lobe from the temporal lobe (hippocampus)

In Alzheimer’s Disease Executive Processes are impaired

Emotional Regulation

Adler, G., & Kuskowski, M. (2003). Driving cessation in older

men with dementia. Alzheimer Disease and Associated Disorders,

17(2),68-71.

SELF REGULATION COMPONENTS

ALERTNESS AROUSAL

AWARENESS FATIGUE INSIGHT

Processing Speed

Speed of processing

How quickly can you take in information, make a decision & response

Notice & response

/

Visual-Perceptual Abilities

Depth perception

Spatial relations

Right-left discrimination

Topographical orientation

Figure ground discrimination

Visual processing

speed

Key PointCognition is more than alert & oriented x3. A range of medical conditions can impact cognitive performance.

Know & understand YOUR role as a DRS/CDRS, OT, practitioner, etc. with screening & assessing cognition

Cognitive function is impacted for a range of ages & conditions – not just the older driver

Common Medical Conditions & Considerations for Driving

TIA & Stroke

Motor, sensation, language, cognition, & balance changes

Visual-perceptual deficits

Insight & judgement

Processing speed Attention Task shifting

TIA & StrokeLundzvist, Gerdle, & Ronnberg, J. (2000). Neuropsychological aspects of driving after a stroke: In the simulator and on the road. Applied Cognitive Psychology, 14, 135-148. Devos, H. Akinwuntan, A.E., Nieuwboer, A., Truijen, S., Tant, M., & De Weerdt, W. (2010). Screening for fitness to drive after stroke: A systematic review 7 meta-ayalsis. Neurolgoy, 76, 747-756.

Lundzvists, Gerdle, & Ronnberg (2000) found, “… evaluations requiring high-order cognitive

functions such as mental control, working memory, & attention

provided the best differentiation of driving skills in stroke survivors.”

Trails Making B performance has been found to be predictive of

impaired driving performance for stroke (Devos et. Al. 2010).

TBI & Concussion

Cognitive impairment is most common problem

with TBI

Arousal, alertness, emotional regulation

Attention, memory, task shifting, visual

scanning, visual processing, processing

speed

Motor skills, coordination

TBI & Concussion

Headache: acute and/or chronic

Whole body: blackout, fatigue and poor balance

Cognitive: amnesia, disorientation, confusion, memory, recall, executive function impairment

Sleep: inability to sleep or prolonged periods of sleep

Gastrointestinal: nausea, vomiting

Mood: irritability, personality changes, depression

Sensory: tinnitus, sensitivity to light and/or sound

Brain Tumor◦ Spectrum of deficits

◦ Range of cognitive and visual spatial performance

◦ Cognitive impairments dependent on location of tumor pre/post surgical resection

Multiple Sclerosis

Visual perceptual

Processing Alertness

Emotional Visual-spatialProblem solving

Parkinson’s Disease

Executive FunctionsTask initiation and shifting

Planning

Attentional Capacity Working memoryProcessing speed

Recall

Mental Illness

Major depression:

Cognitive impairment can be severe and global

Impairment with all cognitive domains and limbic system

Mood disorder associated with

Impaired attention

Impaired Executive Functions

Impaired Memory

Mild Cognitive Impairment

MCI: The four subtypes include:Amnestic (aMCI)Executive (eMCI)Multi-domain (mMCI)Undifferentiated (uMCI)

Research supports those with MCI show at least 1 IADL impairment

MCI conversions to dementia(Mansbach et al, 2018)

Mild Cognitive

ImpairmentPomidor A, ed. Clinician’s Guide to Assessing and Counseling Older

Drivers, 4th Edition. New York: The American Geriatrics Society;

2019.

“For older adults with mild cognitive impairment or early dementia (with or without motor impairment), more information should be obtained to explore the reversibility of the cognitive impairment, the etiology, the potential remaining abilities, and strategies for compensation by having a thorough evaluation for dementia…”

Pomidor, 2019, Chapter 4, 2019

BCAT® MCI Study: What the science tells us https://www.thebcat.com/bcat-research-center

61% of older adults with MCI were dependent in at least one IADL.

Compared to individuals with normal cognition, people with MCI had greater odds of being dependent on 7 of the 10 specific IADLs.

BCAT® factor scores can be used to identify IADL risk, especially for managing finances, meal preparation and remembering events (including medications).

It is critical to accurately identify who has MCI using the BCAT® Approach to detect those at risk for functional issues, not just cognitive ones.

MCI & DrivingMegan Hird, Researcher at University of Toronto, presentation at the Alzheimer’s Association International Conference 2016Citation: Driving skills already affected with mild cognitive impairment Publish date: August 3, 2016 By Michele G. Sullivan Clinical Neurology News

Hird’s research looks at physiologic brain activity and driving

Suggest that patients with mild cognitive impairment (MCI) may already be experiencing potentially dangerous changes in their ability to operate a motor vehicle

Driving Evaluation: MCI made more critical errors on the road

Driving Simulator: MCI showed higher activation in areas of the brain for planning, higher-order attention, & cognitive control

DementiaDementia—a matter of degree◦ Always progressive

◦ Affects cognition, mood, behavior and function

◦ Multiple causes

With Dementia there has to be a memory impairment

Autism Spectrum DisorderUse and understanding of communication are delayed or remain impaired

Lack the understanding of nonverbal communication:◦ Eye contact

◦ Facial expressions

◦ Gestures

◦ Rules of proximity to communication partner

◦ Body language

Autism Spectrum Disorder

Lacking/limited cognitive flexibility

Poor problem solving

Poor planning and

organization

Lack of inhibition

Cerebral Palsy

May affect physical abilities only in some individuals

30-50% of children with CP have some level of cognitive impairment

Adult mobility and ability to perform ADLs should be routinely monitored in adulthood

Key PointThe medical diagnosis & our clinical testing is imperative of gaining an understanding of the client’s cognitive performance skills in order to understand driving behaviors.

Cognition may be impacted by more than a diagnosis

Remember to consider mood, depression, sleep, & medications

Accurate & thorough cognitive testing is imperative for understanding specific performance skill deficits & guiding our evaluations, interventions, & treatment.

Cognitive Assessment Comparison

It’s time to fill in your chart & handout

“The best assessment tools integrate several cognitive processes (e.g., divided attention, visual processing, processing speed) to test high-level cognitive processes or executive functioning.”

POMIDOR A, ED. CLINICIAN’S GUIDE TO ASSESSING AND COUNSELING OLDER DRIVERS, 4TH EDITION. CHAPTER 3 . NEW YORK: THE AMERICAN GERIATRICS SOCIETY; 2019.

The Dynamic Assessment

Common Negative Outcomes of

Cognitive Misdiagnosis

Sub-optimal management of

medical conditions

Inflated rate of hospital

readmissions

Increased frequency of falls

Lowered rehabilitation

services outcomes

Sub-optimal discharge planning

Increased risk for losing

independence

8/16/2019

Barriers to completion of standardized cognitive assessments by interprofessional care team

Physicians: Lack of time to complete assessment

Nursing: Required to use a specific tool, i.e. MDS/BIMS, OASIS items

Physical Therapy: Another discipline addresses that

Occupational Therapy: Speech Therapy works on that

Speech Therapy: I don’t have access to any tests

Background on Cognition and Assessmenthttps://www.thebcat.com/bcat-research-center

Over 5 million people have Alzheimer’s disease (AD), anticipated to be 13-16 million by 2050

Numbers are vastly greater if you include other dementias and people with Mild Cognitive Impairment (MCI)

MCI → dementia conversion rates (10-15% annually)

A majority of MCI patients will develop dementia within 3-5 years.

/

Cognitive Screening Tool Utilization

Early recognition enhances efficacy

of treatmentsAide in diagnosis

Improve disease management and

planning

Identify functional issues

Manage expectations of

patients, families, providers, and staff

Time and cost effective

Lowers patient resistance and

encourages compliance

What should a

good cognitive screening

tool be able to do?

•Administered by professionals and techs

•Completed in less than 15 minutes (sometimes five minutes)

•Able to differentiate between MCI and dementia

•Broadly assess memory skills

•Broadly assess executive skills

•Assess attentional skills

•Predict ADLs & IADLs

Trails Making Test A & B (TMT)

Dickerson, A. E., Brown, D., & Ridenour, C. (2014). Assessment tools predicting fitness to drive in older adults: a systematic review. American Journal of Occupational Therapy, 68, 670-680. https://doi.org/10.5014/ajot.2014.011833.ce on the Trail-Ma

Staplin, L., Gish, K. W., & Wagner, E., K. (2003). MaryPODS revisited: updated crash analysis and implications for screening program implementation. Journal of Safety Research, 34(4), 389-397.king Test Part A and B and poor driving performance

•Working memory, visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination

•Association between poor performance on the Trail-Making Test Part A and B and poor driving performance

Research: TMT & Driving Roy M., Molnar F. (2013). Systematic review of the evidence for Trails B cut-off scores in assessing fitness-to-drive. Canadian Geriatrics Journal, 16, 120-142. https://doi.org/10.5770/cgj.16.76.

Staplin L., Gish K.W., Lococo K.H., Joyce J.J., Sifrit K.J. (2013). The Maze test: a significant predictor of older driver crash risk. Accident Analysis and Prevention, 50, 483-489. https://doi.org/10.1016/j.aap.2012.05.025.

Gibbons C, Smith N, Middleton R, Clack J, Weaver, B et al. (2017). Using serial trichotomization with common cognitive tests to screen for fitness to drive. American Journal of Occupational Therapy, 71, p1-7102260010p8. https://doi.org/10.5014/ajot.2017.019695

Ball, K. K., Roenker, D. L., Wadley, V. G., Edwards, J. D., Roth, D. L., McGwin, G. Jr., ...Dube, T. (2006). Can high-risk older drivers be identified through performance-based measures in a Department of Motor Vehicles setting? Journal of the American Geriatrics Society, 54, 77–84. https://doi.org/10.1111/j.1532-5415.2005.00568.x.

Trails Making Test B: >3 minutes (>180 seconds) = intervention (Roy, 2013).

Research supports relationship between performance on the TMT-B and cognitive function and/or driving performance. (Staplin 2013).

On-road driving performance as evaluated by a DRS was predicted 78% of the time by the drivers’ TMT-B performance (Gibson et al 2017).

Significant correlation between TMT-B performance and future at-fault crash (Ball et al 2006).

Clock DrawingLong-term memory, short-term memory, visual perception, visuospatial skills, selective attention, abstract thinking, and executive skills

Several versions available; know your version & scoring

Freund, B., Gravenstein, S., & Ferris, R. (2002). Use of the clock drawing test as a screen for driving competency in older adults. Presented at the American Geriatrics Society Annual Meeting, Washington, D.C., May 9, 2002.

Research & Clock DrawingCADReS uses Freund Clock Drawing & Scoring

Any errors signal need for intervention

Strong link between Clock Drawing & other cognitive measures and helpful in discriminate healthy individuals vs dementia

Amodeo S., Mainland B.J., Herrmann N., Shulman K. (2015). The times they are a-changin’: clock drawing and prediction of dementia. Journal of Geriatric Psychiatry and Neurology, 28, 145-155. https://doi.org/10.1177/0891988714554709.

Reger, M. A., Welsh R. K., Watson G. S., Cholerton, B., Baker, L. D., & Craft, S. (2004). The relationship between neuropsychological functioning and driving ability in dementia: a meta-analysis. Neuropsychology, 18, 85–93. https://doi.org/10.1037/0894-4105.18.1.85.

Maze TestAttention, visual perception, visuospatial skills, abstract thinking, and executive skills planning & foresight

Several versions of maze testing – Snellgove

Snellgrove, C. A. (2005). Cognitive screening for the safe driving competence of older people with mild cognitive impairment or early dementia. Canberra, AU: Australian Transport Safety Bureau. Retrieved from https://infrastructure.gov.au/roads/safety/publications/2005/pdf/cog_screen_old.pdf.

Staplin L., Gish K.W., Lococo K.H., Joyce J.J., Sifrit K.J. (2013). The Maze test: a significant predictor of older driver crash risk. Accident Analysis and Prevention, 50, 483-489. https://doi.org/10.1016/j.aap.2012.05.025.

Snellgrove Maze Test

Available in CADReS

Snellgrove scores less than 60 seconds, without errors = intact

Re: Driving the Snellgrove maze validated with older adults with mild cognitive impairment or early dementia

Maze Test score was predictive for on-road driving performance for clients with MCI & dementia (Snellgrove 2005 & Staplin et. All 2013)

St. Louis University Mental Status Exam (SLUMS)

Screening tool

Education biased – different scores for education levels

Takes 7-10 minutes to administer

Screens cognitive-communication areas: attention & working memory, executive functioning, language, reasoning, problem solving, & visual spatial

St. Louis University Mental Status Exam (SLUMS)High School Education (Scoring 0 to 30) ◦ 27-30 Normal◦ 20-27 MCI◦ 1-19 Dementia

Less than High School Education◦ 26-30 Normal◦ 14-19 MCI◦ 1-14 Dementia

Scores suggestive of mild cognitive impairment indicate the need for referral to a driver rehab specialist

Scores suggestive of dementia indicate consideration for driving retirement, reference Evidenced Based Consensus statements

Short Blessed Test (SBT)Morris JC, Heyman A, Mohs RC, Hughes JP, van Belle G, Fillenbaum G, Mellits ED, Clark C. (1989). The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology, 39(9):1159-65.

Attention, orientation, sequencing

Immediate & delayed recall

Visual spatial

•0-4 normal

•5-9 mild impairment

•10 or more probable dementia

Score of 6 or more indicates increase crash risk and warrants referral to DRS5

Score of 10 or more driving retirement

Mini Mental Status Examination (MMSE)Wheatley, D. J., Carr, D. B., & Marottoli, R. A. (2014). Consensus statements on driving for persons with dementia. Occupational Therapy in Health Care, 28, 132-139. https://doi.org/10.3109/07380577.2014.903583.

Joseph P.G., O’Donnell M.J., Teo K.K., Gao P., Anderson C., et al. (2014). The Mini-Mental State Examination, clinical factors, and motor vehicle crash risk. Journal of the American Geriatrics Society, 62, 1419–1426. https://doi.org/10.1111/jgs.12936.

Scored 1-30, higher is betterRecall, attention, orientation, simple direction following, visuo-spatial

Research does not support the use of MMSE for predicting crash risk or driving abilities (Wheatley, Carr, & Marottoli, 2014; Joseph, et al, 2014).

Copyright Folstein, Folsein, & McHugh

Montreal Cognitive Assessment (MoCA)

Screens attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.

Time to administer is about 10 minutes.

Score out of 30

26 or above considered normal

Montreal Cognitive Assessment (MoCA)

Hollis, A.M., Duncanson, H., Kapust, L.R., Xi, P. M., & O’Connor, M. G. (2015). Validity of the Mini–Mental State Examination and the Montreal Cognitive Assessment in the prediction of driving test outcome. Journal of the American Geriatrics Society, 63(5), 998–992. https://doi.org/10.1111/jgs.13384.

Cognitive condition – positive & significant relationship between MoCA score and on-road outcome

1.36 times increase on likeliness for BTW failure with each 1 decrease

18 or less of concern regarding driving safety (Hollis et. Al, 2015)

Brief Cognitive Assessment Tool (BCAT®) Approach

A unique applied concept for assessing and working with people who have memory and other cognitive impairments

Designed for any clinical and residential setting in which cognitive functioning and cognitive impairment is a central issue.

Integrates the BCAT® Test System with evidence-based interventions to address working memory, cognitive stimulation and meaningful patient engagement

Brief Cognitive Assessment Tool (BCAT®) ApproachThe BCAT® is currently used by thousands of healthcare professionals

The BCAT® is currently used in hospitals and all locations within the post-acute care setting

Strong emphasis on staff development and education

In a survey of health care providers, the BCAT® received an “A” rating (highest) for clinical utility and value

In a survey of health care providers, 92% reported that they would recommend the BCAT® to colleagues

The BCAT® Test System – The Six Tests

All tests have interactive online scoring programs with test reports.

All six tests have undergone rigorous

testing, peer-reviews.

Multiple publications, professional

presentations

The BCAT® Test System is supported

by the BCAT® Research Center.

Key PointThorough cognitive assessment includes the use of standardized tests & occupation or functional based assessment.

BCAT® & Driving Research

BCAT® GRS DRIVING STUDY: APPLICATION OF BCAT® FOR GUIDELINE ON ROAD READINESS & FITNESS TO DRIVE OUTCOMES

Background & Research Questions

Can the BCAT identify patients who could benefit from a behind the wheel evaluation? Does the BCAT guide readiness to participate a driving evaluation?

Does the BCAT its factor scores (executive functions, memory) predict unsafe driving?

How does the BCAT compare to other cognitive measures in predicting unsafe driving?

Hypothesis: Cognitive impairment, as evidenced by lower BCAT® scores, will significantly predict poorer driving performance and outcomes.

Data Analysis

Used descriptive statistics

Used independent sample t-tests, chi-square tests for independence, and Pearson correlations

Used regression

Driving Data: Sample Characteristics

Original N = 244; final sample 197

7 were excluded for not meeting their state’s minimum vision requirements

38 were excluded for age < 50

2 were excluded for missing BCAT data

Includes drivers from NJ, PA, & FL

Let’s Revisit CMF & EFF Total BCAT® Score: indicates cognitive stage/level◦ Normal, MCI with specific subtype, dementia

CMF: scores indicating level of current memory functioning for IADLS◦ Remembering to turn off the stove, remembering to take medications

ECFF: scores indicating current executive skills◦ Practical Judgment◦ Problem solving◦ Reasoning

CMF & ECFF are helpful to clinician to identify the specific exercise and level of difficulty to start interventions

Big Takeaways

Testing memory isn’t enough

Must test memory & executive functioning for driving

BCAT® is a useful tool because it test memory, executive function, & attention

BCAT® is a boarder screening tool & should be used to start & then guide additional tests & measures

ResultsIf you are in the clinic and only doing TMT, Maze & look at age, you are operating at a 42% predictive value. ◦ Would you be satisfied with someone using

42% to predict your fitness to drive?HOWEVER add in BCAT® and you improve your predictive power from 42% to 70%◦ This is significant for partnering with the

referring OT AND significant if you are program only providing clinical driving evaluations

Results

Memory tests alone will not identify executive function which is necessary for driving/IADL

MoCA has Executive Function but the items are all visually driven tasks. ◦ The ‘blind version’ is a memory test only

BCAT® & Driving

BCAT® is an accurate predictor of MCI versus dementia

The data shows that if BCAT® score falls in the dementia range, the client has a 2.5% increased chance of being recommended for driving retirement

The data also shows that if the BCAT® score fall in the MCI range of 42/43 or below, there is a greater odds or caution at 1.34

Clients who scored 47 to 48 were less likely to need a BTW due to cognitive reasons & more likely to demonstrate fitness to drive

Hierarchy of Tests in Driving Evaluation

Behind the Wheel Test

Functional Cognition Visual/perception Motor

Second Level Testing

Trails Making Test Maze Test

First Level - BCAT® Test

BCAT Total Score ECFF Score CMF Score

Future Research

To determine a BCAT® score associated with automatic driving retirement with out a behind the wheel evaluation

Focused population: moderate-severe dementia

Additional ResearchBCAT® SUPPORTING INTERVENTIONS & COLLABORATION

Better, faster outcomes with BCAT®

Newest Findings from the BCAT® Research Center: Achieving “Better, Faster” Functional Outcomes using the BCAT®

Cognitive Approach

The study examined the efficacy of Speech Language Pathology using working memory exercises (WME)

in a prescriptive treatment approach for patients with MCI

and dementia (mild to moderate).

Key Findings: Better, faster outcomes with BCAT®

◦ Patients who received either WMEB or BR significantly improved ADL skills relative to patients in the control group.

◦ On average, participants in the BCAT® intervention groups (WMEB, BR) could perform an additional ADL over and above baseline ADL ability. Participants in the control group demonstrated no meaningful improvement in ADLs from pre- to post-testing.

◦ The proportion of participants in the BCAT® intervention groups classified as independent on ADLs increased by 20% from pre- to post-testing.

Key Findings: Better, faster outcomes with BCAT®

Research supports that interprofessional practice using the BCAT®Approach results in better, faster functional outcomes, in the area of cognition and specifically in the following ADLs:◦ Continence

◦ Toileting

◦ Dressing

◦ Functional Transfers

Prescriptive Cognitive Treatment Protocol Powered by BCAT®

Protocol was validated and demonstrated:

Patients with MCI and Mild Dementia show more improvement in ADL performance when WMEB or Brain Rehab (BR) was part of the treatment

Improvement in performance and outcome in one discipline is a function of the work of all disciplines

WMEB and BR appear to positively impact cognitive mechanisms underlying functional skills

BCAT® Supports the PDPM Cognitive Measure Classification Methodology

Cognitive Level BCAT® BCAT®-SF BIMS CPS

Normal 44-50 19-21 13-15 0

MCI 34-43 16-18 --- ---

Mild Dementia 25-33 13-15 8-12 1-2

Moderate Dementia

19-24 9-12 0-7 3-4

Severe Dementia 18 and below 8 and below --- 5-6

Additional InterventionsDRIVING REHAB INTERVENTIONS IN THE CONTEXT OF COGNITIVE DEFICITS

Guiding Questions for Interventions

What is the nature of the cognitive deficits?

Is it related to a progressive condition or something that may improve with time & recovery?

Is there an impact from mood, medications, sleep, infection, anemia, blood sugars, etc. been considered?

Has there been a formal evaluation or diagnostic process?

Guiding Questions for Interventions

What is the extent of the cognitive deficit?

Memory, attention, problem solving, executive function, etc.?

What tools are you using to understand the extent of the cognitive impairment?

Are your tools giving you everything you need and increasing your confidence level?

Guiding Questions for Interventions

Does the deficit impact new learning?

Does the deficit improve with intervention and sustain improvement?

Could a restriction or other driving modification be implemented?

*REMEMBER* Not appropriate in the context of progressive memory deficit

3Rs of Driving Retirement

R – Remove access

R – Replace routine activities

R – Remember the fun!

ENRICH for a Brain-Healthy Lifestyle: Tools for aging adults and their families

A one-of-a-kind tool used to help you understand how your daily life impacts your brain health. Your score will give you an idea about your risk so you can begin to practice brain-healthy lifestyle habits.

A strongly predictive assessment of cognitive functioning that can be completed in-home. It provides immediate results, ultimately helping you determine whether a more comprehensive evaluation is necessary.

A scientifically validated tool that allows you to walk through a comprehensive brain health assessment with a live specialist in 30 minutes. You’ll receive a personalized report detailing your results –straight to your inbox!

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Brain Health As You AgeProvides useful, achievable actions you can take to reduce your risk of brain function decline

Recommendations are evidence-based, practical, useful, achievable and measurable

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Collaboration with Referral Sources

Collaboration

OT, SLP, PTPhysician,

neurologist

Social service

coordinatorsDRS/CDRS

ASHA Practice Document-Cognitive AssessmentAssessment is conducted to identify and describe:

•underlying strengths and weaknesses related to cognitive, executive function/self-regulatory, and linguistic factors, including social skills that affect communication performance

•effects of cognitive-communication impairments on the individual's activities (capacity and performance in everyday communication contexts) and participation

•contextual factors that serve as barriers to or facilitators of successful communication and participation for individuals with cognitive-communication impairment. (ASHA, 2019)

ASHA Practice Document-Cognitive InterventionsIntervention services are provided to individuals with cognitive-communication disorders, including problems in the ability to attend to, perceive, organize, and remember information; to reason and to solve problems; and to exert executive or self-regulatory control over cognitive, language, and social skills functioning. (ASHA, 2019)

“Expert in determining how cognitive deficits can impact everyday activities, social interactions, and routines... Occupational therapists have the skills to assess the cognitive aspects of functional activities and design an intervention plan, from acute care to community reintegration,” (AOTA, 2011).

AMERICAN OCCUPATIONAL THERAPY ASSOCIATION (AOTA)

“AOTA recognizes that driving in particular is a critical component of community mobility in the context of living within an industrialized nation and asserts that occupational therapy practitioners are poised to address driving at various levels to evaluate and intervene relative to individual performance as well as contribute to the overall health and safety of the public.” (AOTA Driving & Community Mobility Practice Statement, 2016).

OCCUPATIONAL THERAPY PRACTITIONER

Practitioner Model

BCAT® Total Score

ECFF CMF+ +

Encourage Collaboration & Mentorship with Referral Source

• Evaluation

• BCAT®/Cognitive Assessment

OT/ST

• Mentorship

• Collaboration

OT/ST & DRS• Driving

Evaluation

DRS/CDRS

Collaboration Benefits

IMPROVES THE TIMING FOR THE DRIVING EVALUATION

IMPROVES CHANCE OF POSITIVE OUTCOME

COVERED INTERVENTION

Collaboration Benefits

• Evaluation

• Identify Concerns

CDRS/DRS

• Mentorship

• Collaboration

• Referral

OT & ST/DRS• Address driving

retirement or performance skill deficit

OT/ST

Summary of Key Points

Intact cognition is essential for optimal participation in a range of instrumental activities of daily living (IADLs) including driving and community mobility. Driving is one of the most complex and cognitive demanding activities of all.

Cognition, specifically executive functioning, is critical in the in the evaluation of performance skills needed for the task of driving.

Choosing and using the right standardized cognitive test is vital for improving safety & understanding

It is important to understand the outcomes and potential risks when using various cognitive screening and assessment tools to determine safety in driving in the adult.

Test like the Brief Cognitive Assessment Tool (BCAT®) may be used to understand a client’s cognitive impairments, better anticipate impact on driving performance, AND improve interventions

Ability to differentiate MCI from dementia

Ability to predict functional (IADL) status

Emphasis placed on contextual memory and executive functions (with specific scores for each)

KEY BENEFITS OF THE BCAT®

Occupational therapy practitioners can play a positive role with cognitive assessment & potential referral relationship with driver rehabilitation specialists.