Introduction

Cognitive impairment, also called cognitive dysfunction or neuropsychological impairment refers to any impairment of a cognitive function. There is overwhelming evidence that cognitive impairment affects the ability to drive safely. More than half (57%) of people with some form of cognitive impairment continue to drive of which 30 to 50% will have a crash within three years, and 80% will continue driving following a crash¹.

 A progressive cognitive impairment, such as the common forms of dementia, reduces memory, concentration and judgment, of which all are needed to be a safe driver. According to Dobbs et al (2009), "the progressive nature of dementia means that deterioration of driving skills is a certainty”². Drivers with dementia have poor insight into the risk they pose and are unlikely to self-regulate their driving.

A diagnosis of cognitive impairment is not a good indicator of the ability to drive safely. Approximately one third of drivers with the early stage of dementia are competent. The key to ensuring that drivers with a progressive cognitive impairment cease to drive before they become a risk lies in a process that includes clear communication, appropriate assessment and support for driving cessation.

This paper is intended to provide an overview of the assessment process used in British Columbia to determine driver fitness for those with a cognitive impairment.  

Background

As the lead provincial agency for road safety in British Columbia, the Office of the Superintendent of Motor Vehicles (OSMV) is responsible for ensuring that holders of driver’s licences are able and fit to drive.  The OSMV’s Driver Fitness Program policies and procedures are used to guide driver fitness determinations. These policies and procedures are provided in the 2010 BC Guide in Determining Fitness to Drive³ (the Guide).

Prior to the release of the 2010 Guide, driver fitness determinations were based on a diagnostic model for determining driver fitness. That is, guidelines were based primarily on the medical condition rather than on how the medical condition affected an individual’s functions necessary for driving.

To align with scientific evidence related to fitness to drive and to comply with a Supreme Court of Canada decision that established the requirement to individually assess drivers⁴, the OSMV adopted a functional approach to driver fitness. This means that the OSMV assesses the impact of a medical condition on the functions necessary for driving when making driver fitness determinations. The OSMV’s change in their approach to driver fitness is reflected in the Driver Fitness Program’s policies and procedures contained in the Guide.  

Overview of Driver Fitness Program related to Cognitive Impairment

The Driver Fitness Program assesses about 120,000 drivers annually. In an average year, 3,400 drivers have their driving privileges cancelled or denied for fitness reasons and 2,500 have their driving privileges restricted or reduced⁵.

The Driver Fitness Program has four key activities in the decision making process:

• Screening
• Assessment
• Determination
• Reconsideration

Screening

Although the OSMV can review a driver’s file at any time, screening is generally done when:

• A driver discloses a medical condition or fails a vision screening for a licence application or renewal
• A credible, unsolicited report is received by the OSMV⁶
• A report pursuant to the Motor Vehicle Act s.230⁷ is received
• The driver turns 80 or a routine age related screening is due
• A scheduled reassessment interval expires
• A driver applies for a commercial class licence or routine commercial screening is due

Once the OSMV has identified a driver as having or possibly having a medical condition that may impair the functions necessary for driving, the driver is sent a letter asking them to have their physician complete a Driver’s Medical Examination Report (DMER).

Assessment

The assessment consists of two processes: the Driver’s Medical Examination and the OSMV assessment.

Driver’s Medical Examination

The initial assessment is conducted by the physician the driver took the DMER to. The DMER can be completed by any physician licensed to practice medicine in British Columbia; however it is recommended that the DMER be completed by a physician who knows the driver and will have a role in their continuing care.

Completing the DMER for a patient with cognitive impairment

Previously, for drivers with a cognitive impairment the recommended screening tool for this examination was the Mini Mental Status Exam (MMSE). However, in the past year a valid and reliable screening tool for identifying cognitively impaired drivers whose driving skills may have declined to an unsafe level was introduced: Screen for the Identification of Cognitively Impaired Medically At-Risk Drivers a Modification of the DemTec (SIMARD MD). The OSMV has now adopted the SIMARD MD screening tool in the Driver Fitness Program to replace the MMSE for drivers with a cognitive impairment.

For drivers who have or are suspected of having a cognitive impairment, it is important that the physician conducting the examination complete a SIMARD MD screening and report the score on the DMER along with any other pertinent information. Once the DMER is completed, the physician sends it to the OSMV.

SIMARD MD

The SIMARD MD is a valid and reliable screening tool for the identification of cognitively impaired medically at-risk drivers. It is called a modification of the DemTect because it uses a subset of the items from that screening tool.

The SIMARD MD was developed and validated against actual driving performance using a driving evaluation scientifically developed to identify cognitively impaired drivers who are unsafe-to-drive.

There are three possible outcomes for the SIMARD-MD screen:

A score of:

            ≤   30:    Flagged as unfit to drive

            31-70:    Indeterminate

            >   71:    Flagged as fit to drive

When a driver is flagged as either fit to drive or unfit to drive, a physician must consider whether any mitigating factors exist that could have influenced the result. For example, a language barrier could influence a patient to score lower than their true ability. Conversely, a highly intelligent patient could score higher than their true ability. In these cases, the physician will document the mitigating factors and the SIMARD MD should not be relied upon for licensing decisions.   

OSMV assessment

During the assessment phase, the OSMV collects the information required to make a driver fitness determination. As the first step, the OSMV reviews the Driver’s Medical Examination Report (DMER) and any other relevant information and decides whether a driver fitness determination is required.

If the OSMV decides there is no determination required then the assessment is complete and the driver’s licence status remains unchanged. If the OSMV decides a driver fitness determination is required then the driver’s information, including the DMER, is sent to an OSMV adjudicator or case manager.

 If the OSMV requires more information to make the determination then additional medical or functional assessments are requested. For drivers with a progressive cognitive impairment, the standard functional assessment is a DriveABLE assessment.

DriveABLE

DriveABLE is the brand name of tests developed through scientific research to assess a person’s cognitive functioning necessary for driving. The accuracy of this assessment process for identifying competent drivers and unsafe drivers has been validated through research.

It consists of the following separate procedures:

• DriveABLE Cognitive Assessment Tool (DCAT)
• DriveABLE On-Road Evaluation (DORE)

The DCAT

The DCAT is an in-office assessment of cognitive abilities essential for safe driving. This includes tests of motor speed and control, attention, judgment, memory and decision-making, and making judgments of driving situations.

The tasks are presented on a touch sensitive screen. The tasks only require the driver to either touch the screen or push a button to make a response. Performance is age normed. This DCAT assessment takes approximately 60 minutes to complete.

Note:    While the evaluator uses a computer to present each task on the screen, the driver does not have to have any skills or knowledge about computers to do the tasks.

All drivers undergoing a DriveABLE assessment will complete the DCAT.

The DORE

The DORE is an on-road evaluation which consists of a standardized road course developed through scientific research to reveal competence defining driving errors.

 Only driving errors shown by the research to be associated with competence declines are scored. Driving performance is normed against healthy competent drivers. Only those drivers who score in the ‘inconclusive’ range on the DCAT will undergo a DORE.

Payment

In BC, the OSMV will pay for DriveABLE assessments when the OSMV refers the patient. If a physician refers a patient directly to DriveABLE the patient must pay the $300 fee.

When a driver has completed a DriveABLE assessment, a copy of the final report is sent to the OSMV, the physician who completed the Driver’s Medical Examination Report (DMER), and any other party the driver requested on the signed consent form.

DriveABLE results

Following are the possible final results and recommended actions:

DCAT  

The DCAT score represents the ability to predict a driver’s outcome of an on-road assessment. Following are possible scores on a final report:

0 – 29%	71% – 100%
Normal Range	Impaired
No Immediate Action Required	Driving Cessation – recommend to stop driving

Note: DCAT scores between 30 to 70% are considered ‘inconclusive’. Drivers who score in the inconclusive range will undergo a DORE assessment.

DORE  

The DORE scoring is based on the type and severity of driving errors the driver makes:

Within normal range	Upper end of normal	Significant errors
Normal	Borderline normal	Impaired
No Immediate Action Required	Re-assessment recommended (6 months to 1 year)	Driving Cessation – recommend to stop driving

If a driver’s score falls within the ‘impaired’ range the OSMV will send a letter to the driver informing them that that their driver’s licence has been revoked. This can take four to six weeks.

If the driver’s DCAT or DORE score falls within the ‘normal’ or ‘borderline normal’ range the driver will not receive any communication from the OSMV. The OSMV only informs drivers of a change in their licence status.  To confirm the OSMV fitness to drive determination drivers can call the OSMV at (250) 387-7747.

Determination

Once the OSMV has received the final results of all additional assessments, all the information is reviewed to determine whether the driver is fit to drive. 

If the OSMV determines the driver is not fit to drive, a letter is sent to the driver letting them know the decision to revoke their driver’s licence. If the OSMV determines that the driver is fit to drive a decision is made whether a reassessment interval is required. For drivers with a progressive cognitive impairment the reassessment interval is one year or earlier if there is a significant change in the driver’s medical status. When a driver is found fit to drive no communication is sent to the driver as OSMV only does this when there is a change in a person’s driver licence status. The driver can obtain the results from their physician or by phoning the OSMV at (250)-387-7747

 Reconsideration

An individual can ask the OSMV to review a driver fitness determination. During the reconsideration the OSMV may request additional assessments. Once any new information is received the OSMV will decide whether the original driver fitness determination was correct or whether a different determination is required.

 In some circumstances, a request for review will trigger a new driver fitness determination, based on new assessment results, rather than a reconsideration of a previous determination. This will occur if an individual:

• Submits new information indicating a change in their medical condition or functional ability to drive
• Asks for a review of a determination that is based on assessments that are more than one year old.

Online Resources

Following are links to more detailed information on the determination of driver fitness in BC and the assessments involved:

Driver Fitness BC:
www.driverfitnessbc.com

DriveABLE:
www.driveable.com

SIMARD MD: 
www.mard.ualberta.ca/Home/SIMARD/index.cfm

2010 BC Guide in Determining Fitness to Drive:

Full document:
http://www.pssg.gov.bc.ca/osmv/publications/docs/2010-guide-in-determining-fitness-to-drive.pdf

Searchable document:
http://www.driverfitnessbc.com/kb/

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