Week 14 Flashcards
What is the common thread in all community mobility interventions?
Focus on facilitating participation
IADL that includes walking, bicycling, using transportation like buses and taxis, driving
Community mobility. Addressed in variety of practice settings in diff. ways
Where to most seniors live?
In suburbs or rural areas where public transportation may not be readily available or easily get them where they want to go
Where do most seniors plan to retire?
In suburbs where they have lived–not great public transportation
How do seniors prefer to get around?
Personal automobile is preferred choice for senior drivers and non-drivers. May have reservations about trying new ways
Why is driving so important for many OA?
- Outward sign of adulthood
- Extension of one’s personality and taste
- Freedom to make decisions where and when to go
- Enabler of participation in valued activities
- Sign of continued competence
How may not being able to drive anymore affect an OA?
- Loss of privilege threatens role as respected person
- May feel no longer competent of lose ability to drive
How many driving cessation result in mental health issues?
- Older adults used to freedom and flexibility of driving
- So driving cessation can result in MH issues e.g., depression, reduced life satisfaction, isolation, loneliness
T/F: Number of accidents involving older adult drivers increases as age increases
False. Number of accidents involving OA drivers decreases as age increases.
-OA have a tendency to drive when conditions are safest
T/F: OA have lowest rate of seat belt use and highest incidence of impaired driving of any age group
False. OA have the HIGHEST rate of seat belt use and LOWEST incidence of impaired driving of any age group
-Driving is impacted by…
- Changes in physical and medical abilities (often caused by medical conditions more prevalent in aging
- Physical frailty
- Self-regulation (or lack of)
Why has there been an increased interest in driving with OA?
- Aging population is increasing
- More OA are driving
Why is driving risky for OA?
B/c of physical frailty
Why are OTs good for addressing driving?
- Ethically obligated to address driving
- Focus is on facilitating participation in meaningful activities
- We know about medical diagnoses, disabilities, aging process, medication interactions and implication of these things to driving
- Trained to assess physical fxn, vision, cognition
- Skilled in task aanalysis
Difference between how generalist OT and driving specialist OT approaches driving in OA
Generalist: determines whether there is a need for specialist to address driving specifically
Specialist: determines whether person is medically fit to drive
All of which of the following factors affect driving? A. Medications B. Vision C. Cognition D. Age E. Physical Function
D. Age is not a factor!
90% of what we take in when driving is via…
Vision!
Which of the following except which condition can lead to visual problems that may interfere with driving? A. Cataracts B. Age Related Macular Degeneration C. Glaucoma D. Diabetic Retinopathy E. Stroke
All of them!
Why is vision important when driving?
- Most of what we take in during driving is through vision
- Driving occurs in a visual environment
- What is seen changes as vehicle moves
- Requires central and peripheral vision
- Performed under changing light conditions
What is the most common vision screening tool done nationwide?
Visual Acuity
What often causes changes in visual acuity besides diseases?
Aging
T/F: Visual acuity isn’t related to crash risk
True
T/F: Standards for visual acuity vary widely nationwide.
True. Most states have 20/40 screening standards. Less than 20/30 may have trouble reading signage
How can loss of visual fields (decreases with age) affect driving?
- Driver may not see signs, people stepping off curb, or other vehicles
- Driver may not be aware of problem b/c loss occurs gradually
Deficits in what are common with cataracts?
Contrast sensitivity
Capacity to distinguish between objects of similar color
Contrast sensitivity
T/F: Deficits in contrast sensitivity are not a valid predictor of crash rask
False. Deficits in contrast sensitivity have been found to be a valid predictor of crash risk, although not tested at the DMV
Why may deficits in contrast sensitivity be problematic when driving?
- Affects distance judgment (tailgaiting, hitting curb)
- May not see faded lane markers, pedestrians in dark clothing at night
How does dark affect one’s eyes?
-Pupils get smaller and don’t dilate as much in dark conditions, eye muscles less elastic
Why may deficits in light/dark adaptation be problematic for OA driving?
- Harder to resist glare and see reflective markings
- May have trouble with headlights of oncoming cards
- More time needed to adjust to abrupt light changes
T/F: Deficits in color vision doesn’t seem to be related to crash risk
True
-Can compensate through luminescence, position, pattern e.g., stoplight
T/F: Deficiencies in color vision are higher in males and seniors
True, however, only slightly higher in seniors
T/F: Ability to see a moving object and determine distance between objects decreases with age
True. Seniors inaccurately estimate approaching vehicle speed
T/F: seniors tend to use speed rather than distance to gauge when it’s safe to proceed
False. Seniors tend to use distance rather than speed to gauge when it’s safe to proceed
What may account for over representation in crashes when turning left across traffic, changing and merging lanes in seniors?
-Seniors tendency to use distance rather than speed to gauge when it’s safe to proceed
Area that can be seen and cognitively processed and interpreted
Useful field of view
Why does useful field of vision decrease with age?
With age, becomes harder to process info quickly and track multiple items
Decrease in useful field of view often causes what condition in OA?
tunnel vision–visual attn restricted to area directly in front of driver
T/F: Decreased Useful field of view strongly increases car crash risk
True! Reduction of UFOV greater than 40% increases risk of being in a car crash by 16x
Conditions including stroke, parkinson’s, dementia may impact which abilities related to safe driving?
Cognitive abilities
Determining which relevant aspects to attend to (road sign vs advertising billboard)
Selective Attn
Maintaining for extended periods (long trips)
Sustained Attn
Switching between different stimuli (looking from side mirror to front traffic when changing lanes)
Alternating Attn
Attend simultaneously to two or more tasks (control vehicle while talking, listening to radio)
Divided Attn
Failure to respond to stimuli on side opposite a brain lesion (inaccurate lane positioning and/or inability to attend to a vehicle or pedestrian on affected side)
Lateralized deficit (neglect)
Memory with limited storage for a limited time
Short Term
Active manipulation of what is in STM
Working memory
Memory expressed in the form of actual performance
Procedural memory
T/F: Working memory remains intact in old age, but procedural memory declines
False. Working memory DECLINES with old age, but procedural memory REMAINS INTACT
Umbrella term for cognitive ability to coordinate subprocesses to achieve a goal
Executive Functions
T/F: The older a person gets, the more pronounced deficits in executive functions get
True
Difficulty getting foot moving between gas and break is an example of a problem with…
Initiation (Executive function)
Difficulty getting foot moving between gas and break is an example of a problem with which executive function?
Initiation
Figuring out how to exit the parking lot is an example of which executive function?
Problem solving
Anticipating the need to brake when traffic is stopped is an example of which executive function?
Planning, sequencing, anticipating
Difficulty thinking of routine options if there is a detour is an example of a problem with this executive function…
Flexibility in thinking
Merging into traffic without looking is an example if a problem in what executive function?
Impulsivity
Older adult crashes are often related to what deficits?
- Related to inattention and slowed visual processing speed (vs. inexperience and risk taking)
- The older the person, the more these issues are problematic
Where do OA crushes often occur?
- Often multiple vehicle events at intersections and involve left hand turns, which have high cognitive and perceptual demands
- Usually caused by OA’s failure to heed signs and grant right of way
- Older the adult, the more these issues are problematic
Why is Visual perception/processing/spatial important for driving?
Needed to organize visual stimuli into recognizable forms and to know where they exist in space
T/F: Visual perception remains stable with age, but visual processing skills appear to decline
True
Judging distance/speed/parking is an example of which visual skill
Spatial relations
Following directions requires which visual skill
R/L discrimination
Ability to orient oneself in one’s surroundings
Topographical orientation
Hard to distinguish objects from background is an example of a problem with…
Figure Ground
With deficits in this may not recognize objects/people if partially occluded
Visual closure
What physical functioning skills are important when driving?
Need ROM, strength, proprioception for driving tasks
Which physical deficits associated with normal aging make driving difficult?
- Reduced muscle mass and osteoporosis from aging contributes to physical frailty and increases death/injury risk
- Old age diseases can cause neuropathies (diabetes), limit range and cause pain (arthritis)
How can diseases contribute to pain when driving?
Old age diseases can cause neuropathies (diabetes), limit range and cause pain (arthritis)
T/F: Many OA must cease driving because of physical limitations
False. Only a small % of people must cease driving purely because of physical limitations
T/F: A history of falls is associated with an increased risk for motor vehicle crashes
True. Poor performance on the Rapid Pace Walk has been associated with at-fault vehicle crashes
How can meds affect driving?
- Both Rx and over the counter meds cause side effects like drowsiness, dizziness, sleepiness
- Not taking meds can also cause problems
- Side effects and interactions increase with # meds taken and many people over 65 take 5 or more meds daily
- Seniors more susceptible to side effects b/c number meds taking
- Using certain meds or many meds increases chance of being in crash
Which of the following would a generalist not do when working with an OA on driving mobility?
- Ask questions when establishing occupational profile e.g., do you use eat belt, have you had any accidents in past year, are others concerned regarding your driving
- Screen medical records for red flags e.g., medications used, history of falls, medical/chronic conditions e.g., vision, dementia
- Observe difficulties in performing ADLs and IADLs e.g., sequencing, emory, decision making, vision, reach, balance and strength
- Administer pre-drive screen to identify need for referral
- Use special assessment to determine fitness to drive
- Understanding licensing/reporting laws in state
- Treat performance skills underlying driving e.g., memory, attn, strength, ROM, coordination
- Improve driver/vehicle fit
- Initiate conversation about driving retirement
- Refer to driving rehab specialist
- Establish alternative transportation plan
A generalist would not use a special assessment to determine fit to drive. They may use a pre-driving screen if risk factors have been identified during the occupational history, chart review or physical and ADL assessment, but purpose is to identify need for referral to a DRS, NOT for determining fitness to drive
What may be some red flags in a medical record that may bring OT to look at driving more?
- If there has been an acute event
- Medications used
- Medical or chronic conditions
- History of falls
Why are special driving assessments not necessary to identify potential risks regarding physical and ADLs?
-Generalists already conduct tests of visual abilities, visual perception, cognitive skill, and sensorimotor abilities
When observing performance in ADLs and IADLs, what should you be on the look out for when thinking about driving difficulties?
- Sequencing
- Memory
- Decision making
- Unsafe practices
- Observe use of vision
- Problems with reach, strength, balance
When should you administer a pre-driving screen?
If risk factors have been identified in occupational history, chart review, or physical and ADL assessment, a pre-driving screen that is more targeted may be conducted
What is the purpose of a pre-driving screen?
To identify the need for a referral to a driving rehab specialist, not for determining fit to drive
How can we as generalist address deficits in driving skills?
Treat performance skills underlying driving e.g., activity and exercise programs that address deficits in strength, range of motion, and coordination OR activities and games that challenge memory, attn, decision making
When should we initiate a conversation about driving retirement?
- OTs should talk about driving retirement before the OA loses their privilege to drive
- Planning ahead will ensure that OA able to age in place
Who more often outlives driving retirement, women or men?
We all tend to outlive driving retirement, but women more than men
What should a conversation about driving retirement look like?
- Begin with, “have you ever thought about how you would get around if you couldn’t drive?”
- “Who would you chose to tell if you had to discontinue driving?”
Who do OA often prefer to first tell about discontinuing driving?
Physician
When would you refer a pt to a driving rehab specialist ?
When there is a question about medical fitness to drive
If driving is not possible, how can we help client with transportation?
If driving not possible, help client examine his/her most feasible transportation option e.g., taxi, uber, buss
-But make sure transportation alternative is match for client’s physical and cognitive skills
When examining alternative transportation options with pt, what must you consider?
Must make sure transportation alternative is match for client’s physical and cognitive skills (same problems that interfere with driving could get in way of using alternative transportation e.g., vision)
How do you evaluate fit of transportation option to pt?
Eligibility:
-Requirements? evaluation needed? Wheelchair accessible? Can family member escort?
Affordable:
-Cost of service? Discounts? Membership fee? Will insurance help?
Accessible: Service area? What time operates? Door to door services? Reservation needed? When rides provided? Assistance with packages? Wheelchair accessible? Rides provided to social and medical appointments?
According to Clark, when driving is no longer a safe option, limited to the community can lead to…
- Depression
- Isolation
- Decreased engagement in meaningful occupations
- Decreased ability to perform self-care
- Diminished wellness
According to Clark, what are some important considerations for older drivers?
- Physical changes e.g., arm strength, visual acuity
- Cognitive status e.g., effects of medication, alertness, divided attn
- Driving right care e.g., ease of entry, seat height, automatic transmission
- Eliminating distractions e.g., radio, cell phone, conversations
According to clark, what are two main advantages for using public transportation?
- Can create group cohesion b/c participants share and learn about methods and resources available to them–shared adventures create bonds
- Can empower group as they witness their ability to conquer unfamiliar territory
According to Clark, how should therapists discuss community mobility?
As it relates to occupation. For example, challenge pt to consider how transportation affects access to occupations and vice versa
