Post on 11-Mar-2020
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Delirium, dementia and
can I drive Doc?
31st August 2019 Dr Joel Tate
Geriatrician, Armadale Health Service
Clinical Lead Choosing Wisely
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Case 1: Assessment of Cognition
1. What factors may be contributing to her
presenting complaint?
2. Is it worthwhile assessing her cognition
today, how would you do this?
3. Are any investigations warranted?
4. How would you manage Irene from here?
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
https://www.mocatest.org/
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Case 2: Dementia and driving
1. Does Fred’s new diagnosis of dementia preclude him
from driving?
2. As Fred’s GP are you obliged to report his new
diagnosis to the Department of transport?
3. What approach would you take to bringing up your
concern about his ability to drive?
4. What questions might help you to assess his safety to
drive, particularly considering he is driving to Capel
weekly? and how could this be formally assessed?
5. If Fred does not follow your advice regarding driving,
are you legally allowed to break patient doctor
confidentiality by informing the Department of
Transport?
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Occupational Therapy Driving assessment
Off Road Assessment
• Nil significant physical issues
• Cognitive limitations: – Motor planning
– Attention
– Memory
– Insight
– Speed of processing
On Road Assessment
Error’s in:
• speed modulation
• timely gap selection
• decision making
Recommendation: Suspension of his licence (Class C, HC & R)
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Driving and Dementia
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Austroads - Dementia
A diagnosis of dementia is associated with
a moderately high risk of collision
compared with matched controls.
However, the evidence does not suggest
that all people with a diagnosis of dementia
should have their licences revoked or
restricted.
Throughout all stages of their condition,
drivers require regular monitoring
regarding progression of the disease.
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
How dementia affects driving
errors with navigation, including forgetting routes and getting lost in
familiar surroundings
limited concentration or ‘gaps’ in attention, such as failing to see or
respond to ‘stop’ signs
errors in judgement, including misjudging the distance between
cars and misjudging the speed of other cars
confusion when making choices, for example, difficulty choosing
between the accelerator or brake pedals in stressful situations
poor decision making or problem solving, including failure to give
way appropriately at intersections and inappropriate stopping in
traffic
poor insight and denial of deficits
slowed reaction time, including failure to respond in a timely fashion
to instructions from passengers
Poor hand eye co-ordination
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Collateral history Relatives may be a useful source of information
regarding overall coping and driving skills. They
may comment about the occurrence of minor
crashes, or whether they are happy to be driven
by the person with dementia.
Where the person is judged to be an imminent
threat to safety, all states and territories (except
NT) provide indemnity for health professionals and
other members of the public who notify the driver
licensing authority of at-risk drivers; the driver
licensing authority will then take the necessary
steps
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Dementia diagnosis and driving
Not fit to hold an unconditional licence
A conditional licence may be considered by the
driver licensing authority subject to at least annual
review, taking into account: • the nature of the driving task
• information provided by the treating doctor regarding the level
of impairment of visuospatial perception, insight, judgement,
attention, comprehension, reaction time or memory and the
likely impact on driving ability
• the results of a practical driver assessment if required
• the opinion of an appropriate specialist may also be considered
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Role of technology:
off road pre-testing
Pearson Clinical
Assessment – tablet
based
https://youtu.be/79E
sZE3LlvI
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Case 3: Acute Confusional State
1. Could this be natural progression of his
Alzheimer’s Disease?
2. Are there any investigations you would
like to arrange?
3. What is the significance of positive
leucocytes on urinalysis for Cecil?
4. Can this patient be managed safely in the
community? What factors might prompt
you to consider referring to ED/Geriatric
Services.
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Common:
13.9% women, 2.6% men,
23% inpatients. NEJM, Wise M. 2015
Sterile pyuria
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Therapeutic guidelines
Initial assessment and
management of aged-care
facility residents with
suspected urinary tract
infection
Do not investigate or treat cloudy
or malodorous urine in aged-care
facility residents who do not have
other symptoms or signs of UTI
Augmentin now part of first line treatment
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
More on the Dipstick
Scottish Intercollegiate Guidelines Network 2012
Healthy people, amazing care. - Koorda moort, moorditj kwabadak.
Updates
Proof of cure no longer recommended (Therapeutic Guidelines 2019)
No role for dipstick in elderly hospitalised
Dipstick screening not indicated (unless pregnant
or invasive urological procedure)
Cloudy, dark or
malodourous urine
not a reliable indicator
of UTI