Driving Licence Assessment Panel

Speakers

• Dr Satish KarunakaranConsultant Psychiatrist• Dr Yong Mong Tan Consultant Endocrinologist• Dr Craig Costello Consultant Neurologist• Dr Dharmesh Anand Consultant Cardiologist

Driving in Neurology• Dr Craig Costello• MBBS FRACP

• North Queensland Neurology

Driving

• Complex multifaceted highly skilled task• Encompasses all parts neurological system• Temporary intermittent or chronic conditions• Personal and public safety (risk)• Balance of ones privilege to drive

• Rights and responsibilities

Temporary

• TIA / Stroke with resolution of deficit• Cause orientated• Time for preventative medications to have effect• Altered consciousness rare• Vision is the trap

Progressive• Dementia• Parkinson's and similar syndromes• Peripheral neuropathy (often stable)• Transitional • Mindful of symptoms that cause concern

Epilepsy

• Comprehensive but gaps in guidelines• Straightforward• Complex - neurologists lose sleep over• Explanation and reassurance• Further opinion

• Work together• GP / Specialist / Relatives

• Practical driving assessment• No decision maker QT (conflict)

• Syncope

Diabetes and Driving

Case presentation• Male 55y, holds commercial drivers R, MC, UD x 30 yrs• Type 1 diabetes since 1976, suffered 2 episodes of hypoglycemia

requiring ambulance attendance. ED advised no driving till assessed by an endocrinologist. Could not afford without licence.

• Medications: Humalog 4-4-6-6 with meals, Levemir 12-16 simvastatin Home glucose mostly 5-8 at different times, a few <4 post BF and

afternoon. Qs we must ask?• Examination was essentially normal- what should we examine

for? • Biochem: HbA1c 6.7%, others normal

Assessing people with diabetes for drivers’licence

• Remember it has significant medico-legal implications- do it professionally

• Major areas of concern are hypoglycemia, hypoglycemia unawareness , diabetes complications and related areas of CVD, OSA

• In my practice, at booking I require patients to have: 1. a current eye review, preferably filled in Eye Section 2. provide at least 3 weeks home glucose readings 3. pre warned may not pass the assessment• consider use of 3 month provisional approval pending further

review to improve compliance, assist hardship and defuse anger.

Heart and DrivingDr. Dharmesh Anand MD DNB FRACP FCSANZ

Consultant CardiologistTTH & Mater Hospital

• 55 year truck driver

• Clearance to drive (Conditional Licence)

• BG: – NSTEMI 2007; DES in LAD,

POBA Diagonal in Brisbane; Minor disease in RCA, LCX

– Normal LV systolic function– 2 EST negative since– Smoker– Hypertension– Hypercholesterolemia– Obesity– Nil symptoms

Conditional licence with annual review(PCI/CABG/Angina/ Known CAD, HF, Heart Transplant, HCM)

• there is a satisfactory response to treatment; and

• there is an exercise tolerance of ≥ 90% of the age/sex predicted exercise capacity according to the Bruce protocol (or equivalent exercise test protocol);

and

• there is no evidence of severe ischaemia, i.e. less than 2 mm ST segment depression on an exercise ECG or a reversible regional wall abnormality on an exercise stress echocardiogram or absence of a large defect on a stress perfusion scan;

and

• there is an ejection fraction of 40% or over; and

• there are minimal symptoms relevant to driving (chest pain, palpitations, breathlessness)

What Next ?

• Exercise Stress Test• Exercise Stress Echo• Dobutamine Stress Echo• CT Coronary angiogram• Coronary Angiogram• No testing• Specialist Cardiologist

Referral

MPS

• 11 minutes on the Bruce protocol reaching a peak heart rate of 148 bpm which was 80% of maximum predicted heart rate.

• There were no symptoms. • The ejection fraction was

64%. • There was equivocal evidence

of small reversible ischaemia in the RCA territory.

June 2012

• Anterior NSTEMI with dynamic anterolateral ST depression

• Emergent coronary angiography revealed proximal occlusion LAD instent, treated 2X DES in LAD (P) & (M).

• RCA has proximal to mid long stenosis 70-80% at most in moderate size vessel

• LVEF 30%• Occipital CVA (Homonymous hemianopia); AF

July 2012 : Presyncope

• Most difficult and needs Cardiologist review (Holter ECG, Echo, Function testing, EP studies)

• Cardiac arrhythmias (4 wk-3 mo) , Vasovagal syncope (24 hrs for private vehicle) to are the extreme ends of the spectrum

• Blackouts of unknown aetiology : Non-driving periods (6 mo for private to 5 yrs for commercial vehicles)

Cardiology Review

• No driving for 3 months• Holter ECG; Negative• ESE : LVEF 45%,

Negative, Exercised for 11 mins

• Stopped smoking• OK from cardiology

SUMMARY• NTC guidelines are comprehensive and detailed in

most cases (MI, CABG, PCI etc.)• Non-Driving periods have to be clearly documented

• For conditional licence– Functional testing preferred over coronary imaging– Exercise Stress Echo to be preferred – Careful of cumulative radiation dosage before ordering MPS

• Cardiologist review in complicated cases– Blackout of unknown aetiology– Suspected cardiac arrhythmias– Hypertrophic cardiomyopathy– Adult congenital heart disease– Cardiac defibrillator– Aortic aneurysm