Issues around ability to drive
Can the ACL be used to help determine a cut-off point for safe driving?
Question:
I am an OT working in a community older person’s mental health service and recently completed the 2-day introductory training. We often receive referrals from psychiatrists and care coordinators in the team to complete functional cognition assessments, and in particular in the context of assessing a person’s suitability to drive.
I was wondering what your thoughts are in regards to using the ACLS as part of a cognitive assessment for driving, and if there are specific guidelines around this? My understanding is if the person scores lower than 5.0, then this may indicate some difficulty and safety concerns with driving. Is there a specific score cut off for suitability for driving, or should the ACLS just be used more as a screen and in conjunction with other assessments, to then use all assessment results to inform a clinical opinion?
In addition to the ACLs, would you recommend any other specific cognitive assessments, i.e., an activity analysis/observation of a client completing a functional task?
Response:
There are no research studies about the Allen Cognitive Levels and driving. Catherine Earhart has done an activity analysis that suggests what difficulties people are likely to have with driving, based on their assessed level of function. The people managing the model suggest that we should never use a specific Level.Mode as a cut-off point for any functional ability. See the Manual for the ACLS 2nd Ed. This is because procedural memory, will-do and may-do all influence our functional abilities.
Claudia suggested that at Level.Mode 5.6, people perform most driving tasks well. The major risk is in long-term planning. For example, people at 5.6 are at higher risk if they are travelling complex journeys such as crossing the Nullarbor. We stop scanning the environment around Level,Mode 4.4 and I am always very concerned about people who are driving at 4.4 and below, though this is rare. Once we get to Level.Mode 4.0, we lose the ability to coordinate the physical task of driving and our failure is catastrophic to the point of other people preventing us from driving or we find it so difficult we make excuses not to get behind the wheel. As an OT, it is usually easy to demonstrate driving failure in people functioning at 4.4 and 4.2 such as damage to the car, self-restriction of driving e.g., I only go to the shops and the doctor’.
In Queensland, I see a lot of people who pass a driving test with the Dept of Transport at 5.4 and even 5.2 though a lot of my clients end up on suspended licences at 5.2 or having minor accidents.
My preference is for people at 4.6, 4.8 and 5.0 to have an on-road assessment with a driver OT. I do tell the client that, in my opinion, they are likely to fail the assessment and to discuss with the client and family whether they think it is worth paying the money for the assessment. Often, at 4.6, the OT does not take them on the road after the initial off-road assessments. I find people with scores between 4.6 and 5.0 rarely get an open licence back after their OT assessment. The higher the score the more likely they will be granted a licence. I have had instances where a driver OT has given someone at 4.8 and 5.0 a restricted licence and the client has lost their car or driven off and got lost, parked in the middle of the road to sleep, had an accident etc.
So – to answer your question NO, there is no cut-off point for safe driving. Your suggestion to use the ACLS as a screen and in conjunction with other assessments, then use all assessment results to inform a clinical opinion, is sound.
The following suggestions may help:
In reports, I state “at Level.Mode ______ it may be/is likely that the person is having difficulties with driving (and state them according to Earhart’s activity analysis)”. Present any other evidence you have of driving failure. Include statement about procedural skills, will-do and may-do if relevant. Recommend what you think should happen such as gathering further info, an on-road assessment, driving cessation. Communicate concerns to team/GP etc.
5.4 & 5.6 and above – no need to comment unless you have obtained a history of concerns with driving
5.2 – look for history of driving failure and raise concerns with team. On-road assessment if identified concerns beyond Level,Mode
4.6 – 5.0 – On road assessment particularly if concerns about driving independently exist – need to think about driving safety and do a screening assessment
4.4 and below – strong recommendation person ceases driving – should be easy to get collateral to confirm concerns. Emphasize loss of ability to scan the environment.