Medical Conditions and Driving - NHTSA

[Pages:162]Medical Conditions and Driving:

A Review of the Literature (1960 ? 2000)

Technical Report Documenta tion Page

1. Report No.

DOT HS 809 690

2. Government Accession No.

4. Title and Subtitle

Medical Conditions and Driving: A Review of the Scientific Literature (1960 - 2000)

3. Recipient's Catalog No.

5. Report Date

September 2005

6. Performing Organization Code

7. Author(s)

Bonnie M. Dobbs, Ph.D.

9. Performing Organization Name and Address

Association for the Advancement of Automotive Medicine P. O. Box 4176 Barrington, Illinois 60011-4176

12. Sponsoring Agency Name and Address

U.S. Department of Transportation National Highway Traffic Safety Administration Office of Research and Technology 400 Seventh Street, SW. Washington, DC 20590

8. Performing Organization Report No. 10. Work Unit No. (TRAIS)

11. Contract or Grant No.

DTNH22-94-G-05297

13. Type of Report and Period Covered

14. Sponsoring Agency Code

15. Supplementary Notes

Dr. John Eberhard served as the NHTSA Contracting Officer's Technical Representative for the study. Ms. Elaine (Petrucelli) Wodzin of the Association for the Advancement of Automotive Medicine served as the Project Principal Investigator. Drs. Maria Vegega (NHTSA) and Bonnie Dobbs completed the final report.

16. Abstract:

This report reviews the contribution of medical conditions and functional limitations (e.g., sensory, motor, or cognitive functioning) to motor vehicle crashes. It provides a comprehensive and up-to-date review of the international research literature on the effects of medical and functional conditions on driving performance. The report is divided into 15 sections (Introduction, Vision, Hearing, Cardiovascular Diseases, Cerebrovascular Diseases, Peripheral Vascular Diseases, Diseases of the Nervous System, Respiratory Diseases, Metabolic Diseases, Renal Diseases, Muscuoloskeletal Disabilities, Psychiatric Diseases, Drugs, The Aging Driver, and the Effects of Anesthesia and Surgery). Each section contains a brief overview of the condition/illness; prevalence information; a review of the medical, gerontological, and epidemiological literature relevant to the condition/illness, followed by current fitness to drive guidelines for the condition/illness from Canada and Australia. The Appendix presents preliminary guidelines for physicians to assess medical fitness-to-drive.

The report is a scholarly but practical compendium that can serve as a valuable resource for physicians, rehabilitation practitioners, other allied health care professionals and educators, Department of Motor Vehicle personnel, road and traffic safety personnel, transportation planners, highway safety researchers, and public policymakers. Its value is particularly relevant as the driving population increases in size and age.

17. Key Words

18. Distribution Statement

Medical conditions, functional ability, older driver safety, physician guidelines to driving.

No restrictions. This document is available to the public through the National Technical Information Service, Springfield, VA 22161.

19. Security Classif. (of this report)

20. Security Classif.(of this page)

21. No. of Pages

Unclassified

Unclassified

Form DOT F 1700.7 (8-72)

Repro duction of completed p age autho rized

22. Price

Foreword

This report provides a comprehensive review of past and current research on the effects of medical conditions on driving performance. It is divided into 15 sections (Introduction, Vision, Hearing, Cardiovascular Diseases, Cerebrovascular Diseases, Peripheral Vascular Diseases, Diseases of the Nervous System, Respiratory Diseases, Metabolic Diseases, Renal Diseases, Muscuoloskeletal Disabilities, Psychiatric Diseases, Drugs, The Aging Driver, and The Effects of Anesthesia and Surgery). Each section provides a brief overview of the condition/illness; prevalence information; review of the medical, gerontological, and epidemiological literature relevant to medical conditions and driving; followed by current fitness to drive guidelines from Australia and Canada for the condition/illness. An appendix contains preliminary guidelines developed to assist physicians in determining when patients have medical conditions that can affect fitness-to-drive.

This report is a scholarly but practical compendium that can serve as a valuable resource for physicians, rehabilitation practitioners, other allied health care professionals and educators, Department of Motor Vehicle personnel, road and traffic safety personnel, transportation planners, highway safety researchers, and public policymakers. Its value is particularly relevant as the driving population increases in size and age.

A Review of the Scientific Literature

Acknowledgements

The author is indebted to a number of individuals who made this report possible. Dr. David Carr, Dr. John Eberhard, Dr. Richard Marottoli, Ms. Maureen Malinkowski, Dr. Germaine Odenheimer, Dr. Desmond O'Neill, Dr. Robert Raleigh, and Ms. Elaine (Petrucelli) Wodzin reviewed drafts of the report and contributed to the development of the preliminary guidelines for physicians. Sincere thanks and appreciation are extended to them for their time, effort, and assistance on this project. Appreciation also is extended to the Canadian Medical Association and Austroads for allowing the reproduction of their fitnessto-drive guidelines. Many thanks go to the Association for the Advancement of Automotive Medicine (AAAM) and the National Highway Traffic Safety Administration (NHTSA) for providing funding for this project. Finally, the author recognizes Elaine Wodzin for her support and encouragement during the life of this project.

Bonnie M. Dobbs, Ph.D. University of Alberta Edmonton, Alberta, Canada

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Medical Conditions and Driving: ii

A Review of the Scientific Literature

Table of Contents

Section

Page

Section 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Section 2: Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 2.1 Acuity 2.1a. Static Visual Acuity . . . . . . . . . . . . . . . . .4 2.1b. Dynamic Visual Acuity . . . . . . . . . . . . . .5 2.1c. Low Vision and Telescopic Lens . . . . . .5 2.2 Cataracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 2.3 Color Vision Defects . . . . . . . . . . . . . . . . . . . . . . .6 2.4 Contrast Sensitivity . . . . . . . . . . . . . . . . . . . . . . . .7 2.5 Diabetic Retinopathy . . . . . . . . . . . . . . . . . . . . . . .7 2.6 Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2.7 Loss of Vision in One Eye (Monocular Vision) . .9 2.8 Macular Degeneration . . . . . . . . . . . . . . . . . . . . .9 2.9 Nystagmus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.10 Night Myopia . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.11 Post-Eye Surgery . . . . . . . . . . . . . . . . . . . . . . . . .11 2.12 Visual Field Defects . . . . . . . . . . . . . . . . . . . . . . .11

Section 3: Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Section 4: Cardiovascular Diseases . . . . . . . . . . . . . . . .22 4.1 Coronary Artery/Heart Disease . . . . . . . . . . . .22 4.2 Disturbances of Cardiac Rhythm . . . . . . . . . . . 25 4.2a. Ventricular Arrhythmias . . . . . . . . . . . .25 4.2b. Atrial Fibrillation/Flutter . . . . . . . . . . .26 4.2c. Heart Block . . . . . . . . . . . . . . . . . . . . . . .27 4.2d. Pacemakers . . . . . . . . . . . . . . . . . . . . . . .27 4.2e. Implantable Cardioverter/ Defibrillator Devices (ICDs) . . . . . . . . .27 4.3 Congestive Heart Failure . . . . . . . . . . . . . . . . . .30 4.4 Abnormal Blood Pressure . . . . . . . . . . . . . . . . . .31 4.4a. Hypertension . . . . . . . . . . . . . . . . . . . . .31 4.4b. Hypotension . . . . . . . . . . . . . . . . . . . . . .32

Section 5: Cerebrovascular Diseases . . . . . . . . . . . . . . .39 5.1 Transient Ischemic Attacks . . . . . . . . . . . . . . . . .39 5.2 Cerebrovascular Accidents . . . . . . . . . . . . . . . . .39

Section 6: Peripheral Vascular Diseases . . . . . . . . . . . .56

Section 7: Diseases of the Nervous System . . . . . . . . .58 7.1 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 7.2 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 7.3 Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .62 7.3a. Narcolepsy . . . . . . . . . . . . . . . . . . . . . . .62 7.3b. Sleep Apnea . . . . . . . . . . . . . . . . . . . . . .64

Section 8: Respiratory Diseases . . . . . . . . . . . . . . . . . . .75 8.1 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 8.2 Chronic Obstructive Pulmonary Disease . . . . .75 8.3 Other Pulmonary Conditions . . . . . . . . . . . . . . .77

Section 9: Metabolic Diseases . . . . . . . . . . . . . . . . . . . .80 9.1 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . .80 9.2 Thyroid Disease . . . . . . . . . . . . . . . . . . . . . . . . . .88 9.2a. Hyperthyroidism . . . . . . . . . . . . . . . . . .88 9.2b. Hypothyroidism . . . . . . . . . . . . . . . . . . .88

Section 10: Renal Diseases . . . . . . . . . . . . . . . . . . . . . . . .93 10.1 Chronic Renal Failure . . . . . . . . . . . . . . . . . . . .93 10.2 End Stage Renal Disease . . . . . . . . . . . . . . . . . .93

Section 11: Musculoskeletal Disabilities . . . . . . . . . . . .96

Section 12: Psychiatric Diseases . . . . . . . . . . . . . . . . . .102

Section 13: Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 13.1 Antidepressants . . . . . . . . . . . . . . . . . . . . . . . .109 13.2 Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . .111 13.3 Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . .112

Section 14: The Aging Driver . . . . . . . . . . . . . . . . . . . . .115 14.1 Sensory Decline . . . . . . . . . . . . . . . . . . . . . . . .115 14.2 Motor Decline . . . . . . . . . . . . . . . . . . . . . . . . . .116 14.3 Cognitive Decline . . . . . . . . . . . . . . . . . . . . . .116 14.4 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117

Section 15: The Effects of Anesthesia and Surgery . .126 15.1 General Anesthesia . . . . . . . . . . . . . . . . . . . . .126 15.2 Outpatient Surgery . . . . . . . . . . . . . . . . . . . . .126 15.3 Major Surgery . . . . . . . . . . . . . . . . . . . . . . . . . .128

Appendix A: Preliminary Guidelines for Physicians: Assessing Medical Fitness to Drive (June 2000) . . . . . . . . . . .130

Section 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . .131

Section 2: Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132

Section 3: Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134

Section 4: Cardiovascular Diseases . . . . . . . . . . . . . . .135

Section 5: Cerebrovascular Diseases . . . . . . . . . . . . . .138

Section 6: Peripheral Vascular Diseases . . . . . . . . . . .139

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Medical Conditions and Driving:

Section 7: Diseases of the Nervous System . . . . . . . . . . . 140

Section 8: Respiratory Diseases . . . . . . . . . . . . . . . . . . . . 142 Section 9: Metabolic Diseases . . . . . . . . . . . . . . . . . . .143

Section 10: Renal Diseases . . . . . . . . . . . . . . . . . . . . . . .144

Section 11: Musculoskeletal Disabilities . . . . . . . . . . .145

Section 12: Psychiatric Diseases . . . . . . . . . . . . . . . . . .147

Section 13: Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148

Section 14: The Aging Driver . . . . . . . . . . . . . . . . . . . .150 Section 15: The Effects of Anesthesia and Surgery . .151

Section 16: Conditions under Investigation . . . . . . . .151

Section 17: Miscellaneous Conditions . . . . . . . . . . . . .151

List of Tables

Page

Table 1 Guidelines for Visual Conditions/Diseases .12

Table 2 Estimate of the Prevalence of Hearing Impairments by Age Group . . . . . . . . . . . . . .19

Table 3 Risk of Injury from Motor Vehicle Crashes Associated with Impaired Hearing . . . . . . . .19

Table 4 Guidelines for Hearing . . . . . . . . . . . . . . . . . . .20

Table 5 Sudden Natural Death at the Wheel: Causes of Death . . . . . . . . . . . . . . . . . . . . . . . .23

Table 6 Recurrence of Ventricular Arrhythmias in Individuals with Implantable Cardioverter Defibrillator Devices (ICDs) . . . . . . . . . . . . . .28

Table 7

Percentage of Patients Experiencing Presyncope or LOC Prior to Receiving an ICD Shock for Recurrent Ventricular Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Table 8 Blood Pressure Classification Criteria for Individuals 18 Years of Age and Older . . . .31

Table 9 Guidelines for Cardiovascular Diseases . . . .32

Table 10 Summary of Transient Ischemic Attack Symptoms by Vascular Supply . . . . . . . . . . . .39

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Table 11 Summary of Studies Assessing Fitness-toDrive in Individuals Post-CVA . . . . . . . . . . .42

Table 12 Summary of Studies Assessing the Psychometric Properties of Fitness-to-Drive Evaluations in Patients Suffering from Cerebrovascular Accidents . . . . . . . . . . . . . . .47

Table 13 Guidelines for Cerebrovascular Diseases . . .52

Table 14 Guidelines for Peripheral Vascular Diseases . 56

Table 15 Classification System of Epileptic Seizures as Advanced by the Commission on Classification and Terminology of the International League Against Epilepsy . . . .59

Table 16 Summary of Studies Examining the Risk of Crash for Individuals With Epilepsy . . . . . .60

Table 17 Summary of Studies Examining the Relationship Between Crashes and Narcolepsy, and Simulator Performance and Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . .63

Table 18 Summary of Studies Examining the Crash Rates of Drivers with Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . .65

Table 19 Summary of Studies Examining Differences in Performance on Simulators and Other Performance Measures Between Individuals with Sleep Apnea and Controls . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Table 20 Summary of Studies Examining the Relationship Between Measures of Disease Severity and Crashes and/ or Simulator Measures . . . . . . . . . . . . . . . . . .68

Table 21 Guidelines for Diseases of the Nervous System . . . . . . . . . . . . . . . . . . . . . . . .69

Table 22 Ratings of Impairment in Individuals With Respiratory Disorders . . . . . . . . . . . . . .77

Table 23 Guidelines for Respiratory Diseases . . . . . . .78

Table 24 Summary of Studies on the Risk of Crash for Drivers With Diabetes Mellitus . . . . . . . .81

Table 25 Summary of Studies on the Incidence of

Severe Hypoglycemic Reactions in Individuals With Diabetes Mellitus . . . . . . .84

Table 26 Summary of Studies Examining Predictors of Severe Hypoglycemic Reactions in Individuals With Diabetes Mellitus . . . . . . .86

Table 27 Summary of Studies Investigating the Frequency of Hypoglycemic Unawareness . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Table 28 Summary of Studies Examining Possible Predictors of Hypoglycemic Unawareness . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

Table 29 Guidelines for Metabolic Diseases . . . . . . . . . .89

Table 30 Guidelines for Renal Diseases . . . . . . . . . . . . .94

Table 31 Guidelines for Musculoskeletal Diseases . . . .99

Table 32 Summary of the Research Literature on Psychiatric Conditions and Motor Vehicle Crashes . . . . . . . . . . . . . . . . . . . . . . . . .103

Table 33 Guidelines for Psychiatric Diseases . . . . . . . .106

Table 34 Guidelines for Drugs . . . . . . . . . . . . . . . . . . . .110

A Review of the Scientific Literature

Table 35 Summary of the Research Literature on Dementia and Driving . . . . . . . . . . . . . . . . . . .119

Table 36 Guidelines for the Aging Driver . . . . . . . . . .121

Table 37 Summary of Studies Examining Differences in Cognitive Impairment Between Patients Receiving Either a General or Regional Anesthetic . . . . . . . . . . . . . . . . . . . . .126

Table 38 Summary of Studies of Effects of General Anesthesia on Cognitive Functioning Post-Operatively . . . . . . . . . . . . . . . . . . . . . . . .127

Table 39 Guidelines for Anesthesia and Surgery . . . . .129

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . .Page

Figure 1 Estimated Prevalence of Coronary Artery Disease by Age and Sex in the United States, 1988-1994 . . . . . . . . . . . . . . . . . . .22

Figure 2 Prevalence of CHF by Age, National Health, & Nutritional Examination Survey, 1988-1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

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Medical Conditions and Driving: Figure 3 Leading Causes of Disability Among Persons

Ages 15 years and Older, United States, 1991-1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96

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