JOURNAL TRANSCRIPT
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Driving Under the Influence of Dementia What to Do and NOT Do About It If You Want to Help Well
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Driving is typically viewed by most adults as a civil right and symbol of adulthood and autonomy
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What is Behind that Sense of Privilege? - We develop the skill and receive the license during the transition of kid to teenagers - We maintain our license by checking in and screened episodically: - Getting eyesight checked - Ability to recognize signage noted - Ability to verbally indicate a knowledge of the rules - Not having had a major neurological event or seizure for a period of time - Occasionally retesting on the road if medically indicated - Not DUI © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
So what are we missing?
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What Does the PLwD Believe About Abilities? - Aware of changes making driving risky or different
- Unaware of changes making driving risky or different - Existing driving habits and routines are matched to needs - Existing habits and routines are not matching all needs for transportation © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What do Family/Friends Believe About Abilities? - Aware of changes making driving risky or different
- Unaware of changes making driving risky or different - Existing driving habits and routines are matched to needs - Existing habits and routines are not matching all needs for transportation
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What do Medical Advisors (and others) Believe About Abilities?
- Aware of changes making driving risky or different - Unaware of changes making driving risky or different - Existing driving habits and routines are matched to needs - Existing habits and routines are not making all needs for transportation © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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What Alternatives Exist? - What options for transportation are available? - What skills are needed to access and use the alternatives? - How do these services impact selfdirected lifestyle, long-term roles and responsibilities, safety, and income? - How acceptable/unacceptable are these alternatives to the PLwD? © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Who is a Friend and Who is an Authority Figure for the PLwD? - Change will be difficult, if driving plays a major role in daily life - Support will be needed - Guidelines will probably require monitoring and boundaries that are deemed reasonable and based on some norms or value-based system
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Brain Changes: Dementia: • •
Type(s) Awareness
Delirium Note GEM Level(s): • • • • •
Changed abilities Retained abilities Variability Self-awareness Onset & duration
•
Health Conditions & Physical Fitness:
• •
• • •
Life story – • history Personality traits Preferences – • likes/dislikes • Key values • Joys & Traumas • Roles – • Watch-Talk-Do
The Environment:
(intimate, personal, public)
•
Sensations
(see, hear, feel, smell, taste)
•
Surfaces
(sit, stand, postrate, work)
•
Social
(people, activity, role, expectations)
• • •
Care Partner & Others Around • • • • • • •
History - background Awareness Knowledge Skills Competence Relationship(s) Agenda(s)
Fuel & Fluids Meds & Supplements Emotional & Psychological Condition Sensory Systems Function Health Beliefs of Note Recent Changes•
People - US:
Explore the Four Fs: Friendly Familiar Functional Forgiving • Space
Wellness, Health, and Fitness:
The Person: Past & Present
Acute Illnesses
Time: Time Awareness: • • •
where in life time of day passage of time
Four Categories: (balance) • • • •
Productive: gives value Leisure: Fun – playful Wellness & Self Care Restorative: calm – recharge
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Plan Ahead
Head First
How
Introvert
Go with the Flow
Heart First
Why
Extrovert
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How To Do It
Introvert •
Wants ALONE think/feel time
•
Sensitive to space/boundaries
• •
•
Wants to control access to space and belongings
Wants to know how to do something before doing it • •
•
Keeps home/work separate
• •
Wants prep time before doing Tends to internalize & self-rate Gets quiet & retreats when stressed or distressed Wants a sense of control Answers tend to be final
•
Wants PEOPLE time
•
Thinks out LOUD
• • •
Extrovert •
• •
Why To Do It
Wants to explore with others
Asks questions Wants talk time to talk it through & to prep WITH another person
•
Boundaries are flexible
• •
Connection trumps control Seeks others’ approval & opinion Talks more & seeks more intimacy when stressed
•
•
•
Wants to know why something is being done before doing it •
• •
Details tend to be boring
Likes to try it out and see what happens • •
•
Belief in the value is critical
Likes to try variations not just repeat Drill practicing is NOT exciting
Is excited & energized by new learning
Wants it to be FAIR & Equal • •
• •
Wants data to analyze
Seeks to understand the reason behind the behavior
Feelings First •
Wants it to feel OK to all
•
Seeks to find common ground
• •
Monitors opinions/feelings Enjoys being ‘kind’ & helpful
•
Feels case by case is better than a standard rule Seeks to appreciate the emotions behind behavior
• •
•
•
Plan Ahead •
Wants to PLAN ahead & follow the PLAN • •
•
• •
•
Wants a detailed plan to stay on target Becomes anxious with last minute changes
•
Likes final decisions & finishing projects Focus: Looking ahead – what’s next?
•
Works in the moment
Go with the Flow •
Wants harmony in the space Likes when everyone is comfortable with decisions
Uses schedules & lists Aware of time & its passing
Works toward deadlines
Enjoys being right Tends to explore conflict
Likes & wants information •
•
Likes everyone to be judged under one set of rules May see individualization as favoritism
Likes to solve problems • •
Wants the big picture •
Space is to be shared
Logic/Reason First •
Likes specifics & checklists Likes directions to follow
Finds comfort in the familiar & the routine Wants expectations clearly spelled out Likes facts & evidence before doing New learning increases anxiety until it is routine
Likes privacy •
• • •
•
Wants to think it out inside
•
• •
• •
Likes to lift spirits
• •
Limited awareness of the passage of time Flexible with time and plans
Deadlines are suggestions of when to get going or get done Final decisions are difficult Drafts are better – revisit Re-sets priorities based on new info – adaptable
Delays allow more input or changes that improve Focus: what’s happening now?
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Is it REALLY a Problem? - There are over 5.3 million American living with dementia - Estimates are that 30-40% still drive
- By mid-disease the risk of having an accident while driving much higher than any other situation - More MVA with dementia involved are deadly or result in serious injuries
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Symptoms of Concern: - Getting lost on familiar routes - Slowed reaction time: ‘near misses’ - Increased errors in turning, changing lanes, backing up, signal light or intersection behaviors, parking, pulling out, distances - Emotional distress: anger or frustration - Multiple fender benders or scrapes - Speed not matching situation: too slow or fast © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
More Symptoms: - Reliance on a co-pilot for directions and info - Warnings or tickets from police
- Confusing the brake and gas pedals - Going the wrong way - Drifting over - No noticing signs, pedestrians, signals - Running over curbs or ‘bumping’ things
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A Major Indicator that IT IS TIME: Would you let your child or grandchild ride with them?
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Does EVERYONE Who has Dementia Need to Stop Driving ‘Right Away’? - Skill and ability should be the main indicator - Other diseases will impact the need - Self-awareness is a factor - Alternate arrangements are critical - Approaching the subject is delicate but vital
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Early Alzheimer’s
Normal
Late Alzheimer’s
Child
used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama
G. Small, UCLA School of Medicine.
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Brain Changes with Dementia: From Alzheimer’s: A Broken Brain Tuscaloosa, AL: Dementia Education and Training Program, 1999
used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Normal Brain
used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama
Alzheimers Brain © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama
Vision Center – BIG CHANGES
used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
Normal Brain used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Alzheimers Brain © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Normal Brain
used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama
Alzheimers Brain © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Learning and Memory Center Hippocampus BIG CHANGE
used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
© Teepa Snow, Positive Approach, LLC – to be reused only with permission. used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama
used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama
Understanding Language – BIG CHANGE
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used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama
Hearing Sound – Not Changed
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Sensory Strip Motor Strip White Matter Connections BIG CHANGES
Automatic Speech Rhythm – Music Expletives PRESERVED Formal Speech and Language Center HUGE CHANGES used with permission from The Broken Brain: Alzheimers, 1999 University of Alabama © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What should be done? According to some dementia authorities: - https://www.alz.org/cacentralcoast/documents/8Driving_and_Dementia.pdf - https://www.alzheimers.org.uk/info/20030/staying_independen t/27/driving/2 - https://www.webmd.com/alzheimers/news/20000626/dementi a-driving-do-not-mix#1
used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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More ideas and controversy: - http://abcnews.go.com/WN/AlzheimersNews/guidelinesissed-elderly-driving-dementia-alzheimersdiagnosis/story?id=10355282 - https://www.caring.com/articles/moderate-stagedementia-and-still-driving-4-drastic-measures-to-takenow - https://www.mayoclinic.org/healthy-lifestyle/caregivers/indepth/alzheimers/art-20044924
used with permission from Alzheimers: The Broken Brain, 1999 University of Alabama
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Can Be Done? - Ask the doctor to help - Ask other authority figures to help - Ride with the person – check it out - Ask another ‘objective’ person to ride along - Begin to look at options for getting places
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Specifics to Check: - Assess driving skills - Screen thinking and reasoning skills - Screen speed and reaction time skills - Screen vision and visual processing skills - Screen emotional reactions to mistakes/errors - Screen motor skills
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Options for Testing: - MD office screens - DMV testing
- Driving schools or instructors - Outpatient clinic – OTs - AARP sponsored clinics - ???
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Trail-Making Screen: - Trace a path without picking up your pen - Start with A then go to 1 then back to the next letter in the alphabet and then the next number, etc. - Keep track of time - < 65 should be done in 65 should be done in < 2 minutes
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
E
6
5
B
A 8 1 6
K 3 2 H
D
11
I
C
1 2
9 4 7 J
F
1 0
G
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Trail Making: 1 minute or less GREAT!!! More than 2 minutes BAD NEWS!!!
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
What Then? - Screening for reaction speeds - Visual field function - Visual scanning function - Depth perception awareness - Visual-motor integration
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Challenges? - No national or state-wide guidelines for dementia-related conditions that are ability based - Medical advisor decides yes/no - with or without support, details, or driving data - without a clear treatment/follow-up plan - without a monitoring system in place - without full consideration of impact on daily life for all involved © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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If the Person ‘Does All Right’: - Keep monitoring - Gradually start reductions -Limit distractors in the vehicle -Limit times and places and routes -Select times of day -Begin switching roles some times - Start looking for alternatives
- Re-check skills every 6 months © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
If There Are Problems: - Get help to THINK it thru before you DO anything - THINK it all thru first - THEN raise the concern - How to raise the concern will vary based on the person
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Driving Skill is Complex: - Multi-factorial - Personality and person history - Other medical and sensory conditions - Type and level of dementia - Environmental demand - Care partners behaviors and skills - Flow of the day and routines
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Personality Traits: Who are you? - Introvert - Extrovert - Lots of Details – Big Picture only - Logical – Emotional - Planning Ahead – Being in the Moment Who is the person you are trying to help?
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Introvert – Extrovert: Introvert
Extrovert
•Likes to be alone
•Think out loud
•Likes to think it out
•Talk it out
•Likes personal space
•Seek out people
•Needs alone time
•Share a lot
•Private
•Not good with boundaries
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Details – Big Picture: Details
Big Picture
•Lots of facts and figures
•Likes to know WHY
•Specifics of what to do
•Likes to think about it before doing anything
•Likes to get going doing
•Likes to hear the big plan
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Logical – Emotional: Logical
Emotional
•Head First
•Heart First
•Fair
•Nice
•Reasonable
•Kind
•Rational
•Empathetic
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Drugs That Can Affect Cognition: • Anti-arrhythmic agents
• Antibiotics
• Histamine receptor blockers
• Antihistamines decongestants
• Immunosuppressant agents
• Tricyclic antidepressants
• Muscle relaxants
• Anti-hypertensives
• Sedative hypnotics
• Anti-cholinergic agents
• Anti-Parkinsonian agents
• Anti-convulsants
• Narcotic analgesics
• Anti-emetics Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) – published by Lippencott, Wilkins & Williams , 2003 © Teepa Snow, Positive Approach, LLC – to be reused only with permission.
Should We Talk About IT with the Person? Yes, Probably, But: - Who matters - How matters - When matters - Where matters - AND What you say matters
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How to Talk About It: - Look for values that the person has - Ask questions first – get their thoughts
- Use empathy and validate their feelings - Suggest an objective way of checking - Think through options or alternatives for getting places - Start early before it is really an issue
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
If the Person Won’t Stop: - Get help, if the public is at risk - Try not to be the ‘bad guy’ - Remove visual cues related to driving - Provide alternatives - Let authorities know and seek their help
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
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Copyright 2017, All Rights Reserved Teepa Snow and Positive Approach to Care
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