diagnosis-of-cognitive-impairment-and-the-assessment-of-driving

THE NEW ZEALAND

MEDICAL JOURNAL

Journal of the New Zealand Medical Association

NZMJ 13 December 2013, Vol 126 No 1387; ISSN 1175 8716 Page 87

URL: http://journal.nzma.org.nz/journal/126-1387/5946/ ©NZMA

Diagnosis of cognitive impairment and the assessment of

driving safety in New Zealand: a survey of Canterbury GPs

Petra A Hoggarth

Abstract

Aim To assess how GPs in Canterbury determine the driving ability of their older

patients with cognitive impairment.

Methods A 10-item questionnaire was sent to 514 Canterbury GPs via the mail

system of three Primary Health Organisations. GPs could either post or fax back

responses anonymously and were also able to add their own comments.

Results 185 GPs returned completed questionnaires (36% response rate). Six of 10

items were rated in the middle of the response range, indicating a middling level of

agreement. All but three GPs reported using a cognitive screening test and most talked

to their patients about the need to plan for driving cessation. GPs did not frequently

report referring for on-road driving assessments and many commented they would

appreciate a more structured guideline with specific recommendations.

Conclusion There is room for improvement in the amount of information provided to

GPs about how to best assess older patients with cognitive impairment for fitness to

drive. Recommendations of specific cognitive screens and a flowchart format would

be a valuable addition.

As the population of New Zealand ages, a higher proportion of drivers will be 65

years or older.

A greater proportion of drivers will therefore suffer from diseases of

old age including cognitive impairment. Illnesses associated with cognitive

impairment include the various dementias, Parkinson’s disease, multiple sclerosis,

stroke, and depression.

While some causes of cognitive impairment are irreversible and progressive, such as

the various dementias, others may resolve over time or with treatment, such as

impairment due to stroke or depression.

Prevalence rates for dementia have been reported between 13% and 43% in the 80 to

89 age group, increasing exponentially per year within this age range, with rates

between 40% to 65% in those aged over 90.

2–4

As a group, drivers with dementia are 10.7 times more likely to be involved in a

crash

and have almost 2.5 times as many crashes that result in insurance claims

compared to an age-matched control group.

Nonetheless, many people with early

dementia are able to pass an on-road driving assessment, with observed pass rates

ranging from 35% to 73%.

7-10

The difficulty for driving safety is in determining which drivers are likely to have

their cognitive impairment improve with treatment, which cognitively impaired

drivers are currently safe to continue driving, and which drivers need to stop

immediately and permanently (i.e. those with a deteriorating dementia).

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A number of researchers have recommended that people with moderate and severe

dementia cease driving and suggest that people with mild dementia may be able to

continue driving with appropriate monitoring and assessment.

11,12

Statements have

also been made that results of neuropsychological tests cannot be used reliably to

determine which drivers with dementia are safe and unsafe on the road.

11,13

Following a review of the driving and dementia literature, The American Academy of

Neurology identified the Clinical Dementia Rating (CDR) as the most useful measure

of overall cognitive decline in people with dementia.

This tool is a clinician rated

scale that assesses the level of cognitive impairment and classification into categories

of None, Very Mild, Mild, Moderate, and Severe.

The American Academy of Neurology also lists other risk factors including caregiver

ratings of poor driving, the incidence of traffic offences and crashes, and changes in

driving patterns such as reduced mileage and situational avoidance.

These

recommendations are ranked by order of the strength of relationship to on-road

driving outcomes based on the literature review. A flowchart is provided for clinicians

to aid in decision making and this article is readily available at

http://www.neurology.org/content/74/16/1316.full.pdf+html

In New Zealand, compulsory on-road driving assessments for drivers aged 80 and

over ceased in December 2006. GPs are charged with making decisions regarding

driving safety for their older patients, including those with cognitive impairment.

The task of making decisions about driving is made more difficult because cognitive

impairment must first be adequately assessed and diagnosed. This process takes

longer than a standard GP appointment allows, and should include talking to a reliable

informant about noticed changes in cognition and behaviour. The New Zealand

Transport Agency (NZTA) provides a guide for medical practitioners for assessing

driving safety in a number of medical conditions including dementia (Medical Aspects

of Fitness to Drive

This guide provides no statistics to highlight the increased risks of crashes in those

with dementia, and makes no mention of dementia severity and how it relates to

driving safety. The guide suggests the use of tests of cognitive function, but does not

recommend any. It also suggests the use of a test of road signs provided in an

appendix as a way to determine if problems related to driving ability exist. This test

has no recommended cut point to detect a problem and to the author’s knowledge has

not been tested for reliability or validity for detecting on-road driving problems.

A New Zealand article

published by a group of driving researchers, driving

specialist occupational therapists, an old-age psychiatrist, and a GP representative

provided a detailed review of older driver licensing practice and assessment in New

Zealand, including a section for drivers with cognitive impairment.

The authors suggested that older drivers be routinely assessed for cognitive

impairment when they present to their GP for a medical fitness to drive certificate.

The authors also suggested that driving ability was assessed every 6 months, and that

GPs did not use the road sign test provided in the NZTA’s Medical Aspects of Fitness

to Drive

handbook due to a lack of information about its validity for determining

driving ability. The authors instead suggested use of a standardised version of the

Mini Mental State Examination (MMSE).

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In the current study, the author (PAH) and Christchurch GP and member of the

Primary Care Liaison Team for Older Persons Health at the CDHB, Dr Michael

Thwaites, arranged for a questionnaire to be delivered to all GPs in the Canterbury

region to assess the issues of diagnosing cognitive impairment and driving

assessment.

Canterbury GPs are in a privileged position in that 400 medical driving assessments

per year are funded by the DHB at the Driving and Vehicle Assessment Service at

Burwood Hospital. In almost all other DHBs these assessments must be paid for

privately.

The goal of this survey was to assess how GPs were diagnosing cognitive impairment

and determining driver safety, and also to find areas of perceived need for additional

education or guidance from the NZTA.

Method

A questionnaire was constructed by the author and reviewed by Dr Michael Thwaites and Police

Constable Wayne Stevenson, and is replicated in Table 1. Questions 3, 9, and 10 focused on how GPs

diagnosed and managed cognitive impairment in their older patients.

Question 3 referred to the Cognitive Impairment Pathway, which is part of the Health Pathways online

resource compiled by specialists at the Canterbury DHB and targeted at primary care physicians. The

remaining questions addressed self-rated knowledge and confidence related to making decisions about

driver safety, as well as questions about the use of resources such as the NZTA’s Medical Aspects of

Fitness to Drive

and formal driving assessments.

The response choices for the questions deliberately did not allow for a non-specific

rating, such as “Neither confident nor unconfident”, thus requiring respondents to take

an affirmative or negative side in their response. The response choices also did not

indicate specific timeframes or request estimates of numbers of patients seen by GPs.

One reason for this was that asking for more specific details may have meant a lower

response rate due to a perceived or actual increased amount of time required to

complete the questionnaire. Another reason was that reported numbers may not be

particularly accurate and may present a summary that appeared more precise than it

actually was.

Thus, the outcome of the survey would provide a general but non-specific summary of

thoughts and practices of GPs in relation to cognitive impairment and driving.

Respondents were encouraged to write any additional comments on the back of the

form.

NZMJ 13 December 2013, Vol 126 No 1387; ISSN 1175 8716 Page 90

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Table 1. Text of questionnaire sent to GPs

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514 GPs from three Primary Health Organisations (PHO) in Canterbury were posted

questionnaires in late 2012 through the secure mail delivery network of their PHO.

410 were sent to GPs under Pegasus Health PHO, 40 to GPs under Christchurch PHO,

and 64 to GPs under Rural Canterbury PHO.

The 10-item questionnaire was delivered in an envelope with a one page covering

letter introducing the survey, asking for anonymous responses, and stating that the

results could be used both as part of a submission to the NZTA, as well as submission

to a peer-reviewed journal. GPs could reply either using the included envelope or by

faxing their questionnaire back to the author.

Descriptive statistics of frequency, median, and mode were reported. Statistics were

calculated using SPSS Statistics version 17.0 software. Response options were coded

into nominal values.

Questions 1, 4, 5, 6, 7, and 9 had four response options, coded as values 1 through 4

in order of presentation on the form (see Table 1). Questions 2, 3, and 8 had five

options, coded as the values 1 through 5. For these three questions, the first four asked

for a subjective rating, whereas the last question acted as a way for the rater to note if

they had not come across this situation (e.g. the response “I had not heard of it” for

the question regarding use of the Medical Aspects of Fitness to Drive

handbook).

When descriptive statistics were calculated for questions 2, 3, and 8 the number of

responses rated 5 was first noted, with descriptive statistics performed only for the

responses rated 1 through 4. Additional comments on the back of the form were

recorded and presented in a qualitative manner.

Results

185 GPs responded (36% response rate). The number responding to each question is

shown in the second column of Table 2. For questions 2, 3, and 8 the number from the

third column must be added to the second column to determine the number of

respondents. Missing values were excluded from the analysis for that question.

Descriptive statistics for questions 1 to 9 are presented in Table 2.

Table 2. Results of questionnaire for each question

Question number N N noting they could not rate this item (%) Median (mode)

179

160

156

184

131

185

–

21 (11.6%)

25 (13.8%)

–

53 (28.8%)

–

2 (2)

3 (3)

2 (2)

3 (3)

2 (2)

3 (4)

2 (1)

1 (1)

Due to differences in interpretation in this question (see text below) this result cannot be accurately interpreted.

Twenty-five respondents reported they had not heard of the CDHB’s Cognitive

Impairment Pathway on the Health Pathways information portal (question 3). Of the

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remaining respondents, the median rating for using the Cognitive Impairment

Pathway information was Sometimes.

Question 9 asked how frequently respondents conducted a cognitive screening test

with an older patient suspected of cognitive impairment. It became clear from

participant comments that this question was being interpreted in two different ways.

The intention was to gauge how frequently a GP performed screens within their

practice in general, but some respondents took the question to refer to how often tests

were repeated on specific individuals. Because of this lack of clarity, responses to this

question could not be accurately interpreted.

Question 10 asked respondents to note which cognitive screening tests they used

within their practice for assessment of older patients with suspected cognitive

impairment. The frequency for each response is found in Table 3.

Table 3. Numbers of respondents endorsing the use of different cognitive

screening tests

Cognitive test N (%)

Mini Mental State Exam

(MMSE) 131 (71%)

Montreal Cognitive Assessment

(MoCA) 100 (54%)

Modified Mental State Exam

(3MS) 29 (16%)

IQCODE

(short or long version) 11 (6%)

None 3 (2%)

Addenbrooke’s Cognitive Examination

(ACE-R) 0

Other

– SIMARD-MD

– GP-Cog

– 6CIT

– Road Sign Test

– Hopkins Verbal Learning Test

– Abbreviated MMSE

8 (4%)

5 (3%)

3 (2%)

2 (1%)

1 (1%)

Only three respondents reported that they did not use a cognitive screening test. The

most commonly used test was the MMSE with 131 responses. The MoCA was the

next most common at 100. No respondents reported using the ACE-R. Twenty

respondents reported using a different screen from those listed: eight used the

SIMARD-MD, five used the GP Cog, three used the 6CIT, two used the Road Sign

Test from the NZTA Medical Aspects of Fitness to Drive

handbook, and one each

used the Hopkins Verbal Learning Test and an abbreviated version of the MMSE.

For question 1, respondents median score for their knowledge of driving risks for

older adults with cognitive impairment was Well Informed. For question 2, twenty-

one respondents (11.6%) reported that they had not read the NZTA Medical Aspects

of Fitness to Drive

guidelines for drivers with cognitive impairment. Remaining

respondents satisfaction with this resource was Slightly Satisfied.

For question 4, respondents rated their level of confidence in making decisions about

driving in patients with cognitive impairment as Not so Confident. For question 5,

respondents rated the frequency of their use of a medical driving assessment at

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Burwood Hospital as Sometimes. Thirteen respondents (7%) rated this as Never. For

question 6 respondents rated the frequency of their use of an On-Road Safety Test,

such as offered by the Automobile Association as Seldom, with 60 respondents

(32.4%) reporting they never referred for this assessment.

For question 7 respondents rated how frequently they raised the issue of planning for

driving cessation with patients with cognitive impairment or their families as

Sometimes. Question 8 asked how useful it was to receive information about a driving

incident that sparked an NZTA request for review of a patient’s driving ability. Fifty-

three respondents (28.8%) reported that they had not received such a request. The

remainder rated this as Very Important. It is possible that some people rated this

option even if they hadn’t personally received a report from NZTA.

Thirty-one respondents added additional comments to the back of their

questionnaires. Comments were sorted into a number of super-ordinate categories

based on theme. Ten responses were comments on a GP’s own practice, or about

finding a specific resource useful (such as a cognitive screening test).

Eleven comments expressed dissatisfaction with the current NZTA guidelines or with

the use of cognitive screens. In this category, several GPs stated that cognitive screens

were not sensitive enough, or did not relate to real-world driving. Several respondents

asked for more specific guidelines from the NZTA. Some respondents stated that they

believed that all patients with dementia should stop driving.

Two respondents voiced concerns about patients declining to pay for the On-Road

Safety Test. One respondent noted a situation where the issue of driving led to the

break-down in the patient–GP relationship and subsequent change of GPs for the

patient. Six respondents voiced criticism of being able to tell a person’s on-road safety

from any office-based test, and a few called for a reintroduction of compulsory on-

road testing of all older drivers. One respondent noted that the waiting list for medical

driving assessments at Burwood Hospital was too long (around 8–12 weeks at the

time of writing).

Discussion

Almost all GPs reported using a cognitive screening test with their patients with

cognitive impairment, but only Sometimes utilised the guidelines of the CDHB’s

Cognitive Impairment Pathway. The most commonly used cognitive screen was the

MMSE.

The MMSE is a useful tool for detecting the presence of moderate or severe dementia

and to measure decline over time, but it has poor sensitivity for detecting people with

mild cognitive impairment or mild dementia.

17,25

The second most commonly used

test was the MoCA. This is most likely due to its recommendation as a screening tool

in the CDHB’s Cognitive Impairment Pathway.

The Short IQCODE is also recommended in the Pathway, but only 11 respondents

reported using this measure, which requires administration to an informant. Only two

respondents used the Road Sign Test recommended and provided in the Medical

Aspects of Fitness to Drive

handbook.

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The SIMARD-MD

was used by eight respondents, although some studies have

criticized its use, suggesting it has no advantage over other already available

approaches to predicting driver safety,

and that it was adapted from an existing

screen for cognitive impairment which does not necessarily translate to usefulness in

predicting driving ability.

The remaining questions relating to driving decisions showed that GPs often rated

themselves in the intermediate levels of feeling confident, informed, or satisfied. This

indicates room for improvement in provision of information about how cognitive

impairment affects driving ability and guidelines for helping with decision-making

regarding driving ability (more about this below). Questions 5 and 6 showed that GPs

rated their use of driving assessments, either medical or not, in the Seldom to

Sometimes range, with the On-Road Safety Test not being used by a third of

respondents.

These results suggest that many GPs are making decisions about driving ability

without the use of on-road assessments. This makes it important that GPs receive

information about the additional evidence-based predictors of driving ability that are

not currently included in the Medical Aspects of Fitness to Drive.

This information

will be even more important for GPs in the majority of DHBs where on-road medical

driving assessments are not publicly funded.

Question 7 showed that GPs rated a discussion of future driving cessation occurring

with a patient or their family member Sometimes. It is positive that these discussions

are taking place. Ideally this conversation should occur with every driver with a

progressive dementia as all will become unsafe drivers at some point.

GPs felt strongly that requests for assessment of patients from the NZTA should

include detailed information about the driving incident that triggered the notification.

This has implications for police officers who are present at driving incidents/crashes

that precipitate the generation of a report. Police officers need to know what

information is useful to report to NZTA about a crash and the older driver involved in

a crash.

There are several limitations to this survey. As mentioned in Methods, specific

timeframes and estimates of numbers of patients seen were not requested in order to

make the questionnaire quicker to complete and thus increase the response rate, as

well as to avoid reporting of numbers that might appear more precise than they were.

Therefore, questions that asked about frequency of a behaviour (questions 3, 5, 6, 7,

and 9) can only be used to make general statements that lack specificity. For example,

GPs may have chosen different timeframes to think about frequency, e.g. 12 or 6

months, or may have relied on an internal hunch about frequency without a specific

timeframe. Another factor affecting frequency is the number of older patients in a GPs

practice who present with cognitive impairment, e.g. fewer older patients will lead to

less need to consider driving ability.

Another issue is the response rate of 36%. Due to the high workload of GPs the

questionnaire was designed to be easily completed in less than five minutes, and also

provided two ways to return; by mail and by fax. Reasons for the low response rate

are unknown but are likely multifactorial. These could include that the survey was

still too long for some GPs to find time to complete, that GPs did not consider it a

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worthwhile use of their time, or that it was sent out at a time of year when time was in

short supply (it was distributed in November which could be considered a time of

build up to the festive season).

A low response rate may increase the likelihood of a biasing in results. Perhaps GPs

with higher rates of cognitively impaired older people in their practice were more

likely to respond. Also, some respondents commented about recent education sessions

they had attended related to driving and cognitive impairment, and those who

attended may have been more likely to respond to the survey. Perhaps those GPs who

rarely performed assessments of driving ability with their older patients did not feel

confident in rating their knowledge on the subject.

In summary, the questionnaire provided information about the knowledge and

confidence in assessing driving ability in cognitively impaired older adults. GPs may

benefit from the provision of more detailed information about how cognitive

impairment affects driving, and many would appreciate a more systematic way to

assess driving safety than currently offered by the Medical Aspects of Fitness to

Drive

handbook.

The author would like to see statistics about the increased crash rates of older adults

with cognitive impairment included in Medical Aspects of Fitness to Drive. GPs may

also benefit from the recommendation of specific cognitive tests with high reliability

and validity that both aid in assessing the presence and severity of dementia as well as

making estimates about level of impairment and how this relates to driving ability.

Furthermore, the author would like to see some tests with greater sensitivity to mild

cognitive impairment and mild dementia recommended, such as the 3MS or MoCA,

and others, such as the MMSE, to have their limitations detailed. Since GPs do not

always choose to refer for an on-road assessment, information should be provided

about worthwhile research-based predictors of poor driving such as caregiver report

of marginal or unsafe skills, a history of crashes or traffic citations, reductions in

mileage, avoidance of certain driving situations, and aggressive and impulsive

behaviour.

Lastly the author believes a flowchart similar to that published by The American

Academy of Neurology

and adapted for New Zealand regulations and conditions

would be a valuable addition.

Competing interests: Nil.

Author information: Petra A Hoggarth, Clinical Psychologist, Psychiatric Service

for the Elderly, Canterbury District Health Board, Christchurch

Acknowledgments: The author thanks Michael Thwaites for reading an early version

of the questionnaire and for arranging distribution to the PHOs; Wayne Stevenson for

stimulating this research and for reading an early copy of the questionnaire; and Dr

Carrie Innes and Alex Mortlock for commenting on versions of this manuscript.

Correspondence: Dr Petra Hoggarth, Clinical Psychologist, Psychiatric Service for

the Elderly, The Princess Margaret Hospital, Cashmere Road, Christchurch 8022,

New Zealand. Email: [email protected]

NZMJ 13 December 2013, Vol 126 No 1387; ISSN 1175 8716 Page 96

References:

1. Organisation for Economic Co-operation and Development. Ageing and transport: mobility

and safety issues. Paris: OECD Publications; 2001.

2. Ritchie K, Kildea D. Is senile dementia "age-related" or "ageing-related"? Evidence from

meta-analysis of dementia prevalence in the oldest old. Lancet. 1995;346:931–934.

3. Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the

aging, demographics, and memory study. Neuroepidemiology. 2007;29:125–132.

4. De Ronchi D, Berardi D, Menchetti M, et al. Occurrence of cognitive impairment and

dementia after the age of 60: a population-based study from Northern Italy. Dement Geriatr

Cogn Disord. 2005;19:97–105.

5. Zuin D, Ortiz J, Lopez OL. Motor vehicle crashes and abnormal driving behaviours in patients

with dementia in Mendoza, Argentina. Eur J Neurol. 2002;9:29–34.

6. Cooper PJ, Tallman K, Tuokko H, Beattie BL. Vehicle crash involvement and cognitive

deficit in older drivers. J Safety Res. 1993;24:9–17.

7. Carr DB, Barco PP, Wallendorf MJ, et al. Predicting road test performance in drivers with

dementia. J Am Geriatr Soc. 2011;59:2112–2117.

8. Fox GK, Bowden SC, Bashford GM, Smith DS. Alzheimer's disease and driving: prediction

and assessment or driving performance. J Am Geriatr Soc. 1997;45:949–953.

9. Grace J, Amik MM, D'Abreu A, et al. Neuropsychological deficits associated with driving

performance in Parkinson's and Alzheimer's disease. J Int Neuropsychol Soc 2005;11:766–

775.

10. Lincoln NB, Radford KA, Lee E, Reay AC. The assessment of fitness to drive in people with

dementia. Int J Geriatr Psychiatry. 2006;21:1044–1051.

11. Australian and New Zealand Society for Geriatric Medicine. Position statement: dementia and

driving; 2010.

12. Canadian Medical Association. Determining medical fitness to operate motor vehicles: CMA

driver's guide – 7th edition. Ottawa, ON; 2006.

13. Iverson DJ, Gronseth GS, Reger MA, et al. Practice parameter update: evaluations and

management of driving risk in dementia: report of the Quality Standards Subcommittee of the

American Academy of Neurology. Neurology. 2010;74:1316–1324.

14. New Zealand Transport Agency. Medical aspects of fitness to drive: a guide for medical

practitioners. Palmerston North: New Zealand Transport Agency; 2009.

15. Hoggarth P, Innes C, Dalrymple-Alford J, et al. Assessment of older drivers in New Zealand:

the current system, research, and recommendations. Australas J Ageing 2011;30:148–155.

16. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the

cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.

17. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a

brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–699.

18. Teng EL, Chui HC. The modified mini-mental state (3MS) examination. J Clin Psychiatry.

1987;48:314–318.

19. Jorm AF, Jacomb PA. The Informant Questionnaire on Cognitive Decline in the Elderly

(IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med.

1989;19:1015–1022.

20. Mioshi E, Dawson K, Mitchell J, et al. The Addenbrooke's Cognitive Examination Revised

(ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry.

2006;21:1078–1085.

21. Dobbs BM, Schopflocher D. The introduction of a new screening tool for the identification of

cognitively impaired medically at-risk drivers: the SIMARD a modification of the DemTect. J

Prim Care Community Health. 2010;1:119–127.

22. Brodaty H, Pond D, Kemp NM, et al. The GPCOG: A New Screening Test for Dementia

Designed for General Practice. J Am Geriatr Soc. 2002;50:530–534.

NZMJ 13 December 2013, Vol 126 No 1387; ISSN 1175 8716 Page 97

23. Brooke P, Bullock R. Validation of a 6 item cognitive impairment test with a view to primary

care usage. Int J Geriatr Psychiatry. 1999;14:936–940.

24. Benedict RHB, Schretlen D, Groninger L, Brandt J. Hopkins Verbal Learning Test – Revised:

normative data and analysis of inter-form and test-retest reliability. Clin Neuropsychol.

1998;12:43–55.

25. Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity and utility in a

memory clinic setting. Can J Psychiatry. 2007;52:329–332.

26. Hogan DB, Bédard M. Papers that might change your practice: review of the introduction of a

new screening tool for the identification of cognitively impaired medically at-risk drivers. Can

Geriatr J. 2011;14:51–54.

27. Bédard M, Marshall S, Man-Son-Hing M, et al. It is premature to test older drivers with the

SIMARD-MD. Accid Anal Prev 2013 (in press).