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  • EFA; epilepsy foundation of americaAES; american epilepsy societyMAB; medical advisory board # The conclusions from this study suggested that the overall crash rate was low and that a 6 month SFI was associated with a lower crash rate than a shorter SFI. Crashes related to seizures and other medical conditions are uncommon but when they occur they are often sensationalized in the popular press.# In Arizona, the SFI was reduced from 12 to 3 months without a significantly increased number of seizure related crashes or deaths
  • n addition to the typical motor symptoms of Parkinson disease (PD), persons with PD may develop cognitive impairment/dementia, emotional impairments (e.g., apathy and disinhibition), and visual-perceptual deficits that often do not respond to dopaminergic medications.
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    • 1. Prof. Ashraf Abdou Neuropsychiatry department Alexandria university
    • 2. OBJECTIVES  Mechanism of driving impairment  Driving in Epilepsy  Driving in Dementia  Driving in Parkinson’s D.  Driving after stroke
    • 3. WHO 2012
    • 4. WHO 2012
    • 5. Driving  Higher cognitive functions  Perception and attention to stimulus  Formulation of a plan based on memory experiences  Execution of an action such as applying a brake, steering control, or accelerator  Vision  motor control and coordination.
    • 6. Neurological impairment & Paroxysmal disorders Neurological impairment Paroxysmal loss of awareness Cognitive impairment - AD EPILEPSY Motor control impairment # Weakness Excessive day –time sleepiness/sleep disorders # Bradykinesia # Incoordination Acute hypoglycemia Syncope # Arrythmia # Dysautonomia
    • 7. USA current position for doctor responsibility © 2013 American Academy of Neurology Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49
    • 8. Pros & Cons on reporting  Patient’s safety  Community safety  Doctor-patient confidentiality  Patient conceal medical information that help in treatment  Patient’s right
    • 9. Epilepsy
    • 10. Studies showed  Approximately 700,000 of the 180 million1 Americans     licensed to drive have epilepsy Drivers with well-controlled seizures are not at a high or unacceptable risk for crashes uncontrolled epilepsy poses a substantial risk for MVA 50% patients who have seizures while driving have motor vehicle crashes One recent US study showed that patients with intractable seizures often continue driving.  39% had a seizure at the wheel  27% crashed because of a seizure
    • 11. Evidence-based Not predictive of motor vehicle crash (MVC). protective against crashes Short seizure-free intervals (≥ 3 months) (Level C) Epilepsy surgery (Level B), Seizure-free intervals (6– 12 months) (Level B) Few prior non-seizurerelated crashes (Level B) Regular antiepileptic drug adjustments (Level B) Epilepsy Behav. 2012 Feb;23(2):103-12
    • 12. Risk of driving in medical diseases
    • 13. Seizure-free period & Driving  Most European countries; 1 yr seizure-free  In USA: AAN – AES –EFA; 3 months  3 months (7 states), 6 months (14 states), and 1yr (7 states)  23 state no specific time [Neurologist – MAB]  7 states mandatory physician reporting  In Japan: 1 yr seizure-free
    • 14. Figure. Seizure-free restrictions for noncommercial driving in the United States. Krauss G et al. Neurology 2001;57:1780-1785
    • 15. Copyright © 2012 British Epilepsy Association Terms and Conditions
    • 16. USA current position for doctor responsibility # The official position of the AMA. AES, AAN do not support mandatory reporting of medical conditions to government # Most European medical societies took a position against physician © 2013 American Academy of Neurology reporting Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49
    • 18. USA: 10 yrs EU: 5 yrs Seizure-free Off medication
    • 19. ONLY IN EGYPT
    • 20. Dementia
    • 21. Dementia and driving  Patients with mild AD showed double car crash in age-matched controls.  The average number of crashes per year in patients with AD increased dramatically after the first 3 years from symptom onset.  75% can pass on-road driving
    • 22. Evidence-Based : patients at increased risk for unsafe driving Factor Clinical Dementia Rating Scale [CDR] A caregiver's rating of a patient's driving ability as Level of evidence A C marginal or unsafe A history of traffic citations A history of crashes Reduced driving mileage Self-reported situational avoidance MMSE scores of ≤24 Aggressive or impulsive personality characteristic C C C C C C AAN Practice Parameter update: Evaluation and management of driving risk in dementia 2010
    • 23. © 2013 American Academy of Neurology Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49
    • 24. Stroke
    • 25. Driving after stroke  In developed countries, more than half of persons with stroke are fit to drive following a successful onroad examination  Most reliable test for recognition of resuming driving after stroke:  Road Sign Recognition test  Trail making test B  Compass task  Cube copy test  Stroke Drivers Screening Assessment
    • 26. Parkinson’s Disease
    • 27. Parkinson disease (PD): Typical motor symptoms Cognitive impairment/dementia Emotional impairments (e.g., apathy and disinhibition)  Visual-perceptual deficits Possible side effects (e.g., daytime sleepiness) of PD medications
    • 28. Parkinson’s D & driving  A retrospective survey study: found that patients with Hoehn & Yahr (H&Y) stages 2 and 3 had a significantly higher crash risk compared to healthy controls. However, there was no evidence of increased crash risk among patients in H&Y stage 1 Another survey study: 82% of patients with PD held a driving license and 60% of them were still driving. Of the patients holding a driving license, 15% reported being involved in an accident. Drivers with PD may not reveal medical information when renewing their license or adhere to physician's advice to quit driving.
    • 29. Evidence- Based
    • 30. Tying it all together!  Neurological disorders are most frequent cause for driving disability  Most studies focus on epilepsy and dementia followed by parkinson’s D  For epilepsy most studies and regulations focus on seizure-free period before allowing to drive again  For dementia ; evidence- based guidelines are available to help the physician to take his decision