ACCIDENT RESEARCH CENTRE INFLUENCE OF CHRONIC ILLNESS ON CRASH INVOLVEMENT OF MOTOR VEHICLE DRIVERS by Judith Charlton Sjaanie Koppel Mary O’Hare Dale Andrea Geoff Smith Bereha Khodr James Langford Morris Odell Brian Fildes Project sponsored by April, 2004 Report No. 213 ii MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE REPORT DOCUMENTATION PAGE Report No. Date ISBN Pages 213 March 2004 0 7326 1723 5 472 Title and sub-title: Influence of chronic illness on crash involvement of motor vehicle drivers Authors: Charlton. J.L., Koppel, S., O’Hare, M., Andrea, D., Smith, G., Khodr, B., Langford, J., Odell, M. & Fildes, B., Sponsoring Organisation(s): This project was funded by the Swedish National Road Administration. Abstract: A significant issue for consideration in road safety is the impact of medical conditions on crash involvement and risk of injury. This aim of this project was to review the evidence for the influence of chronic illness and impairments on crash involvement of motor vehicle drivers. A number of methodological issues are discussed and recent research findings are critically evaluated. A risk rating system was applied to the available evidence on crash risk for all medical conditions of interest. This provided a means of identifying those conditions that presented the greatest risk. Eight conditions were found to have at least a moderately elevated risk of crash involvement (relative risk greater than 2.0) compared with their relevant control group. These were alcohol abuse and dependence, dementia, epilepsy, multiple sclerosis, psychiatric disorders (considered as a group), schizophrenia, sleep apnoea, and cataracts. Guidelines regarding fitness to drive from selected jurisdictions were also considered in the light of evidence for crash risk. These comparisons revealed a number of differences across the jurisdictions and highlighted some inconsistencies with the available evidence for crash risk. A number of conclusions are presented which may contribute to the formulation of recommendations for managing the risk of injury crashes associated with medical conditions. The findings of this review also highlighted the need for a cooperative international approach to future research using population- based, prospective studies to advance scientific knowledge linking medical conditions and crash risk. Key Words: Disclaimer Chronic illness, medical conditions, disorders, This report is disseminated in the interest of functional impairment, risk, motor vehicle, information exchange. The views expressed here are automobile, accident, crash, drivers, driving those of the authors, and not necessarily those of performance, injury, safety, fitness-to-drive, Monash University or the Swedish National Road licence restrictions, training, rehabilitation, Administration. treatment, self-regulation, medications, cardiovascular, cerebrovascular, cognitive impairment, comorbidity, metabolic, musculoskeletal, neurological, psychiatric, renal, sleep, respiratory, vestibular, vision. Reproduction of this page is authorised Monash University Accident Research Centre, Wellington Road, Clayton, Victoria, 3800, Australia. Telephone: +61 3 9905 4371, Fax: +61 3 9905 4363 CHRONIC ILLLNESS AND CRASH RISK III PREFACE Project Manager: Judith Charlton* Research Team: Brian Fildes* Sjaanie Koppel* Mary O’Hare* Dale Andrea* Geoff Smith* Bereha Khodr* James Langford* Morris Odell (Chair of Expert Panel)** *Monash University Accident Research Centre, Clayton, 3800 Australia ** Victorian Institute of Forensic Medicine, Melbourne Australia iv MONASH UNIVERSITY ACCIDENT RESEARCH CENTRE CONTENTS CHAPTER 1 INTRODUCTION ........................................................................................ 1 1.1 AIM OF THE REVIEW............................................................................................... 1 1.2 BACKGROUND.......................................................................................................... 1 1.3 THE AGEING POPULATION AND CHRONIC ILLNESS ...................................... 2 1.4 HEALTH, CHRONIC ILLNESS AND FUNCTIONAL IMPAIRMENT .................. 2 1.5 EVIDENCE BASED DECISION-MAKING .............................................................. 4 1.6 APPROACHES TO MANAGEMENT........................................................................ 4 1.7 DISABILITY AND DISCRIMINATION.................................................................... 4 1.8 PRIVATE AND COMMERCIAL LICENCES ........................................................... 4 1.9 BALANCING MOBILITY AND SAFETY ................................................................ 5 1.10 STRUCTURE OF THE REVIEW ............................................................................... 6 CHAPTER 2 METHODOLOGICAL CONSIDERATIONS IN IDENTIFYING CRASH RISK ASSOCIATED WITH CHRONIC ILLNESS..................................................................... 8 2.1 MEASUREMENT OF RISK ....................................................................................... 8 Crash involvement ............................................................................................................ 8 Driving citations................................................................................................................ 9 Driving performance ....................................................................................................... 10 2.2 DEFINITION OF THE STUDY POPULATION...................................................... 11 Recruitment of participants............................................................................................. 11 Diagnostic criteria ........................................................................................................... 11 Chronic illness and functional impairment ..................................................................... 13 Defining an appropriate control group............................................................................ 13 2.3 CHRONIC VERSUS ACUTE EFFECTS OF MEDICAL CONDITIONS............... 13 2.4 STATISTICAL ANALYSES..................................................................................... 14 2.5 SCOPE AND LIMITATIONS OF THE REVIEW.................................................... 14 2.6 LITERATURE SEARCH STRATEGY..................................................................... 16 Keywords ........................................................................................................................ 16 Search databases.............................................................................................................. 16 Search results .................................................................................................................. 16 Critical review of scientific literature ............................................................................. 17 References....................................................................................................................... 17 CHAPTER 3 REVIEW OF SPECIFIC MEDICAL CONDITIONS: CRASH RISK AND APPROACHES TO MANAGEMENT............................................................................ 18 3.1 ALCOHOL ABUSE AND ALCOHOL DEPENDENCE.......................................... 18 Definition of alcohol abuse and alcohol dependence...................................................... 19 Prevalence of alcohol abuse and alcohol dependence..................................................... 20 Functional impairments associated with alcohol abuse relevant to driving.................... 20 Relationship between alcohol abuse and road safety outcomes...................................... 24 Approaches to management ............................................................................................ 35 References....................................................................................................................... 42 CHRONIC ILLLNESS AND CRASH RISK V 3.2 CARDIOVASCULAR DISEASE ..............................................................................46 Definition of cardiovascular disease................................................................................46 Prevalence of cardiovascular disease ..............................................................................47 Functional impairments associated with cardiovascular disease.....................................47 Relationship between cardiovascular disease and road safety outcomes ........................48 Treatment of CVD and road safety outcomes .................................................................57 Approaches to management.............................................................................................64 References .......................................................................................................................85 3.3 CEREBROVASCULAR ACCIDENT (STROKE) ....................................................90 Definition of cerebrovascular accident............................................................................90 Prevalence of CVA..........................................................................................................90 Functional impairments associated with CVA relevant to driving..................................91 Relationship between CVA and road safety outcomes ...................................................92 Approaches to management: ...........................................................................................97