international journal of academics & research …...9 ijarke peer reviewed journal vol. 1, issue...

INTERNATIONAL JOURNALS OF ACADEMICS & RESEARCH ISSN: 2617-4391 IJARKE Science & Technology Journal DOI: 10.32898/istj.01/1.2article02

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9 IJARKE PEER REVIEWED JOURNAL Vol. 1, Issue 2 Nov. ’18 – Jan. 2019

Fitness-to-Drive Medical Assessment for Kenyan Drivers

Cherono Joyce Victoria Sise, Kenyatta National Hospital, Kenya

1. Introduction

Driving a motor vehicle could be central to the functional autonomy of people with psychiatric illnesses or related pressures of

life. For many people, a driver's license could mean independence, the ability to care for themselves, and the freedom to travel

when they wish. However, both psychiatric disorders and psychiatric drug treatments can produce changes in perception,

information processing and integration, and psychomotor activity that can disturb and/or interfere with the ability to drive safely.

The decision to recommend licensure for driving after a stroke, cerebral brain injury, or seizure, or even any other strain in life

that affects the motor capacity of a person is important. There is then a requirement for mental status assessment. In clear-cut or

extreme cases of ill health, assessment is not a problem. For those who fall in between, careful evaluation and informed judgment

on the part of the physician is required.

The fitness-to-drive of people with mental health conditions may vary within individuals due to both the effects of the illness

itself, as well as the impact of psychiatric drugs on driving performance. Individuals diagnosed with mental health conditions may

experience reduced attention, visual spatial functioning, impulse control, judgment, as well as alterations in information

processing ability and slowed psychomotor reaction times. These difficulties can all impair driving abilities and may lead to a

INTERNATIONALS JOURNAL OF ACADEMICS & RESEARCH (IJARKE Science & Technology Journal)

Abstract

Driving is involving, which needs physical, cognitive and perceptual skills. It is important for a driver to be fit

psychologically, physical and emotionally avoid accidents and deaths. There is need to conduct a good test of fitness for

drivers more so those of have medical conditions that may affect their judgement and work. This report examines the medical

fitness-to-drive among divers in Kenya and provide framework for introduction of a mandatory medical assessment for all

Kenyan drivers. The report found that driver must have control over impulse and risk-taking, hence should have mature and

unimpaired judgment when driving. Hence most psychiatric outpatients should not be allowed to drive based on cognitive

impairment. It was also found that many drivers involved in accidents are impaired owing to the use of alcohol, drugs, illness,

or emotional disorders. The research concluded that drivers’ soundness is based psychomotor function which might be

impaired hence there is need to conduct psychophysical test which assess the ability of the driver to drive in different

conditions. Evaluation should assess the mental, physical and sensory abilities with help of physician or medical expert. This

framework can be applied to all drivers as well as ensuring that its part off evaluation test before issue of any driving license. A comprehensive assessment should include questions about their mental and physical health; functional status, medications

and a standardized cognitive test should be administered such as the MMSE, MOCA, RUDAS, ACE-III or equivalent. At the

conclusion of the assessment, which may take place over more than one visit, and may require phone calls to family members

for information, clinicians should be able to make the diagnosis and make an assessment of the likely dementia stage or

severity, and hopefully will have some idea about the most likely etiology of the dementia. A simple, multi-disciplinary test

comprising of assessment of vision and cognitive tests, hazard perception and change detection tests if used will have a

significant capacity to evaluate how safe or unsafe a driver is. To assess visual fitness of a driver, visual acuity, contrast

sensitivity and peripheral vision form critical components. Impairment in visual skills will be a significant causal factor for

road crashes in drivers. The report recommends that laws and legislation should be in place which allows medical evaluation

for one to hold driver’s license. Physicians should also provide letter of driving recommendation with confidentiality. Assess

of medical fitness to drivers should include physical examination assessing physical and cognitive screening. In patients who

show signs of cognitive impairment, additional assessments should include neuropsychiatric, and on- and off-road testing,

depending on the tools available at the facility. Using an integrated approach most carnage can be reduced though driving is

privilege given by state but the live of its citizen depend on their assessment. Medical reports and medical test are important

despite drug and alcohol control to all drivers.

Keywords: Fitness-to-drive, medical assessment, Driving framework, Medical reports


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recommendation not to drive, a restricted driving license, driving suspension or license cancellation (Hammar, Lund & Hugdahl,

2003; Bulmash, Moller, Kayumov , Shen , Wang & Shapiro, 2006; Wingen, Ramaekers & Schmitt, 2006; Austroads, 2006).

While psychiatrists may focus on the impact of medication on fitness-to-drive, occupational therapists are able to take clients

for on-road driving tests and have been noted to emphasize the driver’s physical status, cognitive skills, impulsivity levels and

driving history (Menard, Benoit, Boule-Laghzali, Hebert, Parent-Taillon & Perusse, 2012) to assist determine fitness-to-drive.

Focusing on impulsivity levels may be regarded as important, since impulsivity can be related to risk taking behaviours and

difficulty self-regulating; characteristics present in the profile of those drivers most likely to crash (McNamara & Buckley, 2015).

Menard et al. (2012) additionally found that occupational therapists paid attention to the client’s perception of their driving ability,

factors impacting on their driving capabilities, and identifying goals related to driving. The emphasis was therefore on the

person’s meta-cognitive functions related to self-regulation, risk taking behaviour and on-road driving ability, rather than on the

effects of medication or the medical condition itself. Similar results were reported by Vrkljan, Myers, Blanchard, Crizzle, and

Marshall (2015), with occupational therapists in the study also in favour of the use of an on-road assessment to inform decision

making in clients with a mental health conditions. The on-road assessment was used and seen by most participants as the most

valid means of making fitness-to-drive recommendations.

In response to the high incidence of accidents in Kenya, Kenya's Traffic Act (revised in 2012) requires that every driver of a

public service or commercial vehicle be physically fit (including eyesight and hearing ability) before the license is renewed.

Having a mandatory medical assessment before the renewal of a driving license (every 3 years) will also be in line with Kenya's

new health policy framework (2014–2030). The point remains that there ought to be a clear cut decision that should be made. In

this case, anyone who intends to be a driver should pass through a medical assessment test before getting a driver’s license.

As a factor of necessity, there should be public participation while the stakeholders in the transport, security and health sectors

should seat down and come up with guidelines to be used. There needs to be an agreement on what to be included in the

assessment form, the legal structure and finally a final medical certificate that will be issued before a driving license can be issued

out or renewal done (on termly basis that will be defined). Before all this is done, there ought to be a pilot test to ascertain the

authenticity and effectiveness of the medical assessment test and then when all is done and has been proved as good, it should be

Gazetted (become part of Kenya's law).

2. Research Problem

For millions of people, driving is an important instrumental activity of daily living that contributes to their independence and

physical, economic, and social well-being. When individuals experience a situation that decreases their ability to safely operate a

motor vehicle, such as cognitive decline or a major medical condition, they may need to cease or curtail driving. Clinicians, from

a variety of disciplines (psychologists, neuropsychologists, physicians, occupational therapists, etc.), should be often consulted to

determine if an individual possesses the ability to drive. Each clinical discipline brings its own skill set and perspective to the

assessment of driving capacity. Unfortunately, in many cases, those asked to assess a patient’s ability to drive often lack specific

training and knowledge related to understanding the elements that impact safe driving (Wolfe & Lehockey, 2016). A number of

factors ought to be considered in factoring in the contribution of healthcare professionals to be involved in determining an

individual’s fitness to drive. This study provides an insight into the mental status assessment for Kenyan drivers and provides the

way forward towards ensuring there is decreased crashes in our roads.

3. Objective of the Study

The aim of the study was to assess the medical fitness-to-drive among drivers in Kenyans and provide a framework for

introduction of a mandatory medical assessment for all drivers in Kenya.

4. Literature Review

4.1 Health Assessment Examination

4.1.1 Mental Status Examinations

There are times when an individual’s driving capacity is called into question in a setting (e.g., primary care) where time is

limited and clinicians must rely on brief mental status examinations to screen for cognitive impairment. Such measures include the

Blessed Dementia Scale (Blessed, Tomlinson, & Roth, 1968), Clinical Dementia Rating (Morris, 1993), the Mini-Mental State

Exam (MMSE; Folstein, Folstein, & McHugh, 1975), and the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005).

The MMSE is a popular measure used to screen for cognitive impairment in a variety of clinical settings and diagnoses

(Folstein et al., 1975). As with most screening measures, it was designed as a brief tool, typically requiring 5–10min to administer,


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assessing a broad range of domains including orientation, registration, attention, calculation, recall, language, and visuospatial

perception. Thus, using the MMSE alone to determine fitness to drive may result in overlooking potentially unsafe drivers.

4.1.2 Visual Perception and Visual Spatial Abilities

Driving capacity requires intact visual perception and visual spatial abilities, which are vulnerable to aging and neurological

dysfunction. For example, reductions in visual acuity (Owens, Wood, & Owens, 2007) and visual field loss (Wood et al., 2009)

have been found to be associated with increased crash risk in older adults. However, some research has cautioned against using

visual tests alone when making a determination of an individual’s driving fitness as they are poor predictors of driving

performance (Wood et al., 2009). Thus, while it is imperative to assess visual acuity, visual field integrity, and neglect as part of a

driving capacity evaluation, placing these factors within the context of a broader cognitive framework to better determine an

individual’s ability to drive safely has been suggested (Anstey, Horswill, Wood, & Hatherly, 2012).

Measures that assess visuospatial abilities often incorporated within a traditional neuropsychological evaluation battery include

Block Design (Wechsler, 2008), clock drawing tests, complex figure tests, judgment of line orientation tests, the Hooper Visual

Organization Test (HVOT; Hooper, 1958), and the Motor-Free Visual Perceptual Test (MVPT; Colarusso & Hammill, 2003).

4.1.3 Attention

Distracted driving, which occurs when a driver diverts attention away from critical activities for safe driving and toward a

competing activity, poses a serious threat to safety even among healthy individuals (Regan, Hallet, & Gordon, 2011). Thus,

thorough assessment of various aspects of attention is imperative when determining fitness to drive, particularly for individuals

who have conditions that may affect attentional abilities. For example, impairments in selective attention were among the most

predictive for on-road failures in a study of individuals with Huntington’s disease (Devos et al., 2014).

4.1.4 Processing Speed

Speed of information processing appears to be an important aspect of safe driving, as it likely plays a role in the ability to

react, brake, and efficiently adapt to new situations. There has been some discussion in the literature about the influence of

processing speed on poor performance found on measures of attention. For example, upon adjustment for slowness of information

processing, divided attention has been found to be relatively unimpaired in brain-injured patients (Brouwer, Ponds, Van

Wolffelaar, & Van Zomeren, 1989; Veltman, Brouwer, Van Zomeren, & Van Wolffelaar, 1996).

Thus, thorough assessment of processing speed is recommended when determining driving capacity, and can include measures

such as Trail Making Test Part A (Reitan, 1958), Symbol Digit Modalities Test (SDMT; Smith, 1982), WAIS-IV subtests such as

Symbol Search and Coding (Wechsler, 2008), as well as complex reaction time tests (Wolfe & Clark, 2012).

4.1.5 Executive Functioning

Executive functioning has many face valid implications for carrying out complex behaviors associated with safe driving

(planning, decision-making, judgment, response inhibition, etc.). Many clinical groups are vulnerable to executive dysfunction,

and are thus at risk for unsafe driving. In the Aksan et al. (2015) study described previously, set shifting was a significant

predictor of on-road navigation performance in older drivers with and without neurodegenerative diseases.

Executive dysfunction was found to predict underperformance on a driving assessment in a sample of stroke survivors (Motta,

Lee, & Falkmer, 2014). Specifically, the Trail Making Test Part B and the Key Search Test of the Behavioural Assessment of the

Dysexecutive Syndrome (Burgess & Alderman, 1996) were key predictors in this study.

4.1.6 Driving-specific Measures

There are several driving-specific measures of driving fitness that incorporate simulation and/or on-road evaluations typically

carried out by other disciplines skilled in driving assessment (occupational therapy) that are beyond the scope of this review.

However, there are several measures that are more likely to be incorporated into a neuropsychological evaluation of driving

capacity. Such tests may offer increased opportunities or buying during driving capacity assessment while discussing evaluation

results with examinees as driving-specific measures typically offer more face validity compared to traditional neuropsychological

evaluation measures.

For example, the Neuropsychological Assessment Battery (NAB; Stern & White, 2003) has one subtest called the Driving

Scenes Test that was designed to measure several aspects of visual attention (i.e., working memory, visual scanning, attention to

detail, and selective attention). Examinees are exposed to a scene from the perspective of a driver, and are subsequently asked to

identify everything that is new or absent from a second similar scene. This is done for a total of six different scenes. In a study


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used to investigate the ecological validity of this subtest, the Driving Scenes Test and an on-road driving test were administered to

24 healthy older adults and 31 individuals with very mild dementia. Findings indicated a strong relationship between scores on the

Driving Scenes Test and on-road driving test score, and the subtest was able to correctly classify 66% of the participants into three

safety categories (safe, marginal, or unsafe) for driving (Brown et al., 2005). In contrast, results from another study investigating

the utility of this subtest to predict driving status among participants with PD, Alzheimer’s disease, and healthy older adults did

not find the Driving Scenes test to be a useful tool (Grace et al., 2005).

The Rookwood Driving Battery (McKenna, 2009) was designed to measure the processing of information in visual, praxic,

and executive systems that were deemed essential for safe driving. This battery demonstrated overall high accuracy rate in

predicting a failing performance (92%) and moderate accuracy in predicting a passing performance (71%) on an on-road test in

142 individuals with various neurological conditions (McKenna, Jefferies, Dobson, & Frude, 2004).

Another driving-specific measure is the Stroke Driver Screening Assessment (Nouri & Lincoln, 1994), which was originally

developed in the United Kingdom to measure driving related visual attention and executive functions in stroke survivors. It was

more recently modified for use in the United States, which generally consisted of converting the test stimuli to reflect the laws and

standards of driving in the United States (Akinwuntan et al., 2013). In a pilot study investigating the potential usefulness of the

U.S. version, Akinwuntan et al. (2013) found high accuracy for predicting driving performance among participants with a history

of stroke and healthy individuals. While these findings suggest that this version has the potential to be a good predictor of driving

performance.

4.1.7 Assessing Fitness to Drive

A fitness to drive assessment needs to cover the triad of motor function, visual-spatial abilities, and cognition, with the overall

assessment emphasizing functional abilities rather than medical diagnoses. Along with the fact that functional assessments are

generally best performed by specialized practitioners, such as occupational therapists, physical medicine specialists, or

physiotherapists, this fundamental directive raises the important question of whether the primary care physician working in the

standard office setup is the best person to perform such assessments. Although the most straightforward component of the triad

might seem to be the standard systematic physical examination, it is not without dilemmas. A physical exam is primarily designed

to detect the presence or absence of disease, not to assess function and safety: absence of disease does not translate to “fit to

drive.”

Whatever overall assessment is undertaken, the findings should lead to one of three designations: pass/safe to drive, fail/unsafe

to drive, and indeterminate/requiring further testing. The assessment itself could be tripartite: visual function conducted by those

with adequate equipment (optometrists or ophthalmologists), cognitive testing by a formalized screening scale and conducted by

trained personnel, and a physician exam for those medical diagnoses clearly designated as prohibiting driving. Any physician-

conducted medical examination to ascertain medical diagnoses incompatible with safe driving should be the final, not the first,

component of a fitness to drive assessment (Molnar, Byszewski & Marshall, 2005).

4.2 Conditions Leading to Increased Road Carnage

4.2.1 Chronic Health Conditions

Certain chronic health conditions may contribute to reduced driving proficiency due to their impact on neurocognitive,

sensory, and/or motor ability. For example, unstable and/or untreated cardiac conditions with potential for sudden, unpredictable

loss of consciousness (syncope due to brady- or tachyarrhythmia), uncontrolled diabetes, severe/unmanaged kidney disease,

untreated sleep apnea or narcolepsy, and significant visual disorders (macular degeneration, visual field deficits) are some

examples of medical conditions that may further contribute to reduced ability to drive safely (NHTSA, 2012; Schultheis &

Whipple, 2014).

Many individuals (in countries where medical assessment for drivers are carried out) who are referred for evaluation of driving

capacity have more than one potential risk factor that could lead to reduced driving ability. One must consider the cumulative

effects of all known factors in determining whether driving privileges need to be limited or discontinued. Additionally, clinicians

must be aware of the conditions that are deemed detrimental to driving, and how they are measured, in their particular

state/province as it often varies (Galski & McDonald, 2009).

4.2.2 Mental Illness

Studies have found that people with mental illness may be at greater risk of involvement in vehicular accidents, because of

both their psychiatric illness and other comorbidities (such as general medical conditions and substance abuse). People with

substance use disorders have an elevated risk of death by vehicular accident, and “hidden” suicides are thought to account for

between 1% and 7% of road fatalities (Menard I, Korner-Bitensky, 2008; Callaghan R, Gatley J, Veldhuizen, 2013).


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4.2.3 Dementia

Drivers with dementia are at higher risk of motor vehicle collisions, yet many drivers with mild dementia might be safely able

to continue driving for several years. Because safe driving is dependent on multiple cognitive and functional skills, clinicians

should carefully consider many factors when determining if cognitive concerns affect driving safety. Drivers with dementia are

overall 2.5 to 4.7 times more likely than healthy, age-matched controls to be involved in motor vehicle collisions, yet many

persons with mild dementia can safely continue to drive for several years (Reger, Welsh, Watson, Cholerton, Baker & Craft,

2004). Decisions regarding driving safety still need to be made when assessing any person who might be cognitively impaired.

Lack of knowledge about whether or not a person with dementia is driving does not protect physicians from legal consequences

should that person experience an at-fault motor vehicle crash.

Many people with Mild Cognitive Impairment (MCI) or dementia have already voluntarily limited or ceased driving in most

developed countries. However, some have not; and it becomes a clinical and legal responsibility to make reasonable efforts to

determine that those who are continuing to drive are safe to do so (Fisher & Thomson, 2014).

A person should be warned in advance that driving safety is one factor that has to be considered in all cases where there are

memory problems. This may be done by highlighting the issue in the information package or pamphlet about the service, sent out

prior to the person’s initial assessment. Otherwise it needs to be explained directly to all those who are being assessed for

problems with their memory. It also needs to be emphasized both to the person and their families, when necessary, that they have

a legal obligation to do this for the sake of both their safety and that of the other drivers on road (Fisher & Thomson, 2014).

An explanation should be made to people and their families that there is a clear link between memory impairment, dementia

and unsafe driving, and that this is the reason for concerns and apparent focus on driving safety. This is particularly important for

those clients who have a Mild Cognitive Impairment (MCI) or similar, and whose condition may worsen over the years ahead.

They should be warned about the prospect of becoming unfit to drive in the future, if this is a real prospect for them. All these

discussions should become a normal part of the clinical interaction with patients (Fisher & Thomson, 2014).

4.2.4 Age

There are currently 23 million automobile drivers over the age of 65 years. This number will increase by another 15% in the

next 20 years, making the total number of older drivers equal to 25% of individuals on the highways (Fain, 2003). Of concern is

the safety of the roadways as the effects of aging take their toll upon drivers nationwide. Organizations such as the National

Highway Transportation Safety Administration are now considering potential solutions and fearing a problematic future (National

Highway Transportation Safety Administration, 2002). Age alone does not cause impairment behind the wheel; it is the mental

and physical changes associated with aging that cause the problem.

As older people remain healthier for longer, driving will undoubtedly continue to play a major role in their ability to stay

mobile, independent, and engaged in their community. Hence, there is a need to better understand and delineate the changes that

occur in the attitudes and perceptions of older drivers as they continue to age. This is especially true because older adults are

sometimes perceived as being an unsafe presence on our roads (which is due in part because of both previous literature and media

coverage of accidents involving older drivers (Langford et al. 2008)), even though are more likely to hold “pro-traffic safety”

stances on a variety of issues, including more government intervention and funding with regard to traffic safety and support for

police enforcement of traffic laws compared to younger individuals (Girasek, 2013).

4.2.5 Hypertension and Blood Pressure

Hypertension is a leading risk factor and primary contributor to Cardiovascular Vascular Disease (CVD). In 2000, 972

million people were reported to have hypertension, a prevalence rate of 26.4% and this number is expected to increase to 1.54

billion by 2025 (Kearney et al., 2005). In sub-Saharan Africa, the overall prevalence of hypertension in 2008 was estimated at

16.2% (95% CI: 14.2 - 20.3) and in the Africa region, about 74.7 million (95% CI: 65.2 to 93.4 million) individuals were

estimated hypertensive (Ogah, 2012).

In developed countries such as the United States, hypertension has been found to be a largest contributor to cardiovascular

mortality. Furthermore, developing countries such as Kenya and Nigeria face enormous challenge posed by the social and

economic effects of increasing morbidity and mortality due to CVDs (Gersh et al., 2010). Non-communicable diseases (NCDs)

affect populations that are still economically active such as drivers.

Studies have shown that drivers including other workers whose occupation is professional driving are at a higher risk of

ischeamic heart conditions (Sangaleti et al., 2014). The conditions that drivers work under create a favorable environment for the

development of NCDs such as hypertension. These include sedentary lifestyle, poor diets, poor access to health care and stress. In

addition, all these risk factors may contribute to obesity which is another important risk factor for hypertension.


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Commercial drivers as well as other drivers undergo high stress, their diets are not controlled, smoke while on the wheel, drink

alcohol before driving, may be drunk while driving and may not have time to do one medical checkup, (Chidoka, 2013). Some are

already on treatment for hypertension but are not adherent to anti-hypertensive treatment while they still drive passengers and

putting them at risk of losing lives. Hypertensive encephalopathy has led to many auto-crashes and many deaths among drivers

and passengers (Akanbi et al., 2009).

It is generally accepted that while high blood pressure can lead to heart attacks and strokes, low blood pressure can cause

dizziness, blurred vision and confusion. All of these are dangerous conditions when the focus is needed in dangerous activities

such as driving a motor vehicle. There is medication available to treat both high and low blood pressure. Drivers who are aware of

their abnormal blood pressure and who are using prescription medication should always be alert to the side effects of medication

more so when they are driving.

4.2.6 Drugs and Alcohol Consumption

The behaviours involved in driving a motor vehicle are also impaired by alcohol to varying degrees. Certain skills important

for driving, in particular the brain’s ability to observe, interpret, and process information from the eyes and other senses are

impaired even at the lowest levels of alcohol concentration in the blood that can be measured reliably (Moskowitz & Burns,

1990). It seems reasonable to assume that a driver cannot operate a vehicle safely if information processing is slowed, visual

perception is degraded and/or the ability to allocate attention to multiple sources of information limited.

It is important to understand that crashes are not limited to drivers with high levels of alcohol. Rather, there is a significant risk

that extends to low and moderate levels. Drivers need to know that they are impaired and are at increased risk of crash when they

have consumed even small amounts of alcohol. The safety-minded consumer will restrict alcohol use to times and places that do

not include driving.

More generally, it has now become an important issue to understand whether psychotropic drugs, which are being increasingly

used, can affect driving performance. It is in particular a matter of debate whether psychoactive drugs, such as benzodiazepine,

will affect the overall nervous system, resulting in sleepiness for instance, or whether more specific effects on perceptual abilities

can be evidenced. For instance, recent reports suggest that benzodiazepine use increase significantly the risk of motor vehicle

accidents. It is proposed that, even if no direct relation between drug administration and driving performance can be evidenced,

caution has to be exercised, because of induced sleepiness.

4.2.7 Visual Abilities

The human factors governing road-user behavior predominantly involve visual feedback, visual performance, speed

adaptation, judgment of relative speed, judgment of spacing, overtaking, reaction time, etc. Some personality factors of the driver

may contribute in a significant manner toward road traffic hazard involvement.

Human functional failure can be assessed by identifying the limits in human functions that allow a person to adapt to changing

situations, for example, experience, visual abilities, risk taking behaviour, etc. With respect to driving, human functional failures

can arise from endogenous (inabilities of drivers) and/or exogenous factors (environment which influences endogenous factors)

(Elslande & Fouquet, 2007).

Vision skills are among the prominent physical functions that assist a driver in perceiving traffic situations. These functions

are difficult to quantify and to consider them in road safety evaluation is a difficult task. In heterogeneous and complex traffic

conditions commonly witnessed, drivers need to remain vigilant throughout, to safely respond to vehicles of different sizes

coming their way abruptly from any direction. The complexities further magnify while driving heavy-vehicles. This has caused an

increasing number of heavy-vehicle crashes in many cities (Kaul, Sinha, Pathak, Singh, Kapoor, Sharma & Singh, 2005).

Assessing the influence of visual abilities on crash involvement is essential in identifying the underlying causes of accidents due

to driver fault.

4.2.8 Hearing

Being a road user demands cognitive skills in order to assemble new information in the traffic environment, apply it to stored

knowledge, and make decisions. Hearing loss is one of the most frequent sensory deficits in humans, with a prevalence of

approximately 10% in the general population in the western world, and it is a common chronic condition among the elderly

(Stevens et al., 2013). Hearing loss entails a loss of auditory information, which may affect behavior in traffic and might reduce

traffic safety.

Hearing is important for our sense of spatial orientation and temporal resolution and thus of high relevance for traffic safety.

Sounds behind us provide information about events that it not possible to see and we receive information about positions and


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distances. Most frequency spectra of exterior tires or road noise display a prominent peak in the range of 700–1300 Hz (Sandberg,

2003). Since the noise from cars driving on roads is mainly in low frequencies, i.e. with low-pitched sounds (Wu, Stangl, Bentler,

& Stanziola, 2013), individuals with presbycusis should be able to hear these specific sounds rather well.

5. Research Findings

Driving is a complex skill that requires adequate information processing, sustained attention or vigilance, concentration, and a

good memory. Drivers must have control over impulse and risk-taking, and their judgment should be mature and unimpaired, with

the ability to anticipate the actions of other road users. Problem-solving ability and hazard perception are necessary throughout the

drive. It can be appreciated, therefore, that many psychiatric disorders may present problems with driving. Decisions regarding

fitness to drive on psychiatric grounds, including behavior disorders and drug abuse, can be difficult because of the subjective

nature of the symptoms and difficulty in prediction of disturbed behavior. Moreover, psychiatric drug treatments can produce

changes in perception, information processing and integration, and psychomotor activity that can disturb and/or interfere with the

ability to drive safely.

It should be realized that most of the psychiatric outpatients treated in many mental health center have some cognitive

impairment that implies ineligibility to have a driver's license. Most mental illnesses tend to reduce activity and interest, and

therefore possibly the use of a car. According to current regulations, it is the license holders’ legal responsibility to notify the

authorities if they have a psychiatric condition that may affect safe driving; however, none of the driving persons can freely notify

the traffic authorities that they have had a psychiatric condition that may affect safe driving. No patient has stopped driving,

despite their recognizing that their ability to drive is somehow damaged.

Many of the drivers involved in accidents are impaired owing to alcohol, drugs, illness, or emotional disorder. It may be

worthwhile to note that many traffic accidents is attributable to impairment from medications. This then brings the notion that a

person who is acutely psychiatrically ill is likely to be a source of danger while driving because of the impairment that their state

of mind produces. When recovered, that person will be well enough physically and mentally to drive. However, there is usually a

risk of relapse.

The role of primary care physicians in ensuring road safety through the identification of patients with psychiatric conditions

that make it unsafe for them to drive is an important one which should be the norm in Kenya if accidents are to be reduced to a

minimum. It is generally recognized to be the duty of physicians to report psychiatrically unfit drivers, although it is the motor-

vehicle licensing authority that makes the actual decision to revoke a driving license. Primary care physicians therefore can face

an ethical dilemma when they consider reporting a patient to the licensing authorities: the report will help ensure that neither the

patient nor others on the road are endangered, but may damage the patient-physician relationship, since driving restrictions may be

perceived by the patient as unnecessary, even punitive. At the present time, there is no restriction for a patient to cease driving

when they are found to be mentally unfit or challenged.

6. Conclusions and Recommendations

6.1 Conclusions

Driving is a serious responsibility and it demands and deserves full and undivided attention of the driver. However, there are

many driver distractions which contribute to crashes and injuries. The level of safety of road system is influenced by all road users

among which the driver plays a crucial role in road safety through scanning, processing and applying appropriate action patterns

toward oncoming stimuli. Due to the escalating fear of unsafe driving conditions, testing and evaluation of driver’s

psychophysical ability traits needs to become an integral part of road safety. Driving is a skill that requires constant and complex

co-ordination of mind and body of the driver. It involves multi-task activities, i.e. operating heavy machinery at high speed,

navigating across changing terrain, calculating speeds and distances and responding to all the other drivers and obstacles. It

becomes all the more difficult to drive on many roads where there is lack of lane discipline and the traffic is extremely

heterogeneous. A driver’s ability to manage driving-related psychomotor functions varies widely and can change from day-to-day

depending upon his level of stress and fatigue.

Evaluating capacity to drive is different from evaluating capacity to make decisions or execute legal transactions. Driving

involves a mix of mental, physical, and sensory abilities. It is also known that driving has serious risk not only for oneself but also

for others as well. And the determination of capacity to drive initially rests not with a judge but with the body governing the issue

of licenses which is the traffic department.

It is worth noting here that the capacity to drive may become somewhat passé with the advent of driverless cars, but until then,

there will be a need for a sound conceptual framework to evaluate a driver’s ability to safely operate a car on the road. This may


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be done though an assessment test that should be introduced to be applied to all drivers who are on the road. This should be

applied to all drivers irrespective of the current licenses they hold. All should pass though this assessment test.

When a person is assessed as having problems with memory or dementia, or has received this diagnosis in another service,

then there should be a thorough review of their condition. A comprehensive assessment should include questions about their

mental and physical health; functional status, medications and a standardized cognitive test should be administered such as the

MMSE, MOCA, RUDAS, ACE-III or equivalent. Collateral history should be sought from family or carers. At the conclusion of

the assessment, which may take place over more than one visit, and may require phone calls to family members for information,

clinicians should be able to make the diagnosis and make an assessment of the likely dementia stage or severity, and hopefully

will have some idea about the most likely aetiology of the dementia.

However considering the importance of commercial drivers on the economy, it is imperative to look at prevalence of

hypertension as well as its risk factors in this population. The results would provide important information to be used at personal,

community levels and workplace levels. Such information could be used to develop intervention strategies targeted at the

prevention of hypertension and the promotion of the general health and well-being of drivers.

A simple, multi-disciplinary test comprising of assessment of vision and cognitive tests, hazard perception and change

detection tests if used will have a significant capacity to evaluate how safe or unsafe a driver is. To assess visual fitness of a

driver, visual acuity, contrast sensitivity and peripheral vision form critical components. Impairment in visual skills will be a

significant causal factor for road crashes in drivers.

6.2 Recommendations

It is important that the physician recommend to the patient, preferably with his or her family members present, to refrain from

driving. It is also recommended that physicians provide a patient with a written letter regarding driving recommendations.

As part of the duty to report, physicians should release only the minimal amount of pertinent information and should ensure

that confidentiality of the information is secure. The provider must complete and submit a driver's condition or behavior report.

Assessing medical fitness to drive should include a physical examination assessing physical limitation and screening for

cognitive. The history should focus on physical disabilities and activities of daily living that may affect a patient's ability to safely

enter and exit the vehicle, in addition to the ability to safely operate the vehicle. The history should include questions on whether

the patient has had traffic collision violations, near misses, or become lost in familiar areas. A driving history from family

members or other acquaintances may be informative.

An assessment of activities of daily living (meal preparation, money management) is important given its association to driving

ability. There is a good correlation between activities of daily living and returning to driving in patients with stroke, Parkinson's

disease and traumatic brain injury. It is particularly important to assess and review with the patient, current and over-the-counter

medications that may cause drowsiness and potentially increase motor vehicle collision rates. Patients should be reminded not to

consume alcohol while driving.

A thorough neurologic assessment should be performed, including a Mini-Mental examination. In some cases,

neuropsychiatric testing may be useful in determining the extent and type of cognitive impairment. In patients who show signs of

cognitive impairment, additional assessments should include neuropsychiatric, and on- and off-road testing, depending on the

tools available at the facility.

While guidelines are not currently available for making objective medical determinations of a patient's competence to drive in

the face of the neurological disorders, applying the recommended assessment tools combined with best clinical judgments should

aid in counseling patients in their driving abilities or restrictions.

Driving is a privilege granted by the state, not a right issued by a physician. The current accepted reference standard to

determine fitness-to-drive is an on-the-road test administered by a qualified driving performance examiner. These tests evaluate

driving skills in a controlled environment and thus may not equate to all possible driving conditions. After the occurrence of

certain specified medical conditions, testing of driving abilities may be legislatively controlled by some government laws which is

not effectively carried out as should be.

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