Marys Medicine

Approach to assessing fitness to drive in patients
with cardiac and cognitive conditions
Frank J. Molnar MSc MD CM Christopher S. Simpson MD
Physicians are often uncomfort- able assessing fitness to drive; many have never been taught OBJECTIVE To help physicians become more comfortable assessing
how to perform such an assessment. the fitness to drive of patients with complex cardiac and cognitive The physical examination was devel- oped to detect the presence and sever- QUALITY OF EVIDENCE The approach described is based on the
ity of disease, not to assess functional authors' clinical practices, recommendations from the Third Canadian skills, such as ability to drive. Telling Consensus Conference on Diagnosis and Treatment of Dementia, and patients that they are no longer fit to guidelines from the 2003 Canadian Cardiovascular Society Consensus Conference.
drive can be traumatic for patients, MAIN MESSAGE When assessing fitness to drive in patients with
their families, and health care provid- multiple, complex health problems, physicians should divide conditions ers.1 Furthermore, there is evidence that might affect driving into acute intermittent (ie, not usually present that mandatory reporting of unfit driv- on examination) and chronic persistent (ie, always present on examina- ers to regulatory bodies might adversely tion) medical conditions. Physicians should address acute intermittent affect patient-physician relationships, conditions first, to allow time for recovery from chronic persistent potentially leading to un-intended and features that might be reversible. Decisions regarding fitness to unforeseen suboptimal outcomes.2-9 drive in acute intermittent disorders are based on probability of On the other side of the coin, report- recurrence; decisions in chronic persistent disorders are based on ing unsafe drivers is legally mandated in most Canadian jurisdictions, Assessing fitness to drive is challenging at the best of times. When patients have multiple comorbidities, assessment becomes even where it is not, physicians can even more difficult. This article provides clinicians with systematic ap- still be found liable if they fail to report proaches to work through such complex cases.
a patient who is later determined to have caused harm to others as a result of medical impairment behind the OBJECTIF Aider le médecin à se sentir plus à l'aise pour évaluer la
wheel. Accurate assessment of fitness capacité de conduire des patients présentant des conditions car diaques to drive, however, allows physicians to et cognitives complexes.
help patients avoid disabling injuries QUALITÉ DES PREUVES La méthode décrite est fondée sur
or death and to help patients and their l'expérience clinique de l'auteur, sur les recommandations de la families avoid the grief and legal reper- Troisième conférence canadienne de consensus sur le diagnostic et le cussions associated with contributing traitement de la démence, et sur les directives de la Conférence cana- to the injuries or deaths of other road dienne de consensus 2003 de la Société canadienne de cardiologie.
users or bystanders.
PRINCIPAL MESSAGE Lorsqu'il évalue la capacité de conduire de
To better prepare physicians to meet patients présentant des problèmes de santé multiples et complexes, le this important societal role, we present médecin devrait distinguer, parmi les conditions médicales susceptibles our clinical approach to assessing fit- d'affecter la conduite, celles qui sont aiguës intermittentes (c.-à-d. généralement absentes lors de l'examen) et celles qui sont chroniques ness to drive in the context of a fictitious persistantes (c.-à-d. toujours présentes lors de l'examen). Il devrait case, which contains several common d'abord s'occuper des conditions aiguës intermittentes pour laisser elements that might be encountered in le temps aux conditions chroniques persistantes potentiellement everyday practice.
réversibles de guérir. Pour les problèmes aigus intermittents, la décision repose sur la probabilité de récurrence; pour les problèmes chroniques This article has been peer reviewed.
persistants, elle repose sur l'évaluation fonctionnelle.
Cet article a fait l'objet d'une révision par des pairs.
CONCLUSION L'évaluation de la capacité de conduire est presque
Can Fam Physician 2010;56:1123-9 toujours difficiel. En présence de facteurs multiples de morbidité, la difficulté est encore plus grande. Cet article suggère une approche systématique pour aborder ces cas particulièrement complexes.
This article is eligible for Mainpro-M1 credits. To earn
credits, go to and click on the Mainpro link.
Vol 56: NoVemberNoVembre 2010 Canadian Family PhysicianLe Médecin de famille canadien 1123
Clinical Review Assessing fitness to drive in patients with cardiac and cognitive conditions
Case description

Furthermore, general lists such as this do not provide Mr M. is an 84-year-old widower living alone. His guidance on how to sequence complex assessments. medical history includes diabetes with mild periph- A helpful addendum can be borrowed from the decades- eral neuropathy and coronary artery disease with long history of dividing medical conditions into acute ver- a remote myocardial infarction (MI). His daughter sus chronic conditions, which has inevitably been adapted telephones you to report that over the past 6 months to ascertain medical fitness to drive.1,10,13 A further enhance- Mr M. has become repetitive and has been making ment of the acute versus chronic distinction is to divide the increasingly frequent errors in banking activity and problems identified into acute intermittent and chronic per- medication use. Before you have a chance to assess sistent disorders. Chronic persistent disorders can be fur- him, he is admitted to hospital with delirium, hyper- ther divided into reversible versus irreversible conditions. glycemia, hypotension secondary to dehydration and Acute intermittent disorders—known as "acute or fluctuat- medication overuse, syncope, and a non–ST-segment ing illnesses" in the CanDRIVE mnemonic—are medical elevation MI.
problems that can suddenly incapacitate an otherwise Mr M. experiences several bouts of sustained, low-risk driver. The symptoms associated with these hemodynamically significant ventricular tachycardia (VT) and is eventually fitted for an implantable car- Figure 1. The CanDRIVE fitness to drive mnemonic
dioverter defibrillator (ICD). He is found to have triple- vessel disease, which is not amenable to any revascu-larization procedure, and has a left ventricular ejection fraction (EF) of 28%, with moderate to severe mitral Dementia, delirium, depression, executive function, memory, regurgitation; he is stabilized after beginning a regi- judgment, psychomotor speed, attention, reaction time, and visuospatial function men of acetylsalicylic acid, a statin, a β-blocker, amio-darone, an angiotensin-converting enzyme inhibitor, CUTE OR FLUCTUATING ILLNESS and a nitrate.
Delirium, seizures, Parkinson disease, and syncope or Upon discharge, Mr M. and his daughter are told presyncope (cardiac ischemia, arrhythmia, postural that he "should not drive for a few months" and that you, his family physician, will have to decide EUROMUSCULOSKELETAL DISEASE when it is safe for him to drive. When you see him, OR NEUROLOGICAL EFFECTS he asks when he can resume driving. Notable find- Speed of movement, speed of mentation, level of conscious- ings on examination include symptomatic postural ness, stroke, Parkinson disease, syncope, hypoglycemia or hypotension, slow mentation, and a Mini-Mental hyperglycemia, arthritis, cervical arthritis, and spinal stenosis State Examination score of 22 out of 30. He denies any symptoms of angina and has New York Heart Association (NYHA) functional class II symptoms. His Drugs that affect cognition or speed of mentation, such as benzodiazepines, narcotics, anticholinergic medications (eg, most recent ICD check was unremarkable, with no tricyclic antidepressants, antipsychotics, oxybutynin, evidence of recurrent sustained arrhythmias or deliv- dimenhydrinate), and antihistamines ery of device therapies. What should you do? Sources of information
Patient or family report of accidents or moving violations The approach described below is based on the authors' clinical practices, recommendations from the Third N-CAR EXPERIENCES Patient or family descriptions of near accidents, unexplained Canadian Consensus Conference on Diagnosis and damage to car, change in driving skills, loss of confidence or Treatment of Dementia ( self-restriction, becoming lost while driving, others refusing Recommendations_CCCDTD_2007.pdf),11 and the 2003 to be driven by patient, need for assistance of a copilot Canadian Cardiovascular Society Consensus Conference (particularly concerning would be the need for cues to avoid dangerous situations that could result in a crash), and other drivers having to drive defensively to accommodate changes in the patient's driving skills Acuity, visual field defects, glare, contrast sensitivity, Main message
comfort driving at night When faced with complex cases, general lists such as the CanDRIVE mnemonic presented in Figure 1 can Physician's opinion regarding whether ethanol use is have limitations. Figure 1 does not represent a scale excessive and whether alcohol is imbibed before driving with a scoring template, but rather a guide to what infor- mation physicians should gather to allow them to best Adapted from Molnar et al1 with permission.
employ their clinical judgement regarding fitness to drive. 1124 Canadian Family PhysicianLe Médecin de famille canadien Vol 56: NoVemberNoVembre 2010

Assessing fitness to drive in patients with cardiac and cognitive conditions Clinical Review
conditions (eg, syncope, seizures) can cause sudden changes arrhythmias, myocardial rupture, and symptomatic heart in cognition or level of consciousness but cannot be detected failure after the first month, and allows a "stabilization" by examination, as they are not present most of the time. phase for new medical therapy. If patients have Decisions regarding when patients can resume driving are undergone coronary artery bypass grafting, they must based on the probability of recurrence. Chronic persistent dis- wait 3 months before resuming driving.
orders are medical problems that are present at all times and can be detected by examining and testing patients.
Ischemic cardiomyopathy (level III evidence).12 In addi- In the case of Mr M., first decide when he might tion to having suffered a recent MI, the patient was also resume driving based on the diagnosed acute intermit- found to have substantial cardiomyopathy, with an EF of tent disorders (eg, post-MI, arrhythmia treated with ICD). 28%. The moderate to severe mitral regurgitation indi- This will provide time for recovery from any associated cates that some of the EF might be moving in a backward chronic persistent features that might be reversible (eg, direction, and that the forward EF is likely less than 28%. delirium, postural hypotension), allowing for a more While ischemic cardiomyopathy is a persistent condi- accurate assessment of irreversible chronic persistent tion, the risk posed in a driving context is that of cardiac conditions (eg, dementia). To demonstrate, we will dis- arrhythmias and sudden death—acute intermittent condi- cuss each of these issues in turn.
tions. Patients with severe cardiomyopathy who are pri- vate drivers face no restriction if they have NYHA class Assessment for acute intermittent disorders
I (ie, no symptoms and no limitation in ordinary physi- Post-MI (level III evidence).12 Private drivers (ie, those cal activity), class II (ie, mild symptoms [such as mild with noncommercial licences) who have suffered non– shortness of breath or angina] and slight limitation dur- ST-segment elevation MIs with substantial left-ventricle ing ordinary activity), or class III (ie, marked limitation in damage can resume driving 1 month after the event, activity due to symptoms, even during less-than-ordinary presuming there are no additional comorbidities that activity such as walking short distances) symptoms. In impose a longer waiting period. This recommendation contrast, commercial drivers with an EF of less than 35% is based on the rapidly decreasing risk of serious are no longer eligible for licensure, and commercial driv-ers with NYHA class III or IV (ie, severe limitations, with Grades for recommendations for
symptoms experienced even while at rest) symptoms are specific clinical actions
deemed ineligible to drive regardless of their EF.
Grade A: Good evidence to recommend the clinical
Ventricular tachycardia and ICD implant (level III evi- dence).12 The patient suffered hemodynamically unstable Grade B: Fair evidence to recommend the clinical
VT and was implanted with an ICD for secondary preven- tion indications. The presence of VT makes the patient Grade C: Existing evidence conflicts and does not
ineligible to drive for 6 months (during which time there allow making a recommendation for or against must be no recurrences). The implantation of the ICD for taking the clinical action; however, other factors secondary prevention also imposes a 6-month restriction.
might influence decision making The Canadian Cardiovascular Society guidelines state Grade D: Fair evidence to recommend against the
that when more than one disqualifying medical condi- tion is present at the same time, the most restrictive Grade E: Good evidence to recommend against the
recommendation is to be applied (level III consensus).12 Therefore, for this patient's cardiac disease portfolio, a Grade I: Insufficient evidence to make a
6-month suspension from driving is recommended, dur- recommendation; however, other factors might ing which time he must have no recurrence of his VT, influence decision making must not have another MI, and must not deteriorate to NYHA class IV symptoms.
Assessment of chronic persistent disorders
Levels of evidence
Delirium. In the period following discharge from hospi-tal, residual delirium is a concern. Florid delirium is char- Level I: At least one properly conducted randomized
acterized by the following features: sudden onset and controlled trial, systematic review, or meta-analysis short duration; new-onset unpredictable hourly fluctua- Level II: Other comparison trials, non-randomized,
tions in cognition; new-onset hallucinations; decreased cohort, case-control, or epidemiologic studies, and attention or concentration; and changes in level of con- preferably more than one study sciousness. When patients recover from such obvious Level III: Expert opinion or consensus statements
deliriums in hospital, it can still take weeks to months for their mentation to return to normal. Many suffer from a Vol 56: NoVemberNoVembre 2010 Canadian Family PhysicianLe Médecin de famille canadien 1125
Clinical Review Assessing fitness to drive in patients with cardiac and cognitive conditions
slowly resolving subclinical delirium, which presents as slow mentation, decreased attention (ie, decreased focus), Box 1. Common causes of postural hypotension:
and altered scores on cognitive tests.
3D-AID acronym. Those with an underlying dementia are more prone to developing delirium (ie, recurrent delirium or delirium pre- Causes associated with a compensatory cipitated by minor stresses are red flags suggesting under- lying dementia). When such patients become delirious, the delirium often takes longer to resolve (weeks or months) and resolution might be incomplete, leaving them with per- manent cognitive loss. The dementia is often "unmasked" by the delirium, leaving family members with the impres- sion that the dementia began during hospitalization.
Anorexic drugs—narcotics, digoxin, In Mr M.'s case the slow mentation suggests delirium, antibiotics, cholinesterase inhibitors and the history of cognitive difficulties over the previous 6 months suggests an underlying dementia. It would be reasonable to tell the patient that he cannot drive for 6 months owing to his cardiac issues, during which time (eg, levodopa and carbidopa) his noncardiac issues can be assessed and treated (Figure Antidepressants (eg, anticholinergic tricyclics) 1). During this recovery time, the physician can wean Antipsychotics (anticholinergic effects) Mr M. off medications that might be contributing to the Anti–benign prostatic hypertrophy medications delirium (eg, benzodiazepines, narcotics), search for and (eg, terazosin hydrochloride, tamsulosin hydrochloride) treat reversible causes (eg, infection, postural hypoten- Causes that present with lack of sion [Box 1]), and decide if it is safe for Mr M. to continue living alone (eg, assess risks of malnutrition, medication errors, falls, fire, and inability to address emergencies). Diabetic autonomic neuropathy Should relocation to a supervised setting become neces- (ie, consider if patient has peripheral neuropathy) sary, the family can be directed to online resources (such Low levels of vitamin B12 as "Home to Retirement Home: A Guide for Caregivers of Persons with Dementia," available from www.rgpeo.
com/en/resources/RRR_Guide_Sept_09.pdf). As the Parkinsonism (ie, Parkinson disease, progressive delirium clears in a safe setting, the physician can assess supranuclear palsy, multisystem atrophy) the patient to determine if he has an underlying dementia.
Idiopathic conditions (ie, pure autonomic failure)
Depletion of norepinephrine from sympathetic Dementia. The assessment of fitness to drive in demen-tia is based on very limited evidence. Guidelines recom- mend employing the Mini-Mental State Examination,10 the clock-drawing test,14 and the Trail Making Test (parts A and B).15 In more advanced stages of dementia, performance funded a 5-year longitudinal prospective cohort study on these cognitive tests might be so impaired that it will ( to derive and validate screening be clear that it would be unsafe for the patient to resume tests for fitness to drive that can be employed in front- driving, and further testing is not required. Furthermore, line clinical settings. While we wait for the results of this driving is contraindicated in moderate to severe dementia, research study, physicians can consider employing the defined as a loss of the ability to perform 2 instrumental experience-based approach to the assessment of fitness activities of daily living or 1 activity of daily living (grade B, to drive in dementia depicted in Figure 2.10,16 This figure level III evidence), owing to cognitive decline rather than does not represent a scale with a scoring template, but physical disability.10,11 Activities of daily living and instru- rather a practical sequence of steps to follow to gather mental activities of daily living are reviewed in Figure 2.10,16 information, allowing physicians to best employ their The true clinical challenge lies in the assessment of clinical judgment regarding fitness to drive.
patients with mild dementia who require individualized Some patients' fitness to drive might be too bor- assessment (grade B, level III evidence).11 In persons with derline to assess in a clinical setting; they will require mild dementia, the approach to assessment is relatively on-road testing (grade B, level III evidence).11 When unstudied—a recent systematic review has demonstrated sending persons with dementia for on-road testing, it that no in-office cognitive tests have well-validated cut- is important to let them know that if they pass they off scores predicting fitness to drive in dementia (level I might need to repeat the on-road test every 6 to 12 evidence).17 In recognition of this "evidence-based vac- months as the dementia progresses.18 Many patients uum," the Canadian Institutes of Health Research has will not pursue on-road testing when informed of this 1126 Canadian Family PhysicianLe Médecin de famille canadien Vol 56: NoVemberNoVembre 2010
Assessing fitness to drive in patients with cardiac and cognitive conditions Clinical Review
Figure 2. Dementia and driving checklist for use by physicians and health care professionals*
Given the following findings, would you be willing to get into a car (or would you allow your children or grandchildren to get into a car) with your patient driving? (Note that it is not necessary to complete all items if it is obvious that the patient is unsafe to drive based on early items) Problem
1. Functional impact of the dementia

According to CMA guidelines,10 patients are unsafe to drive if they demonstrate the following: impairment of >1 IADL due to cognition (IADLs SHAFT mnemonic: Shopping; Housework/Hobbies; Accounting [banking, bills, taxes]; Food preparation; Telephone /Tools/Transportation [driving]) impairment of ≥1 personal ADLs due to cognition (ADLs DEATH mnemonic: Dressing; Eating; Ambulation; 2. Family concerns (to be asked away from the patient)
Family members feel safe or unsafe in the car with the patient (and have recently been in the car with the patient) The child safety question: Would you feel it was safe if a 5-year-old child were alone in the car while the patient was driving? (Often a different response from family member's answer to previous question) Generally, if family members believe the patient is unsafe to drive, he or she usually is. If family members believe the patient is safe to drive, he or she might still be unsafe to drive, as family members might be unaware or might be protecting the patient 3. Physical inability to operate a car

Medical or physical concerns, such as musculoskeletal problems, weakness, hindered neck turn, problems using steering wheel or pedals, cardiac or neurological problems, episodic cardiac or neurologic "spells," or other multiple medical conditions that inhibit the patient's ability to operate a vehicle 4. Visuospatial issues

Substantial problems relating to visual acuity and field of vision, inability to draw intersecting pentagons, and substantially abnormal results of the clock-drawing or cube-drawing tests 5. Drowsiness, slow reaction time, and lack of focus
Review potentially contributory medical conditions (eg, sleep apnea, delirium, depression) or medications that might represent potentially reversible factors: alcohol, benzodiazepines, narcotics, antipsychotics, and sedatives anticholinergic medications (antiparkinsonian drugs, muscle relaxants, tricyclics, OTC antihistamines, antiemetics, antipruritics, antispasmodics, etc) 6. Trail Making Test, parts A and B (available from
Trail Making A: Sample trail A, full trail A, and sample trail B should be performed before full trail B Trail Making B: Safe = < 2 minutes and < 2 errors (0 or 1 error) Unsure = 2 to 3 minutes or 2 errors (consider qualitative dynamic information regarding how the test was performed—slowness, hesitation, anxiety or panic attacks, impulsive or perseverative behaviour, lack of focus, multiple corrections, forgetting instructions, inability to understand test, etc) Unsafe = > 3 minutes or ≥ 3 errors (the longer the patient takes and the more errors they make, the more certain you can be that they are unsafe) Safe Review fitness to drive every
Unsafe Tell patient to stop driving
Unsure Refer for further assessment
6 to 12 months. Ask family
and report to MOT
members to call you if sudden
Give patients a letter to remind
changes in health occur
them they are not to drive
(eg, review signs of delirium)
Keep documentation of report
to MOT in chart
ADL—activity of daily living, CMA—Canadian Medical Association, IADL—instrumental activity of daily living, MOT—Ministry of Transportation, OTC—over the counter.
*This figure is a shortened version of the 10-minute office-based dementia and driving checklist for use by physicians and health care professionals16; based on clinical opinion and experience, not evidence.
Adapted from Molnar et al16 with permission.
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Clinical Review Assessing fitness to drive in patients with cardiac and cognitive conditions
• Assessment of fitness to drive is an important societal role for family physicians, and can help pre- For more information on the assessment of fitness to drive in vent further injury to patients and others; however, patients with dementia, please refer to the following resources: if a patient presents with multiple comorbidities, • The Canadian Geriatrics Society:
assessment can be difficult. • Ontario Alzheimer Knowledge Exchange Resource Centre: • To better organize their assessments of fitness to drive, physicians should divide conditions into acute The Driving and Dementia Toolkit: www.champlain
intermittent (ie, not usually present on examina- tion) and chronic persistent (ie, always present on • Regional Geriatric Program of Eastern Ontario:
examination) medical conditions. They should fur-ther divide the chronic persistent conditions into For more information on cardiac illness and fitness to drive, reversible and irreversible disorders.
please refer to the Canadian Cardiovascular Society's Assessment • Decisions regarding fitness to drive in acute inter- of the Cardiac Patient for Fitness to Fly and Drive final report: mittent disorders are based on probability of recur- rence, while decisions in chronic persistent disorders are based on functional assessment.
possibility. The cost of specialized comprehensive on- • Guidelines are available for assessing fitness to drive road tests varies from $50 to $800 (to be paid by the for various conditions; for patients with multiple patient), depending on the province. The high costs affecting factors, the most restrictive recommenda- in some provinces might discourage physicians from tion should be applied.
assessing fitness to drive, as it places physicians in the • Some patients' fitness to drive might be too border- undesirable position of presenting patients with an ulti- line to assess in office; these patients often require on-road testing, which can be costly. Funding strat- matum: pay for expensive on-road tests or stop driving. egies to reduce costs of comprehensive road testing This type of interaction is destructive to physician- should be examined further.
patient relationships and is unfair to patients of limited financial means. This barrier must be addressed at the POINTS DE REPÈRE DU RÉDACTEUR
provincial level by either improving funding to minis- • L'évaluation de la capacité de conduire est un rôle tries of transportation so they can fund comprehensive sociétal important pour le médecin de famil e puisqu'il on-road testing or involving organizations that would peut contribuer à prévenir des blessures éventuelles financially benefit from better funding of comprehen- aux patients comme aux autres personnes; cette sive on-road testing. When people are involved in car évaluation peut toutefois s'avérer difficile lorsque le crashes, it is the ministries of health and the insur- patient présente plusieurs états de comorbidité. ance industry that pay the extremely high immediate • Afin de mieux gérer son évaluation de la capacité and long-term costs of care and disability. The health de conduire, le médecin devrait distinguer les condi- care system and the insurance industry could poten- tions médicales aiguës intermittentes (c.-à-d. géné- tially save taxpayers and investors millions of dollars ralement absentes lors de l'examen) et les conditions by funding comprehensive on-road tests. In order to chroniques persistantes (c.-à-d. toujours présentes lors improve access to well-funded on-road testing, medi- de l'examen). De plus, il devrait diviser les conditions cal organizations and patient advocacy groups need to chroniques persistantes en réversibles et irréversibles. push for such a shared-payer system.
• Dans le cas de problèmes aigus intermittents, Some patients with very mild or mild dementia might la décision concernant la capacité de conduire be determined to be safe to drive, albeit temporarily. In dépendra de la probabilité de récurrence, alors que such cases the discussion of eventual driving cessa- dans les conditions persistantes, elle sera basée sur tion should be broached (grade B, level II evidence),11 and follow-up assessment of fitness to drive must be • Il existe des directives sur l'évaluation de la capacité arranged approximately every 6 to 12 months (grade de conduire dans différentes conditions médicales; B, level III evidence).11,18 When assessment results pour les patients qui présentent plusieurs facteurs indicate that patients are unsafe to drive, physicians de risque, les recommandations les plus restrictives must then engage in the often painful and emotion- devraient être appliquées. ally charged process of disclosing findings. To view a • La capacité de conduire de certains patients peut step-by-step approach to disclosing to a patient that être difficile à évaluer au bureau et une évaluation they are not fit to drive, we recommend The Driving and de la conduite sur route est parfois nécessaire, ce Dementia Toolkit, made jointly available by the Regional qui peut être onéreux. Il faudrait penser à des stra- Geriatric Program of Eastern Ontario and the Champlain tégies de financement pour réduire le coût de ces tests sur route.
1128 Canadian Family PhysicianLe Médecin de famille canadien Vol 56: NoVemberNoVembre 2010
Assessing fitness to drive in patients with cardiac and cognitive conditions Clinical Review
3. Harvey P, Hopkins A. Views of British neurologists on epilepsy, driving, and the law. Lancet Assessing fitness to drive is challenging at the best of 4. Bornemann MT. Viewpoint of a driver with epilepsy. Epilepsia 1994;35(3):665-7.
5. Dickey W, Morrow JI. Epilepsy and driving: attitudes and practices among patients attend- times. When one encounters layered comorbidities, as ing a seizure clinic. J R Soc Med 1993;86(10):566-8.
6. Taylor J, Chadwick DW, Johnson T. Accident experience and notification rates in people demonstrated in the case presented here, the assessment with recent seizures, epilepsy or undiagnosed episodes of loss of consciousness. QJM becomes even more difficult. This article provides clin- 7. Dalrymple J, Appleby J. Cross sectional study of reporting of epileptic seizures to general icians with systematic approaches to working through 8. Lee W, Wolfe T, Shreeve S. Reporting epileptic drivers to licensing authorities is unneces- such complex cases. For those interested in learning more sary and counterproductive. Ann Emerg Med 2002;39(6):656-9.
9. Simpson CS, Hoffmaster B, Mitchell LB, Klein GJ. Mandatory physician reporting of drivers about assessment of fitness to drive in patients with cogni- with cardiac disease: ethical and practical considerations. Can J Cardiol 2004;20(13):1329-34.
10. Canadian Medical Association. CMA driver's guide. Determining medical fitness to operate tive and cardiac issues, a number of resources exist. motor vehicles. 7th ed. Ottawa, ON: Canadian Medical Association; 2006. Available from: Accessed 2010 Sep 28.
Dr Molnar is a member of the Canadian Institutes of Health Research CanDRIVE research 11. Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia [web- team at the Ottawa Hospital Research Institute in Ontario and an Associate Professor in site]. Recommendations. Montreal, QC; 2007. Available from: the Division of Geriatric Medicine at the University of Ottawa. Dr Simpson is an Associate Recommendations_CCCDTD_2007.pdf. Accessed 2010 Sep 28. Professor of Medicine in the Division of Cardiology at Queen's University in Kingston, Ont, 12. Simpson C, Ross D, Dorian P, Essebag V, Gupta A, Hamilton R, et al. CCS Consensus and Co-Chair of the Canadian Cardiovascular Society Consensus Conference on Assessment Conference 2003: assessment of the cardiac patient for fitness to drive and fly—executive summary. Can J Cardiol 2004;20(13):1313-23.
of the Cardiac Patient for Fitness to Drive and Fly.
13. Dobbs BM. Medical conditions and driving: a review of the literature (1960-2000). Washington, DC: National Highway Traffic Safety Administration; 2005. Report no. DOT HS 809 690. Available from: Dr Simpson is supported by an operating grant from the Heart and Stroke Foundation driving/pages/TRD.html. Accessed 2010 Sep 28.
14. Carr DB, Schwartzberg JG, Manning L, Sempek J. Physician's guide to assessing and counsel- ing older drivers. 2nd ed. Washington, DC: National Highway Traffic Safety Administration; Drs Molnar and Simpson contributed to the literature search and to preparing the manuscript introduction.pdf. Accessed 2010 Sep 28.
for submission.
15. Hogan DB, Bailey P, Carswell A, Clarke B, Cohen C, Forbes D, et al. Management of mild to moderate Alzheimer's disease and dementia. Alzheimers Dement 2007;3(4):355-84. Epub 2007 Sep 17.
16. Molnar FJ, Byszewski, AM, Rapoport M, Dalziel WB. Practical experience-based approaches to assessing fitness to drive in dementia. Geriatr Aging 2009;12(2):83-92.
Dr Frank J. Molnar, Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, 17. Molnar FJ, Patel A, Marshall SC, Man-Son-Hing M, Wilson KG. Clinical utility of office- ON K1Y 4E9; telephone 613 798-5555, extension 16486; fax 613 761-5334; based predictors of fitness to drive in persons with dementia: a systematic review. J Am Geriatr Soc 2006;54(12):1809-24.
18. Molnar FJ, Patel A, Marshall SC, Man-Son-Hing M, Wilson KG. Systematic review of the optimal frequency of follow-up in persons with mild dementia who continue to drive. 1. Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of medi- Alzheimer Dis Assoc Disord 2006;20(4):295-7.
cal fitness-to-drive. Practical approaches for assessing older people. Can Fam Physician 19. Champlain Dementia Network, Regional Geriatric Program of Eastern Ontario. The driv- ing and dementia toolkit for health professionals. 3rd ed. Ottawa, ON: Champlain Dementia 2. Krumholz A, Fisher RS, Lesser RP, Hauser WA. Driving and epilepsy. A review and reap- Network; 2009. Available from: praisal. JAMA 1991;265(5):622-6.
Resources/kitjune09.pdf. Accessed 2010 Oct 14.
Vol 56: NoVemberNoVembre 2010 Canadian Family PhysicianLe Médecin de famille canadien 1129


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Auswirkungen eines 6-monatigen Power Plate Programms auf die Hüftknochendichte, Muskelkraft und Haltungskontrolle bei Frauen im postmenopausalen Alter. Verschueren et al. Journal of Bone and Mineral Research, 2004; 3:352–359 Ziel der Studie: Untersuchung, ob ein Power Plate Programm positiven Einfluss auf die Muskelkraft, Knochendichte und