The Assessment of Driving Fitness Using an On-Road Evaluation in Patients With Cirrhosis

Abstract

INTRODUCTION:The association between cirrhosis and driving performance is of particular clinical relevance because of the life-threatening safety issues both for the driver with cirrhosis and the general public. Study aims were to assess (i) driving competency through the use of an in-office computerized battery and on-road driving assessment (DriveABLE) and (ii) the association between minimal hepatic encephalopathy (MHE), in-office paper-pencil tools, and additional measures (e.g., frailty, depression, cognitive testing) with unsafe driving.METHODS:Patients were prospectively recruited from 2 tertiary care liver clinics. In-office tests and in-office and on-road assessments of driving competence were completed. The χ2 test and 1-way analysis of variance were used to analyze differences among those with and without MHE. Logistic regression was used to evaluate predictors of an indeterminate/fail result on the in-office computerized driving assessment battery (DriveABLE Cognitive Assessment Tool [DCAT]).RESULTS:Eighty patients participated with a mean age of 57 years, 70% male, 75% Child-Pugh B/C, and 36% with a history of overt hepatic encephalopathy. Thirty percent met MHE criteria on both the psychometric hepatic encephalopathy score and the Stroop app tests. Only 2 patients (3%) were categorized as “unfit to drive” in the on-road driving test, one with MHE and the other without. Fifty-eight percent of the patients were scored as indeterminate/fail on the DCAT. This corresponded to a higher mean number of on-road driving errors (5.3 [SD 2.1] vs 4.2 [SD 1.6] in those who passed the DCAT, P = 0.01). Older age (odds ratio 1.3; confidence interval 1.1, 1.5; P = 0.001) and MHE by Stroop/psychometric hepatic encephalopathy score (odds ratio 11.0; confidence interval 2.3, 51.8; P = 0.002) were independently predictive of worse performance on the DCAT.DISCUSSION:Worse performance in in-office testing was associated with worse scores on a computerized driving assessment battery and more on-road driving errors, but in-office tools were insufficient to predict on-road driving failures. A diagnosis of MHE should not be used alone to restrict driving in patients with cirrhosis. At-risk patients require on-road driving tests under the supervision of driving regulatory agencies. Future studies should continue to refine and evaluate in-office or at-home testing to predict driving performance.

Short‐latency reaction time and accuracy are impaired in patients with cirrhosis: An international multicenter retrospective study

“…People with MHE/CHE are at increased risk for falls and injuries, and for motor vehicle crashes. 27,28 Accordingly, ReacStick parameters have shown relationships with physical function in people with and without cirrhosis. SRT has shown a strong relationship with the ability to quickly produce a natural head-protective response to a threat in healthy adults (r = 0.725, P < 0.001).…”

“…People with MHE/CHE are at increased risk for falls and injuries, and for motor vehicle crashes 27,28 . Accordingly, ReacStick parameters have shown relationships with physical function in people with and without cirrhosis.…”

Development and evaluation of a virtual reality driving test for patients with cirrhosis

“…However, it has to be acknowledged that our cohort of patients with MHE was quite small in this study and these results should therefore be interpreted with caution. A study by Tandon et al 17 recently found that in-office testing using the DriveABLE Cognitive Assessment Tool predicts more errors during on-road driving tests, but was insufficient to detect patients who are unfit to drive. Formentin et al 15 evaluated the usefulness of the Psychomotor Vigilance Task for predicting car accidents and were able to demonstrate a potential predictive value.…”

“…However, patients with very advanced stages of cirrhosis are frequently not driving routinely and a recent study demonstrated that the frequency of patients who are unfit to drive is quite low even in Child-Pugh C cirrhosis. 17 Third, it is a limitation that traffic accidents were assessed by self-assessment, which may be prone to recall bias. Fourth, the control group does not represent the general population of drivers and we are therefore reluctant to produce reliable norms for the VR test based on this group.…”

Animal naming test is a simple and valid tool for detecting covert hepatic encephalopathy and predicting outcomes in Chinese-speaking regions: a preliminary study

“…The detection and quantification of covert HE (CHE) (i.e. when there are minimal cognitive/neurophysiologic alterations or slight and equivocal clinical findings without clear disorientation or asterixis [ 1 ])is relevant [ 2 ], since it is associated with increased risk for (i) overt HE (OHE) [ 3 ], (ii) poor health-related quality of life [ 4 ], (iii) increased caregiver burden [ 5 ], (iv) poor driven ability [ 6 ], (vi) falls [ 7 ], and (vii) poor income [ 8 ]. Furthermore, detecting CHE before the occurrence of OHE [ 1 ] may enable precocious treatments in a wider number of patients to reduce the burden of HE on patients, caregivers, and the health system.…”