|3. Assessment and Ongoing Reassessment
||Dementia Care Practice Recommendations for End-of-Life Care (Alzheimer's Association, 2007)
- Direct care workers observe the resident's comfort level at the end-of-life and report symptoms to their supervisors such as:
- Changing behaviors, such as becoming more withdrawn or agitated.
- Change in mental status, such as increased confusion or lack of responsiveness.
- Verbal communication, such as yelling or calling out.
- Motor restlessness.
- Facial grimacing or teeth grinding.
- Gestures that may communicate distress.
- Rigidity of body posture and position or posturing of extremities.
- Labored breathing pattern.
- Changes in swallowing ability.
- Loss of appetite and thirst.
- Excessive thirst.
- Disturbed or restless sleep.
- Scratching or picking at skin or other body parts.
- Changes in skin condition, such as bruising, open or discolored areas.
- Excessive sweating.
- Dry mouth or problem with oral cleanliness.
- Excessive oral secretions or drooling.
- Accumulation of secretions in the eyes, nose, lungs, genitalia.
- Bowel patterns and incontinence.
- Change in general cleanliness, such as dirty nails, body odor, etc.
- Change in grooming habits, such as unkempt hair, unbrushed teeth, etc.
- Direct care workers observe residents behavioral and psychological symptoms and report the symptoms to their supervisors such as:
- Changes in attention span.
- Changes in level of arousal (distractible, inattentive, fluctuating arousal, variably alert).
- Psychomotor agitation.
- Changes in mood/affect.
- Withdrawal from others.
- Groaning or calling out.
- Facial grimacing.
- Striking out or other physical gestures of discomfort or distress.
|Dementia Care Practice Recommendations for Assisted Living and Nursing Homes (Alzheimer's Association, 2009)
- A holistic assessment includes understanding a resident's:
- Cognitive health.
- Physical health.
- Physical functioning.
- Behavioral status.
- Sensory capabilities.
- Decision making capacity.
- Communication abilities.
- Personal background.
- Cultural preferences.
- Spiritual needs and preferences.
- Assessments should acknowledge that the resident's functioning might vary across different staff shifts.
- Thorough assessment includes obtaining verbal information directly from residents and from family when possible.
- Regular formal assessment, as required by federal or state regulation, is key to appropriate management of resident's care. Equally important is ongoing monitoring and assessment of residents, particularly upon return from the hospital or upon a significant change in their condition.
- Provide good screening and preventive systems for nutritional care.
- Treat pain as the "fifth vital sign" by routinely assessing and treating it in a formal systematic way, as one would treat blood pressure, pulse, respiration and temperature.
- Ensure that causes of wandering are assessed and addressed, with particular attention to unmet needs.
|Dementia Care Practice Recommendations for Professionals Working in a Home Setting (Alzheimer's Association, 2009)
- Assess family members to identify needs for education, support and services and reassess as the person's dementia progresses or the caregiver's health and emotional well-being is impacted.
- A person showing behavioral symptoms needs a thorough medical evaluation especially when symptoms come on suddenly.
- Assessment of behavioral symptoms can also include nonmedical causes such as a change in the person's care, admission to the hospital, a change in care provider, the presence of houseguests, or a request to bathe or change clothes at a different time of day. Assessment should also address personal comfort, pain, hunger, thirst, constipation, full bladder/bowel and fatigue. Loss, boredom and isolation can also cause behavioral symptoms.
- Direct care providers need to be able to recognize behavioral symptoms of dementia and communicate the symptoms to supervisors or other members of the home care team.
- Improve pain assessment and treatment by routinely assessing pain as the fifth vital sign.
- Monitor the person for changes in eating and drinking habits and help him or her avoid significant weight loss or gain. Any significant changes should be communicated to the physician.
- Assess the causes of wandering and address any unmet needs that may be inducing the behavior.
- Identify problems that have led to restraint use in the past and address them using other methods.
- Evaluate surroundings for any particular dangers and intervene to ensure safety at all times.
- Assess the person's ability to manage daily activities and be alert to any changes in condition.
- Monitor for caregiver strain or stress.
|Dementia in the Long-Term Care Setting (American Medical Directors Association, 2012)
- Soon after admission or a significant condition change, assess the patient's capabilities in various domains.
- Assess the patient's cognition, mood and behavior using a validated tool, such as items in the MDS 3.0 instrument.
|Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (American Psychological Association, 2012)
- Psychologists recognize the value of longitudinal follow-up for monitoring change in cognitive status.
|Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care (British Columbia Ministry of Health, 2012)
- Conduct an assessment to evaluate the person's behavioral symptoms and define specific goals.
- Assess for possible causes and triggers that may contribute to behavioral and psychological symptoms of dementia. It is important to have a baseline reference point, including information from others on admission, to enable comparisons of newly expressed behaviors over time.
- Assess for possible medical causes for the behaviors through a comprehensive assessment and review of medical and psychiatric history and to distinguish dementia from depression or delirium.
|Guideline for Alzheimer's Disease Management (California Workgroup on Guidelines for Alzheimer's Disease Management, 2008)
- Conduct and document an assessment and monitor changes in:
- Daily functioning, including feeding, bathing, dressing, mobility, toileting, continence, and ability to manage finances and medications.
- Cognitive status using a reliable and valid instrument.
- Comorbid medical conditions which may present with sudden worsening in cognition, function, or as change in behavior.
- Behavioral symptoms, psychotic symptoms, and depression.
- Medications, both prescription and nonprescription (at every visit).
- Living arrangement, safety, care needs, and abuse or neglect.
- Need for palliative or end-of-life care planning.
- Reassessment should occur at least every 6 months, and sudden changes in behavior or increase in the rate of decline should trigger an urgent visit to the PCP.
- Identify the primary caregiver and assess the adequacy of family and other support systems, paying particular attention to the caregivers on mental and physical health.
- Assess the patient's decision making capacity and determine whether a surrogate has been identified.
- Identify the patient's and family's culture, values, primary language, literacy level, and decision making process.
- Use a structured approach to the assessment of patient capacity, being aware of the relevant criteria for particular kinds of decisions.
|Redesigning Systems of Care for Older Adults with Alzheimer's Disease (Callahan et al., 2014)
- Regularly reassess the psychoactive side effects of prescription and nonprescription medications and alcohol and other substance abuse.
|Clinical Practice Guideline for Dementia. Part I: Diagnosis and Evaluation (Clinical Research Center for Dementia of South Korea, 2011)
- Assessment of behavioral and psychological symptoms of dementia is essential for both diagnosis and management, and should be performed in all patients.
- ADLs should be assessed in all patients for diagnosis of dementia. Assessment of ADLs should include both the physical and instrumental fields.
|Advanced Dementia Expert Panel Summary and Key Recommendations (Coleman & Mitchell, 2015)
- Incentivize documentation and tracking of level of functional and cognitive status to identify people with advanced dementia.
- Use quality metrics to measure effective symptom assessment.
|Alzheimer's Association Recommendations for Operationalizing the Detection of Cognitive Impairment during the Medicare Annual Wellness Visit in a Primary Care Setting (Cordell et al., 2013)
- The Annual Wellness Visit requires the completion of a Health Risk Assessment by the patient either before or during the visit. The Health Risk Assessment should be reviewed for any reported signs and symptoms indicative of possible dementia.
- The Annual Wellness Visit will likely occur in a primary care setting. Tools for initial cognitive assessments should be brief (less than 5 minutes), appropriately validated, easily administered by nonphysician clinical staff, and available free of charge for use in a clinical setting.
- If further evaluation is indicated based on the results of the Annual Wellness Visit, a more detailed evaluation of cognition should be scheduled for a follow-up visit in primary care or through referral to a specialist.
- By assessing and documenting cognitive status on an annual basis during the Annual Wellness Visit, clinicians can more easily determine gradual cognitive decline over time in an individual patient--a key criterion for diagnosing dementia because of Alzheimer's disease and other progressive conditions affecting cognition.
- Annual unstructured and structured cognitive assessments could be used to monitor significant changes in cognition and potentially lead to a new diagnosis of dementia for those with mild cognitive impairment or new care recommendations for those with dementia.
- The first step in detection of cognitive impairment during the Annual Wellness Visit involves a conversation between the clinician and the patient and, if present, any family member or other person who can provide collateral information. This introduces the purpose and content of the visit, which includes: a review of the Health Risk Assessment; observations by clinicians (medical and associated staff); acknowledgment of any self-reported or informant-reported concerns; and conversational queries about cognition directed toward the patient and others present.
- A noted deficit in ADLs (e.g., eating and dressing) or IADLs (e.g., shopping and cooking) that cannot be attributed to physical limitations should prompt concern, as there is a strong correlation between decline in function and decline in cognitive status across the full spectrum of dementia.
- Recognizing that there is no single optimal tool to detect cognitive impairment for all patient populations and settings, clinicians may select other brief tools to use in their clinical practice.
- Any patient who does not have an informant present should be assessed with the structured tool.
|Dementia Care: The Quality Chasm (Dementia Initiative, 2013)
- The reasons for behavioral expressions are complex and vary by individual. Determine the root cause of the behavior and then address the cause, such as pain, hunger, thirst, boredom, illness, loneliness, or an underlying medical condition that the person with dementia is challenged to communicate.
|Clinical Practice Guideline on the Comprehensive Care of People with Alzheimer's Disease and Other Dementias (De Sanidad, 2014)
- The assessment of the impact of cognitive impairment on the ADLs is recommended given their affectation, which forms the dementia diagnostic criterion and determines the subsequent management of these patients.
- An assessment of the psychological and behavioral symptoms is recommended because of their importance for the diagnosis.
- The systematic assessment of the presence of BPSD is recommended as a fundamental component of the clinical picture, as it appears very frequently, it is difficult to manage, it has an impact on the quality of life and is a frequent reason for urgent care, family claudication and institutionalization.
- The use of specifically designed instruments is recommended to evaluate BPSD in dementia independently from cognitive and functional alterations.
- Starting treatment with nonpharmacological strategic measures to manage BPSD is recommended.
- A meticulous assessment is recommended if behavioral and psychological symptoms of dementia appear, to rule out concomitant pathology and achieve optimal environmental surroundings.
- Sensory stimulation, behavioral therapy, structured activities and social contact should be used to reduce the incidence of behavioral and psychological symptoms of dementia, although there is no scientific evidence to support this.
- It is advisable to inform and train caregivers of dementia patients on strategies to address and manage the behavioral and psychological symptoms of dementia so that it is possible to adopt and promote an appropriate attitude towards patients and prevent strain and claudication of the caregivers.
|Recognition and Management of Dementia (Fletcher, 2012)
- Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.
- Tests that assess functional limitations are useful in monitoring the progression of functional decline.
- Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.
- Evaluate for depression because it commonly coexists in individuals with dementia.
- A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause or existence of a reversible form of cognitive impairment.
- A thorough evaluation of all prescribed, over-the-counter. Homeopathic, herbal, and nutrition products taken is done to determine the potential impact on cognitive status.
- Follow-up appointments are regularly scheduled; frequency depends on the patient's physical, mental, and emotional status and caregiver needs.
|Practice Guidelines for Assessing Pain in Older Persons with Dementia Residing in Long-Term Care Facilities (Hadjistavropoulos, Fitzgerald, & Marchildon, 2010)
- Determine if MMSE scores are available or can be obtained. This would facilitate determination of patient ability to provide valid self-report.
- Baseline scores should be collected for each individual (ideally on a regular basis which would allow for the examination of unusual changes from the person's typical pattern of scores).
- Patient history and physical examination results should be taken into consideration.
- If assessments are to be repeated over time, assessment conditions should be kept constant (e.g., use the same assessment tool, use the same assessor where possible and conduct pain assessment during similar situations).
- Pain assessment results should be used to evaluate the efficacy of pain management interventions.
- Use of synonyms when asking about the pain experience (e.g., hurt, aching) will facilitate the self-report of some patients who have limitations in ability to communicate verbally.
- Self-report scales should be modified to account for any sensory deficits that occur with aging (e.g., poor vision, hearing difficulties).
- Use self-report tools that have been found to be the most valid among seniors (e.g., the Colored Analog Scale, Numeric Rating Scales, Behavioral Rating Scales, 21 Point Box Scale).
- Use of horizontal visual analog scales should be avoided, as some investigators have found unusually high numbers of unscorable responses among seniors.
- Observational tools that have been shown to be reliable and valid for use in this population include PACSLAC and DOLOPLUS-2. The PACSLAC is the only tool that covers all 6 behavioral pain assessment domains that have been recommended by the American Geriatrics Society. Nonetheless, clinicians should always exercise caution when using these measures because they are relatively new and research is continuing.
- When assessing pain in acute care settings tools that primarily focus on evaluation of change over time should be avoided.
- Observational assessments during movement-based tasks would be more likely to lead to the identification of underlying pain problems than assessments during rest.
- Some pain assessment tools do not have specific cutoff scores because of recognition of tremendous individual differences among people with severe dementia. Instead, it is recommended that pain be assessed on a regular basis (establishing baseline scores for each patient) with the clinician observing score changes over time.
- Examination of pain assessment scores before and after the administration of analgesics is likely to facilitate pain assessment.
- Some of the symptoms of delirium (which are seen frequently in long-term care) overlap with certain behavioral manifestations of uncontrolled pain (e.g., behavioral disturbance). Clinicians assessing patients with delirium should be aware of this. On the positive side, delirium tends to be a transient state, and pain assessment, which can be repeated or conducted when the patient is not delirious, is more likely to lead to valid results. It is important to note also that pain can cause delirium, and clinicians should be astute to avoid missing pain problems among patients with delirium.
- Observational pain assessment tools are screening instruments only and cannot be taken to represent definitive indicators of pain. Sometimes they may suggest the presence of pain when pain is not present, and at other times they may fail to identify pain.
- In addition to improved scores on various assessment tools, evidence of more effective pain management can be observed in areas such as greater participation in activities, improved sleep, reduced behavioral disturbance, improved ability to ambulate, and improved social interactions.
|Pain Assessment in the Patient Unable to Self-Report: Position Statement with Clinical Practice Recommendations (Herr et al., 2011)
- Attempts should be made to obtain self-report of pain from all patients. When self-report is absent or limited, explain why self-report cannot be used and further investigation and observation are needed.
- Iatrogenic pain associated with procedures should be treated before initiation of the procedure.
- A change in behavior requires careful evaluation of pain or other sources of distress, including physiologic compromise (e.g., respiratory distress, cardiac failure, hypertension). Generally, one may assume that pain is present, and if there is reason to suspect pain, an analgesic trial can be diagnostic and therapeutic. Other problems that may be causing discomfort should be ruled out (e.g., infection, constipation) or treated.
- In the absence of self-report, observation of behavior is a valid approach to pain assessment. Establish a procedure for pain assessment:
- Identify pathologic conditions or procedures that may cause pain. Consider common chronic pain etiologies. Musculoskeletal and neurologic disorders are the most common causes of pain in older adults.
- List patient behaviors that may indicate pain. A behavioral assessment tool may be used. Observe facial expressions, verbalizations/vocalizations, body movements, changes in interactions, changes in activity patterns or routines, and mental status. Behavioral observation should occur during activity whenever possible.
- Identify behaviors that caregivers and others knowledgeable about the patient think may indicate pain. In the long-term care setting, the certified nursing assistant is a key health care provider shown to be effective in recognizing presence of pain. The family is helpful if they visit regularly.
- Attempt an analgesic trial. Estimate the intensity of pain based on information obtained from prior assessment steps and select appropriate analgesic. Opioid dosing in older adults warrants initial dose reduction to 25% to 50% of adult dose.
|EFNS Guidelines for the Diagnosis and Management of Alzheimer's Disease (Hort et al. & European Federation of Neurological Sciences Scientist Panel on Dementia, 2010)
- Assessment of behavioral and psychological symptoms of dementia should be performed in each patient. Information should be gathered from an informant using an appropriate rating scale.
|Using Dementia as the Organizing Principle when Caring for Patients with Dementia and Comorbidities (Lazaroff et al., 2013)
- Assessment by an occupational therapist or another member of the health care team can help determine what the patient is capable of doing independently with the help of aids and with which activities the patient needs assistance.
- An environmental assessment can identify modifications that can be made to a home to reduce a person's risk of falling and wandering off.
|Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia: Recommendations for Family Physicians (Moore et al., 2014)
- Nonpharmacologic interventions for agitation and aggression in dementia include recognition and management of potentiating factors (medical, psychiatric, medications, environment).
|Dementia: A NICE-SCIE Guideline on Supporting People with Dementia and Their Carers in Health and Social Care (National Institute for Health and Clinical Excellence, 2007)
- All people with suspected or known dementia using inpatient services are assessed by a liaison service that specializes in the treatment of dementia. Care for such people in acute care should be planned jointly by the hospital staff, liaison teams, relevant social care professionals and the person with suspected or known dementia and his or her carers.
- At the time of diagnosis of dementia, and at regular intervals subsequently, assessment should be made for medical comorbidities and key psychiatric features associated with dementia, including depression and psychosis, to ensure optimal management of coexisting conditions.
- Care for people with dementia should include assessment and monitoring for depression or anxiety. A range of tailored interventions, such as reminiscence therapy, multisensory stimulation, animal assisted therapy and exercise, should be available for people with dementia who have depression or anxiety.
|PQRS 2105 Measure List, Measure Numbers 25, and 149-157 (Physician Quality Reporting System, 2014)
- Staging of Dementia: Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12-month period.
- Cognitive Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
- Functional Status Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12-month period.
- Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12-month period.
- Screening for Depressive Symptoms: Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12-month period.
|American Psychiatric Association Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias (Rabins et al., 2007)
- The treatment of patients with dementia should be based on a thorough psychiatric, neurological, and general medical evaluation of the nature and cause of the cognitive deficits and associated noncognitive symptoms, in the context of a solid alliance with the patient and family.
- It is particularly critical to identify and treat general medical conditions, most notably delirium, that may be responsible for or contribute to the dementia or associated neuropsychiatric symptoms.
- Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms and their response to intervention.
- Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, and evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse.
- To offer prompt treatment, enhance safety, and provide timely advice to the patient and family, it is generally necessary to see patients, usually together with their caregivers, in routine follow-up at least every 3-6 months. Patients who require active treatment of psychiatric complications should be seen regularly to adjust doses and monitor for changes in target symptoms and side effects.
- Monitor and enhance the safety of the patient and others: the psychiatrist should assess suicidality, assess the potential for aggression and agitation, make recommendations regarding adequate supervision, for example, medication administration, make recommendations regarding the prevention of falls and choking, address nutritional and hygiene issues, and be vigilant regarding neglect or abuse. Patients who live alone require careful attention. Events that indicate that the patient can no longer live alone include several falls, repeated hospitalization, dehydration, malnutrition, repeated errors and taking prescribed medication, dilapidated living conditions, or other signs of self-neglect. Other important safety issues in the management of patients with dementia include interventions to decrease the hazards of wandering and recommendations concerning activities such as cooking, driving, hunting, and the operation of hazardous equipment.
|Dementia. Diagnosis and Treatment (Regional Health Council, 2011)
- General practitioners should assess the presence of comorbidities.
|Caregiving Strategies for Older Adults with Delirium, Dementia and Depression 2010 Supplement (Registered Nurses' Association of Ontario, 2010)
- Nurses should use the diagnostic criteria from the DSM-IV-R to assess for delirium, and document mental status observations of hypoactive and hyperactive delirium.
- Nurses must monitor, evaluate, and modify the multicomponent intervention strategies on an ongoing basis to address the fluctuating course associated with delirium.
- Nurses should contribute to comprehensive standardized assessments to rule out or support the identification and monitoring of dementia based on their ongoing observations and expressed concerns from the client, family, and interdisciplinary team.
- Nurses caring for clients with dementia should be knowledgeable about pain assessment and management in this population to promote physical and emotional well-being.
- Nurses should use the diagnostic criteria from the DSM-IV-R to assess for depression.
- Nurses should use standardized assessment tools to identify the predisposing and precipitating risk factors associated with depression.
- In care settings where Resident Assessment Instrument and MDS instruments are mandated assessment tools, nurses should use the MDS data to assist with assessment for delirium, dementia and depression.
|Occupational Therapy Practice Guidelines for Adults with Alzheimer's Disease and Related Disorders (Schaber, 2010)
- Occupational Therapy evaluation questions should be directed toward the client, allowing the client to take an active and central role in the interview process. Information is gathered through an occupational profile, analysis of occupational performance, and standardized and nonstandardized assessments.
- If cognition is the primary concern limiting participation, a brief cognitive assessment using a screening tool such as the Large Allen Cognitive Lacing Screen is administered to determine whether a full cognitive functional assessment is warranted.
- An individual with cognitive deficits may exhibit a decline or impairment in performance of functional activities caused by comorbidities that affect motor and praxis, sensory-perceptual, emotional regulation, cognitive, communication, and social skills. One difficulty in assessment with comorbidities is delineating the source of the performance deficit. With clinical expertise, all factors that limit occupational performance are considered, along with thinking, memory, or executive function abilities.
- The purpose of an occupational therapy evaluation is to design an intervention plan to create opportunities for participation, maintain occupational performance or modify activity demands, or prevent deterioration in performance capability. The area of occupation targeted depends on the cognitive ability of the client and stage of the disease. For instance, the focus of intervention in the early stages work or employment, if applicable, and IADL participation, whereas the focus in the middle and later stages of the disease is ADL performance. Leisure, social participation, and rest/sleep are considered through the early to the later stages of the disease.
- Occupational therapy evaluation with people with Alzheimer's disease entails an exploration of the activity demands relative to the client's capabilities.
- The purpose of the evaluation is to determine what potential the client brings to the intervention process and to identify the barriers to optimal performance on the basis of physiological functions of body systems or personal values and beliefs.
|EFNS-ENS Guidelines on the Diagnosis and Management of Disorders Associated with Dementia (Sorbi et al., 2012)
- Cognitive assessment is central to diagnosis and management of dementia and should be performed in all patients.
- Assessment of behavioral and psychological symptoms of dementia is essential for both diagnosis and management and should be performed in each patient.
- Assessment of comorbidity is important in demented patients, both at the time of diagnosis and throughout the course of the illness and should always be considered as a possible cause of behavioral and psychological symptoms of dementia.
- Advice either to allow driving, but to review after an interval, to cease driving, or to refer for retesting should be given.
|Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia (2007)
- Determination of how medications are being consumed and identification of any problems/concerns with medication management, including poor adherence, should be conducted for all patients with mild or moderate dementia. The effectiveness of any alterations in medication management has to be assessed.
- Assess cognitive status, functional abilities, and behavior and neuropsychiatric symptoms, and reassess regularly.
- Obtain information from caregivers about the person's cognition, behavior, and social and daily functioning.
- Patients with sleep problems should be assessed for medical illnesses (including pain), psychiatric illnesses (including depression), potentially contributing medications, poor sleep habits (including naps), and environmental factors that may be adversely affecting sleep.
- Patients with severe dementia should be assessed at least every 4 months. Assessment should include cognition, function, behavior, medical status, nutrition, safety, and caregiver health.
- Clinicians should counsel persons with a progressive dementia and their families that giving up driving will be an inevitable consequence. Strategies to ease this transition should occur early in the clinical course of the condition. The driving ability of persons in earlier stages of dementia should be tested on an individual basis. For persons deemed safe to drive, reassessment of their ability to drive should occur at least every 6-12 months.