Monthly Archives: December 2012

Bicycle Helmet Success Story From Boston Medical Center

“I’m pretty sure me wearing a helmet in this instance saved my life or at the very least a lot more serious damage…it’s a $15 helmet and it definitely changed my life.” – BMC Patient Jonathan Steer

House Calls and a Higher Purpose

MED’s Home Care Program teaches how to care for the elderly

Boston University BU, School of Medicine BUSM, Eugene Lee, home care visit geriatric patients Boston

Eugene Lee (CAS’08, MED’12) (left) and Lisa Norton, a School of Medicine clinical assistant professor, on a home care visit to 87-year-old Pauline Harris. Photos by Vernon Doucette

Lisa Norton walks briskly to her first home visit of the day, hardly slowing to update her student about the assortment of health problems afflicting her 87-year-old patient Pauline Harris, who lives in the South End. Norton, a geriatrician and a School of Medicine clinical assistant professor of geriatrics, mentions one last thing before she and Eugene Lee buzz Harris’ apartment: “She’s not horribly compliant with her meds.” Turns out, that’s a big understatement.

Opening the door to her second-floor home, Harris radiates Southern charm as she invites her guests to take a seat in her cluttered living room. She walks slowly past prints of Mary Baker Eddy in the hallway and settles into a red velvet armchair wedged between a futon and an end table. Over the next hour, Norton and Lee will ask questions, draw blood, and take her pulse and blood pressure.

Norton is one of six geriatricians and as many nurses in MED’s Home Care Program caring for approximately 570 patients who find it difficult to leave their homes. The program, the oldest of its kind in the country, has been a part of the University’s curriculum since the 1870s, and its core practices—along with lectures from insurance coverage to end-of-life care—are taught to fourth-year MED students in a monthlong geriatric rotation. It’s one of myriad ways that MED faculty and students venture beyond campus and into the community.

Lee (CAS’08, MED’12) asks about Harris’ breathing, balance, and diet while Norton takes notes on her laptop. She scans the papers, magazines, and knickknacks covering nearly every flat surface and asks Harris where her pills are. The patient gazes around the room and eventually unearths several yellow and blue cards covered in rows of plastic bubbles, each one designed for daily or nightly dosage. They’re all empty, and they’re seven months old. “I think there’s some compliance issues here,” Norton says. “We definitely need to get you new pills.”

The troubling details about Harris’ compliance might have gone unseen in a clinic visit, as would the literature revealing that Harris is a Christian Scientist.

Home visits like this one give Norton and her colleagues a better look into their patients’ lives and help them treat the whole person, not just a collection of ailments. “That’s really important in geriatrics,” she says. “You can lose the forest for the trees.”

“There’s so much more that we can understand about a patient just by doing one home visit,” says Lisa Caruso, a MED assistant professor of geriatrics. Visiting doctors learn how well patients navigate stairs, stock their fridges, and take (or don’t take) their medication.

Boston University BU, School of Medicine BUSM, Eugene Lee, home care visit geriatric patients Boston, public health

Lee checks Harris’ medication cards for dates and dosage levels.

And educating the next generation of doctors about elder care has never been more important. The American Geriatrics Society counts about 7,100 board-certified geriatricians in the country. That number will have to multiply nearly fivefold to meet the needs of the more than 71 million Americans who will be over 65 by 2030, according to the American Medical Student Association.

The School of Medicine does not track how many graduates go into geriatrics, but it is understood to be one of the less glamorous medical specialties. According to the Medical Group Management Association’s Physician Compensation and Production Survey, geriatricians earned an average salary of $183,523 in 2010—half of the yearly $392,885 earned by dermatologists. And the specialty doesn’t exactly come with the same adrenaline rush as cardiology or emergency medicine.

Labor of love

Doctors at Boston Medical Center, MED’s primary teaching hospital, who pursue geriatrics do so as a labor of love, and they hope to use the Home Care Program to show medical students the field’s quiet appeal. “You have to get them to fall in love with what you do,” says Daniel Oates (CAS’00, MED’00, SPH’05), the Home Care Program’s medical director and a MED assistant professor of geriatrics. And while Oates knows that most students will choose more lucrative or sexy specialties, he and his colleagues hope the experience they’ve gained will inform their future specialties.

Lee, for one, thinks his geriatrics rotation will greatly help his future in primary care. Back at Harris’ home, he and Norton try to solve the medication mystery. Harris tells them that her son, Billy, used to help with her medication, but he no longer lives with her. They analyze the pill packages to determine which is the most recent. (Harris “keeps empties to recycle.”) While Lee calls the pharmacy, the doctor takes a vial of her patient’s blood. Soon Lee has an answer, a discouraging one: Harris’ medication deliveries had been put on hold four months ago, which means she has been taking her medication only sporadically.

Boston University BU, School of Medicine BUSM, Eugene Lee, home care visit geriatric patients Boston, public health

Lee takes Harris’ blood pressure as part of her home exam.

The problems of BMC’s geriatric patients, like Harris, are complex. They are usually in their mid-80s, live below the poverty line, and are eligible for subsidized health insurance. Many are not native English speakers. They often live with multiple chronic conditions—high blood pressure, diabetes, anemia—each treated with a different medication. Knowing how those drugs interact, especially in the elderly, is key to a geriatrician’s job, as is knowing that typical diseases like pneumonia and heart failure may manifest themselves differently than they do in younger patients.

“Elder adults sometimes get marginalized,” says Oates. “They sometimes get forgotten. People don’t know what to do with them.” But he’s familiar with the special requirements of caring for elderly patients, and a lot of it has to do with using a team approach that relies on the help of many specialists.

Oates is also ever mindful of how he communicates with his patients. He knows that 45 percent of the U.S. population reads at or below an eighth-grade level, and that patients who don’t understand a doctor’s message could end up in the hospital, or in severe cases, in a fight for their lives. That’s why he runs a workshop for students on how to avoid medical jargon, especially when talking to elderly patients. Oates typically reviews care plans with his patients and then has them “teach it back to me.” If it’s clear they haven’t understood, he repeats it until he’s sure they do.

But sometimes, as Norton knows well, what’s most important is just listening to patients. Harris, for example, says she feels good. And Lee’s blood pressure and pulse readings a full two days after she took her last pills don’t raise any red flags. Her legs and feet also show no signs of swelling. Maybe, the doctor tells her student, it’s time to take a second look at Harris’ medication list.

“The most important thing,” Norton says, “is not really how the disease is doing, but how the patient is doing.”

And Harris seems to be doing OK. An hour after they arrive, Norton and Lee head out the door for their next appointment. They have several patients to visit and it’s nearly noon. Time to pick up the pace.

Boston Medical Center launches dog visiting program for patients!

Emily_Otis_BMC.jpg

Boston Medical Center social work manager Emma Riley sits with Otis, a black Labrador retriever. Riley helped establish the Healing Paws visitation program at the hospital and Otis visited patients for the first time Friday. (Photo courtesy Boston Medical Center)

A visit from a special friend during a hospital stay can brighten nearly any patient’s spirits, and now patients at Boston Medical Center can expect visitors with their wet noses and wagging tails to help make them feel better.

The hospital has launched an animal visitation program, Healing Paws, which allows certified therapy dogs and their handlers visit eligible patients.

Otis, a black Labrador retriever certified by the National Education for Assistance Dog Services, made the program’s inaugural visit to the cardiac unit Friday. Otis, along with his handler Emma Riley, visited patients throughout the afternoon.

Riley, a BMC social work manager, helped establish the program at the hospital.

“Given my experiences with dogs, I have seen firsthand how they can have a calming effect on people. I know that our patients and staff will benefit from their presence,” said Riley, who also is an animal behaviorist and has trained assistance dogs for years.

Research shows that pet therapy has both physical and mental health benefits, including lowering blood pressure and decreasing anxiety and depression, according to the hospital.

Labrador retriever, visited Boston Medical Center patients Friday as part of the hospital’s new Healing Paws program.(Photo courtesy of Boston Medical Center)

 *Courtesy of www.Boston.Com

http://www.boston.com/yourtown/news/south_end/2012/12/bmc_launches_dog_visiti…

Boston Medical Center Patient Stories

A Worksite Fall and the Long Path to Recovery

BMC neurosurgeon, orthopaedic trauma and critical care team get a roofer back on his feet after a devastating worksite fall.

It was a cold and breezy December day when Arthur McGuire, an experienced roofer, and foreman at a Wilmington Mass., construction site, lent a hand to his crew. Moments later his world would literally be turned upside down. 

TO WATCH THE VIDEO, FOLLOW THE LINK: http://www.bmc.org/traumasurgery/patient-stories.htm

“I was stepping backwards with some equipment when I lost my footing and fell off of the roof”, says McGuire. “For the first five feet of the fall, I tried grabbing at the brick or anything that I could catch myself on. When I realized I was going down, that’s when my skydiving training kicked in.” An experienced skydiver, McGuire went into a safety technique called Parachute Landing Fall or PLF—a technique commonly used by skydivers or paratroopers during hard landings to avert injury. “I kept my eyes on the horizon, chin tucked and elbows to the side, preparing to roll my body as soon as my feet hit,” he says. “As I landed, I used the force to roll and as I rolled, I could hear bones breaking.” McGuire had fallen from 40 feet. “Next thing I know I am on the ground in the fetal position and could hear someone yelling to call 911”, he says. “I looked to my side and my wrist bone was sticking out.”

As the first-responders arrived, Arthur lay on the ground unable to feel anything for what felt like an eternity. “I thought I was paralyzed”, says McGuire. “It was not until the paramedics started cutting off my clothes and moving me onto the stretcher that I began to experience excruciating pain. It was then I realized I probably wasn’t paralyzed and oddly enough the pain was comforting.”

As the first-responders attended to McGuire, a Boston MedFlight helicopter was en route to bring him to the trauma center at Boston Medical Center (BMC). “I love roofing, I love climbing, my specialty is in complex slate steeple work on churches but I also did a lot of work on the high-rises in Boston,” says McGuire. “One of those sites was another hospital where the helicopter landed on the roof. We would have to stop the work and leave the site when they were landing, and I always thought to myself ‘that person must be in pretty bad shape to come in the helicopter’ and now here I was being loaded into MedFlight on my way to Boston.”

McGuire arrived at Boston Medical Center and immediately was brought into the trauma bay. “It was very impressive,” says McGuire. “As soon as I landed there was a team of doctors and nurses going over me from head to toe.”

McGuire sustained very serious injuries. “He had a lumbar spine burst fracture with retropulsion,” says Justin L. Massengale, MD, Neurosurgeon at Boston Medical Center and Assistant Professor of Neurosurgery at Boston University School of Medicine.  McGuire had broken one of the bones of the spine in his lower back (the lumbar spine) at the time of his fall. The bone was crushed (burst) in such a way that a broken piece was pushed into the spinal canal (retropulsion) just above where the spinal cord ends.  In addition to the spinal fracture, McGuire also fractured his femur, his wrist and sustained spinal epidural  hematoma. “This means that some of the veins that run between the bone and spinal cord where torn by the fractured bone pieces,” says Massengale. “These veins released blood into the space between the bone and spinal cord—the epidural space— that formed a clot, adding to the pressure on the spinal cord and nerves that the bone pieces were already causing.”


The fracture and blood clot were serious enough that Dr. Massengale was concerned that if McGuire were allowed to try to walk in his condition, the fractured bone might break further or the blood clot might grow larger, causing worse pressure on the spinal cord or nerve roots, which could cause problems with their function or even paralysis. “The treatment options included use of a back brace to try to keep his back alignment straight while the fracture healed by itself, which could take months and which could provide him no guarantee that the fracture might still get worse during that time despite the brace,” says Massengale. The other option was an operation to stabilize the spine on the inside with screws and rods, remove the blood clot directly, and reconstruct the broken bone. “This option would provide him the best chance of recovery and prevention of future neurological damage,” says Massengale.

“Dr. Massengale is a saint,” says McGuire. “He came in and sat right down with me and my wife. He told me exactly what was wrong with my spine, what he was planning on doing, what the risks were and how he was going to fix it. And he did just was he said.” 
They opted for surgical intervention and the surgical treatment for the spine was divided into two stages. First, an operation was performed through an incision in McGuire’s back to eliminate the pressure on the spinal cord by removing the parts of the bone overlying the blood clot, as well as the blood clot itself. The torn covering of the spinal cord and nerve roots was also repaired at that time, and screws and rods were placed in the normal bones above and below the broken one so that the alignment of the spine would be corrected and held in place (stabilized) while the rest of the surgical treatment and recovery could occur safely.

The second stage of the spine operation was performed through an incision in McGuire’s side. The pieces of the front part of the bone that were causing the greatest amount of compression on McGuire’s spinal cord were removed this way, and replaced with a barrel shaped cage to restore the support that the broken bone could no longer provide. “We were able to perform this portion of the operation with minimally invasive techniques,” says Massengale.

Although the reconstruction of the spine by implanting a titanium cage from the lateral (side) approach are standard for spine surgeons treating this kind of condition, Dr. Massengale and his team in the neurosurgery department at BMC are currently the only practice in the area where a multistage reconstruction operation like Maguire’s is being performed in its entirety with minimally invasive techniques.  According to Massengale, “a patient who undergoes this procedure with minimally invasive techniques can achieve the same result with a much smaller incision, less blood loss, and lower risk of infection than the traditional approach.”

McGuire had four major operations in just five days. “The staff was amazing,” says McGuire.  “They kept me very comfortable. Before my last operation, I actually got nervous, but one of nurses came over and held my hand. She and the entire staff kept me very calm in what was a very difficult situation.”

The surgery was a success but McGuire’s road to recovery was just beginning. He spent nearly two weeks in the Surgical Intensive Care Unit (SICU). “They treated me like a king,” says McGuire. “The communication was top-notch; the staff explained everything to me and my family. My wife and three daughters were able to spend a lot of time with me in my room and the whole family was treated like royalty.” According to Massengale, “Coordination of care between the multiple surgical and critical care teams, as well as availability of the most state-of-the-art surgical treatment tools, are very important to achieving the goal of providing the best care for patients with serious traumatic injuries like Mr. McGuire’s.”


This experience certainly has changed McGuire’s outlook on life. “You have to enjoy every minute”, says McGuire. “It can end without warning and I value every day. I cannot say enough about the staff at BMC. Knowing I was in their hands during the worst experience of my life and how they went out of their way to make me and my family feel at home during such a tough experience is special.”

It has been a year since the accident and McGuire has been getting stronger every day. He has participated in extensive rehabilitation and according to Massengale, “He has done very well thus far in his recovery process.” In fact, he is now able to hold his first grandchild. “I am looking forward to taking walks on the beach soon with my wife, three daughters and grandson,” says McGuire.

Older Driver Safety Awareness Week

The Americal Occupational Therapy Association, Inc. (AOTA) Older Driver Safety Awareness Week seeks to raise awareness and increase education about the aging driver’s options. Each day of the week, AOTA spotlights a different aspect of older driver safety.  We will be sharing this information each day this week.

 

Friday: Taking Changes in Stride

 

Man in car

When an older driver discovers the need to make adjustments to drive safely or can no longer do so, families and friends can help him or her take these changes in stride. But to do so, the older driver and the family need to know about resources for independent community mobility before driving cessation occurs.

Losing one’s ability to drive, limiting the amount of driving, or changing the way one drives does not have to mean losing independence, and older adults have options to continue to stay involved in their communities. They can consider trading favors in exchange for rides from friends, family members, and neighbors; they can take advantage of grocery stores, places of worship, and other organizations that provide transportation or delivery services; and they can explore public transportation, volunteer driver programs, paratransit resources, and taxi services. Occupational therapy practitioners can help older adults determine which options are best, based on physical and cognitive demands (e.g., can the older adult walk to the bus, coordinate complex transit schedules, etc.?) and affordability, and focus on ways to overcome any barriers.

Occupational therapy emphasizes finding ways to help older adults participate in activities and occupations and helping to remove barriers to community mobility. Without driving, individuals can be at risk for social isolation and depression, which makes participation in the community an essential component of living life to its fullest.

hand with car key

Additional Information: 

 

     

     

    Older Driver Safety Awareness Week

    The Americal Occupational Therapy Association, Inc. (AOTA) Older Driver Safety Awareness Week seeks to raise awareness and increase education about the aging driver’s options. Each day of the week, AOTA spotlights a different aspect of older driver safety.  We will be sharing this information each day this week.

    Thursday: Equipment That Can Empower Drivers

    AOTA’s Older Driver Safety Awareness Week seeks to raise awareness and increase education about the aging driver’s options (products, programs, and services). Each day of the week, AOTA spotlights a different aspect of older driver safety.

    Pamela Toto, PhD, OTR/L, BCG, FAOTA, an occupational therapist who is board certified in gerontology, recalls the impact of introducing an array of adaptive equipment to older adults at a rural senior center during an educational in-service.

    “Driving is an essential activity for many older adults who wish to maintain their independence,” she notes. “After allowing them to test our swivel seat, leg-lifter, seat cushion, and Handybar, they wanted to buy our items from us on the spot. For many of those seniors in that rural community, the only way to get to the center was by car, and those adaptive items would enable them to do so with greater ease and safety.”

    Physical challenges can often be compensated for by equipment, adding to a driver’s safety and confidence. If neck turning is limited or painful, a wide-angle mirror may offer a solution. If foot pedals are harder to manage when diabetic changes have resulted in partial amputation, hand controls can offer a safe alternative.

    Examples of adaptive equipment include:

    ·         Low-effort steering: Modification to the power steering system that reduces the effort required to turn the steering wheel, which is helpful for those with painful arthritic shoulders and limited flexibility.

    ·         Ribbon attached to seatbelt: A simple adaptation that allows the driver or passenger to pull the seatbelt across the body without twisting and reaching behind the shoulder.

    ·         Hand controls: Adaptive equipment allowing drivers to control the accelerator and brake functions with their hands.

    ·         Handybar: Removable grab bar that hooks onto the door latch to give the driver something to hang on to when transferring into and out of the vehicle.

    ·         OnStar: Subscription system using wireless and GPS technology to offer navigation services in case the driver becomes lost, emergency services assistance (including an automatic alert to first responders in the event of a crash), and other safety options.

    ·         Extra or extended mirrors: Add-on or replacement mirrors to help broaden peripheral vision and expand the field of view to minimize head turning.

    ·         Swing-out seat: A replacement seat with a swivel base that extends the seat beyond the car threshold so drivers don’t have to maneuver around the steering column to get in and out.

    ·         Siren detector: An electronic device that detects the high-decibel sound waves of an ambulance or fire truck and alerts drivers who have a hearing impairment.

    ·         Bioptics: A system in which a small telescope is attached to prescription eyeglasses that allows a driver with very low vision to be able to drive by glancing briefly and intermittently through the special lens. Note: Locate a specially trained low vision specialist trained in bioptics and driver rehabilitation before considering this option. Laws for licensing drivers using bioptics varies by state.

    ·         Tire pressure sensors: Electronic sensors that let the driver know when air pressure is low, which can help prevent a flat tire from a slow leak or loss of vehicular control due to under-inflation.

    ·         Traction control sensors: Add-ons to an antilock brake system that can improve traction when the driver is accelerating too quickly or on a wet surface.

    ·         Back-up camera: A wireless system that projects the view from the rear of the car onto an LED screen that can be mounted on the dashboard or windshield so the driver doesn’t have to turn around to see what is behind the vehicle.

    ·         Seat cushions: Round swivel seat cushions turn 360° to help drivers and passengers rotate in and out of the vehicle. Other types of cushions can help relieve back pain. Safety Alert: Any cushion may also pose a safety risk. The cushion placed on the driver’s seat could compress in the event of a crash, creating space that allows the driver to “submarine” or slip forward under the now loose seatbelt.

    ·         Foot pedal extensions: Professionally installed pedal extenders allow better, more comfortable reach of the accelerator and brake pedals without causing the driver to position the seat dangerously close to the steering wheel.

    Adaptive equipment can also help caregivers who are transporting passengers. Schold Davis recalls a woman in her 80s struggling with the realization that she needed help caring for her husband with advancing Parkinson’s disease. They feared becoming homebound because she was afraid of dropping him while helping him in and out of their car.

    “The couple invested in a swing-out passenger seat, reducing the demands of her husband’s assisted transfer to within her capabilities,” Schold Davis said. “Not only could they resume afternoon visits to the lake, but the prospect of maintaining their residence in their home was once again a possibility.”

    Additional Information:

    ·         More information about assistive accessoriesAAA’s accessories and equipment for your vehicle.

    ·         More information on equipmentThe Hartford’s “Top Technologies for Mature Drivers”

    ·         Articles on adaptive equipment, brochures, regulations, standards, and a questionnaire:NHTSA’s Automotive Safety Issues for Persons With Disabilities.

    ·         More information on a wide range of adaptive equipment and vehicle modification (including many videos of how they work) at The National Mobility Equipment Dealers Association 

    ·         Make sure any equipment is properly installed by a certified installer. Read about the Quality Assurance Program (QAP).

    Older Driver Safety Awareness Week

    The Americal Occupational Therapy Association, Inc. (AOTA) Older Driver Safety Awareness Week seeks to raise awareness and increase education about the aging driver’s options. Each day of the week, AOTA spotlights a different aspect of older driver safety.  We will be sharing this information each day this week.

    Wednesday: Screening and Evaluations

    AOTA’s Older Driver Safety Awareness Week seeks to raise awareness and increase the availability of education about the aging driver’s options. Each day of the week, AOTA spotlights a different aspect of older driver safety.

    “Driving evaluations by occupational therapists are necessary for individuals living with medical conditions that may affect the skills required for driving,” says Anne Dickerson, PhD, OTR/L, FAOTA. “Driving school instructors are trained to address and focus on the rules of the road and the safe control of the vehicle, , but not the medical condition faced by the senior driver. Select an occupational therapy practitioner who is trained and/or certified as a driving rehabilitation specialist [CDRS, or SCDCM] if the driver is concerned with the effect of his or her medical condition on driving safety.”

    When preparing for a comprehensive driving evaluation, older adults need to present the truest picture of their current functional level. “I recommend making no changes to the older driver’s routine, such as medication schedule, sleep pattern, meal intake, etc. prior to the appointment,” says Meredith Sweeney, OTR/L, CDI, CDRS. A driving evaluation should measure drivers at their best, so a good nights sleep and healthy nutrition are the best way to prepare. “The older driver should be involved in the scheduling process, as the opportunity to ask specific questions to the occupational therapy driver rehabilitation staff typically decreases anxiety.”

    It is also important for older drivers and their family members to know what will happen at the evaluation, and because every facility is different, that question needs to be asked before making an appointment. “Generally, there will be a clinical component that may last approximately 1 hour and consists of tests of vision, physical abilities, memory, and ‘quickness’ of mental functioning,” says Dickerson. “There is usually a break and then the person is asked to drive in the facility’s vehicle, on roads in the neighborhood, for about an hour. It is important that the older driver is prepared to be driving a different vehicle for the driving test.” The testing vehicle is equipped with an instructor brake, to ensure safety for driver and evaluator.

    Families should plan to have an adult child or another family member attend the evaluation to help with the initial interview that reviews driving history and medical history, to have another set of ears when hearing the results, to have the information to assist with recommended adaptations, and to have family or friends prepared to help with planning for driving retirement if that is the recommendation.

    “The therapist can assist the family in talking with the older adult if cessation is necessary and just the opposite—the therapist can help the family understand that the older adult can learn to make judgments that are safer or use adaptive equipment that might make it easier to get in and out of the car or improve visibility” to maintain driving, says Dickerson.

    “The driving rehabilitation assessment is often viewed as a mechanism by which older drivers lose their licenses,” says Carol Wheatley, OTR/L, CDRS. “In actuality, the focus is on determining the means, such as adaptive equipment or strategies, to enable the person to continue to drive safely.”

    If you are you looking for an evaluation tailored individually to you, looking at your strengths and your limitations, and generating a plan for your continued safe mobility, an occupational therapy driving evaluation will offer the following:

    1.     Identify your strengths and any changes in vision, physical ability, and/or cognition that may pose a risk for driving safely.

    2.     Recommend how you might strengthen skills, compensate for weaknesses, and develop a relationship with the driving specialist to work together to explore every option.

    3.     Prioritize your goal to continue driving safely, but recommend a plan to stop driving now or in the near future if changes in your skills and abilities are too severe, placing you or others in your community in harm’s way. .

    4.     Remain focused on transportation and participation in your community. The occupational therapy professional will work with you to identify the alternative modes of transportation that would work for you, and provide the support you need to get you where you want to go when you want to get there.

    Additional Information:

    ·         Find a driving specialist: Locate a driving specialist near you.

    ·         How to decide whether to get an evaluation: The Hartford’s Guide to Considering a Driving Evaluation

    ·         What to expect at an evaluation:  The Hartford’s What Happens During a Driving Assessment?and Your Road Ahead: A Guide to Comprehensive Driving Evaluations available free of charge from The Hartford.

    ·         Self-rating and suggestions for safe driving: Drivers 65 Plus: Check Your Own Performanceprepared by the AAA Foundation for Traffic Safety.

    ·         Tips for Driving Safely: AOTA’s tip sheet for older drivers on Driving Safely as You Age.