Licence Appeal Tribunal File Number: 15379/MED

An appeal under subsection 50(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8, from a decision of the Registrar of Motor Vehicles to suspend a licence pursuant to Section 47(1) of the Act.

Between:

Nicola Galati

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Isla McPherson, Member

APPEARANCES:

For the Appellant: Nicola Galati, Appellant
For the Appellant: Jami Sanftleben, Representative
For the Respondent: Ian Sookram, Agent

Held by teleconference: March 20, 2024

OVERVIEW

1Nicola Galati (the “appellant”) appeals from the decision of the Registrar of Motor Vehicles (“Registrar”) to suspend his commercial and GM driving privileges under s. 47(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8 (the “Act”) after the Registrar received a requested driver’s medical report from a treating physician stating that the appellant suffers from medical conditions that may affect his ability to drive a motor vehicle safely.

2The Registrar has the authority under s. 47(1)(g) of the Act to suspend or cancel a driver’s licence for any sufficient reason. Section 14(1)(a) of O. Reg. 340/94 under the Act (the “Regulation”) states that a holder of a driver’s licence must not suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with their ability to drive a motor vehicle of the applicable class safely. Under s. 14(2)(b) of the Regulation, the Minister of Transportation may require a driver to provide satisfactory evidence that they are able to drive safely.

3The Registrar takes the position that the appellant suffers from three medical conditions, namely persistent hypoglycemia, a mental health condition, and cognitive impairment, that are likely to significantly interfere with his ability to drive safely and that this provides sufficient reason to suspend his licence under s. 47(1)(g) of the Act.

4The appellant appeals the suspension under s. 50(1) of the Act. He denies that he suffers from persistent hypoglycemia and cognitive impairment. The appellant does not dispute that he suffers from a mental health condition. The appellant denies that he suffers from any medical condition that would interfere with his ability to drive a vehicle of the applicable class safely.

5Pursuant to s. 50(2) of the Act, after a hearing the Tribunal may confirm, modify, or set aside the decision or order of the Registrar.

PROCEDURAL MATTERS

6It was reviewed at the outset of the hearing that there were several submissions from the Registrar received after the due date for disclosure of March 8, 2024 as set out in the Adjournment Order dated February 5, 2024. These submissions included:

i. A letter to the appellant responding to the new submission of medical information from the appellant dated March 11, 2024.

ii. An amended copy of the March 11, 2024 letter, dated March 19, 2024.

iii. Chapter 6 from the CCMTA Standards.

7The appellant’s representative indicated that they had no objection to the late submissions of the respondent. The representative cited that they had prepared for the hearing under the assumption that the entirety of the CCMTA Standards could be applied to the appellant’s case and were therefore prepared to proceed.

ISSUES

8The issue in this appeal is whether the appellant suffers from any of the three medical conditions alleged, and if any of these conditions are likely to significantly interfere with his ability to drive a motor vehicle safely.

9To resolve that issue, I will address the following questions:

i. Does the appellant suffer from a medical condition?

a. Does the appellant suffer from persistent hypoglycemia?

b. Does the appellant suffer from a mental health condition?

c. Does the appellant suffer from cognitive impairment?

ii. If so, are any of these medical conditions likely to significantly interfere with his ability to drive a motor vehicle safely?

10The Registrar bears the burden of proving on a balance of probabilities that the answer to each of the above questions is “yes.”

RESULT

11Having considered all the evidence and submissions and for the reasons that follow, I find that the Registrar has satisfied its burden to establish that the appellant suffers from a medical condition, in fact from each of the three alleged medical conditions, and that they are likely to significantly interfere with his ability to drive a motor vehicle of the applicable class safely. I therefore confirm the Registrar’s decision to suspend the appellant’s driver’s licence.

ANALYSIS

Does the appellant suffer from a medical condition?

Does the appellant suffer from persistent hypoglycemia?

12The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely persistent hypoglycemia.

13The Registrar’s position is supported by:

i. a Medical Report Form dated October 2, 2023 completed by Dr. W.;

ii. a Diabetes Assessment form dated March 8, 2024, completed by Dr. K.;

iii. a narrative letter dated March 8, 2024, completed by Dr. K.

14The Medical Report Form submitted by Dr. W., the appellant’s former family physician, supports the respondent’s position. Dr. W. has written on this form the appellant suffers from hypoglycemia “once a week while in nursing home”.

15The Diabetes Assessment Form completed by the appellant’s new endocrinologist, Dr. K., documents that the appellant suffers from persistent hypoglycemia unawareness. Dr. K. has circled “Yes” to the question of whether the appellant has experienced hypoglycemia unawareness in the past three months. Dr. K. has also circled “Yes” to the question of whether the appellant has had more than one reported episode of hypoglycemia unawareness in the past 12 months.

16A submitted narrative letter written by Dr. K., additionally supports the respondent’s position when it documents the presence of hypoglycemic episodes and provides reasoning for why the appellant is unaware of these episodes occurring, “It appears he [the appellant] was noted to have hypoglycemia on his continuous glucose monitoring device but was otherwise asymptomatic during these occurrences of low glucose levels. His hypoglycemia unawareness may in part be related to the beta blocker he is taking which may have been masking some of his hypoglycemia symptoms.”

17A second Diabetes Assessment Form was submitted by the appellant and completed by the appellant’s new family physician, Dr. D. on March 3, 2024. This Form provides somewhat contradictory information about the appellant’s diabetes history and management and is not relied on by either the appellant or the respondent. As the Diabetes Assessment Form completed by Dr. K. is the most recent submission, is more informative as it is supplemented by a narrative letter, and as Dr. K. is a specialist in the field of endocrinology, I accept that the information provided on Dr. K.’s Diabetes Assessment Form should be weighted more heavily than the Diabetes Assessment Form completed by Dr. D.

18The appellant submits that he has had diabetes for approximately 10 years. He monitors his blood sugar through the use of a continuous glucose monitor (CGM) that will alarm when his blood sugar is low, and he also carries a glucometer with him to test his blood sugar if his CGM is not working. He submits that he will check his blood sugar four to five times per day, which corresponds to checking in the morning and at mealtimes. The appellant agrees that he has had experienced hypoglycemia previously.

19The appellant relies on the narrative letter from Dr. K. to support his position. The appellant testified that he has recently undergone several medication changes to his diabetes management including discontinuing insulin and changing the oral medications used to manage his blood sugar. The narrative letter from Dr. K. documents that the medication gliclazide has been discontinued to further reduce the risk of hypoglycemia and the appellant has started a new oral medication, metformin, while also continuing to take the previously prescribed canagliflozin. Dr. K’s letter provides the medical opinion that he suspects the prior history of hypoglycemia was related to insulin and gliclazide therapy, both of which have been discontinued and on the current diabetes regimen the risk of hypoglycemia is less likely, with the last episode of hypoglycemia occurring February 20, 2024.

20Under cross-examination, the appellant submits that the last time he experienced hypoglycemia was three weeks prior to the hearing, which would have been after the February 20, 2024 date provided by Dr. K, and would indicate that he has continued to experience hypoglycemia since the latest medication change, supporting the Registrar’s position.

21When the appellant was questioned about his awareness of the hypoglycemic state, he reports that he experiences symptoms of hypoglycemia “hardly ever”, and the only symptom he occasionally has is his hands will shake “a bit”.

22The medical evidence before the Tribunal from Dr. W. confirms the appellant has had hypoglycemia once per week while residing in a nursing home. I take note of the close monitoring that would be available while residing in a nursing home with 24-hour access to medical care and the accuracy of this documentation. The appellant describes that he was in assisted living for several weeks in 2023.

23The more recent medical evidence from the appellant’s endocrinologist confirms that he has had hypoglycemia unawareness in the past 3 months and more than one episode in the past 12 months. The appellant by his own testimony reports that his last episode of hypoglycemia was three weeks prior to the hearing, and further testimony was provided describing that he has hypoglycemia unawareness and relies on his CGM to notify him of a hypoglycemic event.

24I find the medical evidence in this case relevant and persuasive and the testimony of the appellant supportive of the Registrar’s position. Based on the information available, I find that the Registrar has established on a balance of probabilities that the appellant suffers from persistent hypoglycemia.

Does the appellant suffer from a mental health condition?

25The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely a mental health condition.

26The Registrar’s position is supported by:

i. a Medical Report Form dated October 2, 2023, completed by Dr. W.

ii. a Mental Health Disorder Form dated October 2, 2023, completed by Dr. W.

iii. a Mental Health Disorder Form dated March 3, 2024, completed by Dr. D.

27On the Medical Report Form by Dr. W. she has checked the box corresponding to Psychiatric Disorders.

28On the Mental Health Disorder Form submitted by Dr. W., Dr. W. has checked the boxes indicating that the appellant suffers from depress/dysthymia, anxiety disorder and “other”. Dr. W. has also indicated that the symptoms are ongoing and mild and have been stable/unchanged for less than 3 months.

29On the Mental Health Disorder Form submitted by Dr. D., completed 5 months following the Form completed by Dr. W., Dr. D. has checked the boxes indicating that the appellant suffers from depression/dysthymia and symptoms are ongoing and mild and stable/unchanged for 6 – 12 months.

30The appellant submits that he has suffered from anxiety for approximately twenty years. He additionally submits that he has experienced times of “feeling down”. He submits he has been on medication for several years for these mental health concerns. Initially he was prescribed Zoloft, but due to side effects this was changed to a new medication approximately 5-6 years ago. He continues on treatment presently.

31As the appellant is in agreement with the Registrar that he suffers from a mental health condition, and since the evidence presented at the hearing supports this conclusion, I therefore find on the balance of probabilities that the appellant suffers from a mental health condition.

Does the appellant suffer from a cognitive impairment?

32The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely cognitive impairment.

33The Registrar’s position is supported by:

i. a Medical Report Form dated October 2, 2023, completed by Dr. W.;

ii. a Mental Health Disorder Form dated October 2, 2023, also completed by Dr. W.;

iii. The Cerebrovascular Diseases, Traumatic Brain Injury, Tumour or Other Neurological Diseases Form dated February 12, 2024, completed by Dr. T.-W.

iv. a Mental Health Disorder form dated March 3, 2024, completed by Dr. D.

34On the Medical Report Form submitted by Dr. W., Dr. W. has documented “MCI [Mild Cognitive Impairment]” separately under the categories of Disease in Cognition and Mental Competence, and then provided the following narrative, “Patient has recent diagnosis of Parkinson’s with non-amnestic MCI”.

35On the Mental Health Disorder Form from Dr. W., Dr. W. responds to the question of whether the appellant has any difficulties in cognition, attention or memory by checking the box for the diagnosis of “Mild Cognitive Impairment or Mild Dementia.”

36The Cerebrovascular Diseases, Traumatic Brain Injury, Tumour or Other Neurological Diseases Form completed by neurologist, Dr. T.-W., supports the respondent’s position that the appellant suffers from cognitive impairment as well. On this Form Dr. T.-W. has circled “Cognitive impairment” in response to the question as to whether the appellant has any significant functional impairment/symptoms.

37The Mental Health Disorder Form completed by Dr. D., the appellant’s new family physician, supports the respondent’s position that the appellant suffers from cognitive impairment. On this Form, Dr. D. has written “cognitive impairment” in response to the question about the patient’s primary mental illness. Dr. D. has additionally responded “Yes” to the question as to whether the appellant has any difficulties in cognition, attention or memory and then circled the terms, “Mild Cognitive Impairment or Mild Dementia”.

38The appellant disagrees that he suffers from cognitive impairment. The appellant submits that he has never been informed by any of his treating physicians that he has a diagnosis of cognitive impairment and has no idea how this diagnosis was made. He denies any difficulty remembering daily tasks or remembering important information regarding how to manage his medical illnesses.

39Under cross-examination the appellant testified that Dr. T.-W. had completed a series of tests with him asking him to close his eyes, name objects and recite a list of animals in a minute, but was told the results were “good”. He testified that he only sees Dr. T.-W. for his diagnosis of Parkinson’s Disease, not for cognitive impairment. He testified that he has only ever had a very brief encounter with his new family physician, Dr. D. who conducted no cognitive testing. The appellant submits he lives independently and handles all of his own affairs. Under cross-examination he testified that he required an admission to an assisted living facility in early 2023 for several weeks to assist him in transitioning back to his own home after a 2-month hospital admission.

40There is medical evidence before the Tribunal in the form of four submissions from three different doctors completed over a six-month period of time that all document the diagnosis of cognitive impairment. One of these physicians is Dr. W. who by the appellant’s testimony was his family doctor for several years, and another form by a neurologist whose specializes in this area of medicine. These medical submissions are weighed against the appellant’s testimony that he does not have cognitive impairment, has never been informed he has this diagnosis and reports no difficulty with completing tasks necessary for independent living. While the appellant disagrees with a diagnosis of cognitive impairment, he has not provided any medical evidence to dispute the diagnosis.

41I find the medical evidence in this case relevant and persuasive. Based on the information available, I find that the Registrar has established on a balance of probabilities that the appellant suffers from cognitive impairment.

Does the appellant’s medical condition of persistent hypoglycemia interfere with his ability to drive a motor vehicle safely?

42The Registrar relies on the CCMTA Medical Standards for Drivers (“CCMTA Standards”), in particular Chapter 7.6.9 (Persistent Hypoglycemia Unawareness – Commercial drivers) and 7.6.6 (Persistent Hypoglycemia Unawareness – Non-commercial drivers), along with internal policies at the Ministry of Transportation. Chapter 7.6.9 provides that persistent hypoglycemia unawareness presents the greatest risk for hypoglycemia while driving and that, given the increased driving exposure associated with commercial driving, individuals who have persistent hypoglycemia unawareness are not fit to drive and therefore not eligible for a commercial licence. The respondent indicated that the Ministry relies on internal policies to require twelve months of being episode-free before reinstating the appellant’s commercial driver’s licence.

43Chapter 7.6.6 on Persistent Hypoglycemia Unawareness for non-commercial drivers provides that drivers are eligible for a licence if:

i. It has been 3 months since the last episode of hypoglycemia.

ii. A treating physician has indicated stable glycemic control and takes steps to ensure they do not become hypoglycemic while driving.

iii. Conditions for maintaining a licence are met.

44The CCMTA Standards indicate that there is clear evidence to show that both non-commercial and commercial drivers with diabetes are at an increased risk of motor vehicle crashes and a relationship between hypoglycemia and crashes has been found. These Standards document that the neuroglycopenic symptoms associated with severe hypoglycemia can significantly impair the sensory, motor and cognitive functions required for driving. There are other studies noting mild hypoglycemia may also impair these functions. Thus, experiencing a hypoglycemic episode while driving would significantly interfere with a driver’s ability to drive safely and present a safety risk to the driver themselves and other road users.

45The CCMTA Standards outline the challenge posed by hypoglycemic unawareness, as the driver is unable to recognize the autonomic symptoms of hypoglycemia and thus treat with fast-acting carbohydrates before brain function is impaired, affecting insight, judgment, calculation, speech and memory. This is why the CCMTA Standards indicate that one of the conditions for maintaining a non-commercial licence for those with persistent hypoglycemia unawareness is to test blood glucose immediately before driving and approximately every hour while driving, as without testing, the driver would have no awareness of the hypoglycemic state.

46The appellant argues that he does not suffer from a medical condition that significantly affects his ability to drive safely. The appellant submits that he is aware of the consequences of experiencing hypoglycemia while driving, has never lost consciousness due to hypoglycemia and never required third party intervention to treat his hypoglycemia. He submits that his employer is aware of his diabetes, and he has had no incidents while driving.

47When asked if he would get into a vehicle and drive with a blood sugar of 4.5 mmol/L, the appellant indicated he would because the alarm on his CGM would not have gone off yet. He confirmed he drives 9 to 9.5 hrs per day five days per week as part of his employment as a commercial driver. As the appellant checks his blood sugar in the morning and at mealtimes, approximately 4-5 times daily, his practice of checking blood sugar supports the Registrar’s position, as it falls significantly short of the recommended frequency of every hour while driving outlined in the CCMTA Standards.

48When asked to describe how he treats a low blood sugar, the appellant’s response was that he treats with DexTabs, but did not identify how many fast-acting carbohydrates would be needed to consume, nor how long he would need to wait before resuming driving, nor what blood sugar he would target prior to resuming driving. Twice during the hearing, the appellant reported that water would be part of his approach to treat or stabilize blood sugars.

49Although not bound by the CCMTA Standards, the Tribunal may consider them when making the decision for the reason that these Standards are the result of a lengthy and intensive process to provide medical standards based on the best evidence available and with a focus on functional ability to drive rather than exclusively on medical diagnoses. While each appeal including this one must be judged on its own merits, I am persuaded to apply the CCMTA Standards here. My review of the evidence shows that none of the conditions recommended for non-commercial relicensing outlined in the CCMTA Standards have met. As the appellant would not be eligible for a commercial licence under the CCMTA Standards, I take note that he has not met the Ministry’s internal policy for reinstating a commercial licence either.

50I acknowledge the appellant’s position that he does not have a medical condition that will affect his ability to drive and has taken steps to reduce the risk of hypoglycemia, engaging with his endocrinologist to optimize his disease management. However, I take note that by the appellant’s own testimony he has continued to experience hypoglycemia since these medication changes, with the last episode being three weeks prior to the hearing. This falls significantly short of the three-month time frame the CCMTA Standards deem appropriate for reinstatement of a G class licence, or and the twelve months episode-free for a commercial licence.

51The persistent hypoglycemia unawareness is concerning for driving safety, as the appellant does not check his blood sugar hourly while driving as suggested by the CCMTA Standards. Furthermore, I find that the appellant’s willingness to drive a vehicle with a blood sugar in the 4 mmol/L range with no plan to recheck with increased frequency is concerning. It demonstrates a lack of insight into the cognitive functions affected by hypoglycemia and thus the seriousness of the condition and its potential consequences while driving.

52I also take note that the appellant did not provide testimony consistent with being knowledgeable about managing a hypoglycemic episode while driving. He lacked details around the number of carbohydrates required to treat a hypoglycemic event, indicated water would be included in how he treats a hypoglycemic event, did not demonstrate awareness of how long he would need to wait to regain cognitive functioning before resuming driving, and had no target blood sugar prior to resuming driving.

53Lastly, I take note that while there are four separate medical submissions addressing the appellant’s diabetes, none of them offer support for reinstatement of driving privileges. Dr. K.’s note specifically acknowledges that the appellant’s driver’s licence was suspended due to hypoglycemia unawareness, but makes no recommendation or comment at all supporting the reinstatement of a driver’s licence.

54I acknowledge the burden that the lack of a driver’s licence has on the appellant; however, driving is a privilege and not a right. As such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition of persistent hypoglycemia is likely to significantly interfere with his ability to drive safely.

Does the appellant’s medical condition of a mental health condition interfere with his ability to drive a motor vehicle safely?

55The Registrar’s position is supported by:

i. A Mental Health Disorder Form, dated October 2, 2023, completed by Dr. W.

ii. A Mental Health Disorder Form, dated March 3, 2024, completed by Dr. D.

56The Mental Health Disorder Form from Dr. W. reports that the appellant has had 2 or more admissions to hospital in the past 12 months and that he takes medication for his mental health condition that results in impairment of judgment.

57Dr. W. has additionally checked “Yes” to whether the patient has difficulties with cognition, attention or memory and circled “Mild Cognitive Impairment or Mild Dementia”. The diagnosis of cognitive impairment is specifically addressed in paragraphs [70] - [81] below.

58Dr. W. has additionally checked “Yes” in response to the question of whether the appellant requires an independent functional assessment and writes in the comment portion of the form, “Patient would benefit from functional + on-road driving evaluation”.

59As the Mental Health Disorder Form completed by Dr. W. reports on both the appellant’s mental health concerns as well as his cognitive impairment, it appears that the functional driving assessment is recommended both due to the mental health concerns and the cognitive impairment.

60The Mental Health Disorder Form that is completed by Dr. D., is completed five months after the same form completed by Dr. W. The form by Dr. D. states that the appellant is currently experiencing mild depressive symptoms, and that the appellant has been prescribed medications for his condition that result in side effects that may impair the appellant’s ability to safely operate a motor vehicle.

61Dr. D. has additionally written “not sure” to respond to the question of whether the appellant has appropriate insight / sufficient understanding of his medical condition and the impacts on his functional ability to drive. Dr. D. has similarly responded with “not sure” to the question of whether the appellant has difficulties with his judgement.

62Dr. D. has additionally checked “Yes” to whether the patient has difficulties with cognition, attention or memory and circled “Mild Cognitive Impairment or Mild Dementia”. The diagnosis of cognitive impairment is explicitly addressed in paragraphs [70] - [81] below.

63Dr. D. has also checked “yes” to the question of whether the appellant requires a functional driving assessment and written in the narrative comments, “I think that the results of his [the appellant’s] functional driving assessment will be very helpful in determining his overall mental health status”.

64The Registrar relies on the CCMTA Standards, in particular Chapter 14.6.1 (Psychiatric Disorders). Specifically, this chapter outlines the cognitive abilities that may be affected by depression, including attention and concentration, memory, reaction time, and psychomotor functioning. In addition, this Chapter describes that pharmacological treatment with anti-depressants may result in side effects that impair psychomotor functioning, cause sedation and result in impairment in cognitive functioning. For these reasons, functional assessment may be required. The CCMTA Standard 14.6.1 articulates the conditions for reinstatement of a driver’s licence as:

i. The condition is stable.

ii. The driver has sufficient insight to stop driving if the condition becomes acute.

iii. The functional abilities necessary for driving are not impaired.

iv. A treating physician supports a return to driving, for drivers who have stopped driving due to a psychiatric disorder, and

v. The conditions for maintaining a licence are met.

65The Registrar submits that confirmation of improvement in the appellant’s judgment (along with meeting the criteria for persistent hypoglycemia will likely result in the Registrar requesting a functional driving assessment.

66The appellant submits that he has been managing mental health conditions for many years and the conditions have been mild, as he has not been referred to a psychiatrist. He reports that he has been taking his present medication for the past 5-6 years and has no side effects of the medication. The appellant submits he has no suicidal ideation and has never had a panic attack. He describes that he has demonstrated good judgment while driving as evidenced by completing a pre-trip assessment log for his commercial licence. No material evidence of this log was submitted.

67The appellant argues that he does not know why Dr. W. had documented that he has had 2 admissions to hospital as he reports he has never been admitted to hospital. However, I take note of the inconsistency in the testimony, as during the hearing the appellant also described that he had a two-month admission to hospital in 2023 followed by an admission to an assisted living facility.

68I acknowledge the appellant’s position that he has lived with his mental health conditions for several years, has not recently changed medication, has no side effects from the medication, and his submission that these conditions will not affect his ability to drive. However, I am concerned about the inconsistency in the appellant’s testimony and the reported hospitalizations. Regarding the submitted medical documentation, I find the two Mental Health Disorder Forms submitted five months apart by two different physicians both align in their answers articulating that the appellant: has ongoing symptoms, takes medication that may result in side effects to an extent that may affect his ability to operate a motor vehicle and both physicians recommend completing a functional driving assessment. Furthermore, the latest form completed only 2.5 weeks prior to the hearing also documents the physician’s uncertainty with the appellant’s insight into his conditions and his judgment. I note that on the medical submissions there is no supportive statement regarding reinstating the appellant’s driving privileges. Lastly, I acknowledge that no medical evidence has been submitted to contradict the evidence of these two physicians, which supports the Registrar’s position that the appellant’s mental health condition will impact his ability to drive safely.

69As such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with his ability to drive safely.

Does the appellant’s medical condition of cognitive impairment interfere with his ability to drive a motor vehicle safely?

70The Registrar’s position is supported by:

i. The Medical Report Form dated October 2, 2023, completed by Dr. W.

ii. The Cerebrovascular Form by Dr. T.-W.

iii. The Mental Health Disorder Form completed by Dr. D.

71The Medical Report Form from Dr. W., in addition to reporting that the appellant has Mild Cognitive Impairment, writes “would benefit from executive function testing”.

72The Mental Health Disorder Form also completed by Dr. W. documents (as mentioned earlier in paragraph [57]) “Patient would benefit from functional + on road driving evaluation”. As the Mental Health Disorder Form reports on the appellant’s mental health concerns as well as his cognitive impairment, it appears that the functional driving assessment is recommended both due the mental health concerns and the cognitive impairment.

73The Cerebrovascular Form completed by Dr. T.-W., in addition to documenting the appellant has a diagnosis of cognitive impairment, checks “Yes” in response to the question of whether the appellant requires a functional driving assessment.

74The Registrar relies on the CCMTA Standards, in particular Chapter 6.6.1 which describes cognitive impairment in general and the concerns that result regarding driving safety, noting that cognitive problems often have a direct effect upon fitness to drive.

75Specifically, Standard 6.6.1 states that drivers who are diagnosed with cognitive impairment would be eligible for a licence if:

i. Complete medical assessment indicates cognitive functions necessary for driving are not impaired.

ii. Where required, functional driving assessment shows condition does not affect ability to drive; and

iii. Conditions for maintaining a licence are met.

76Standard 6.6.1 additionally states that the effects of Mild Cognitive Impairment may be subtle and difficult to assess in an office setting. This standard acknowledges that judgement and insight are important for driving, yet the usual battery of tests to assess the extent of cognitive limitations do not evaluate these functions. For these reasons, this standard concludes that a functional driving assessment is usually the most appropriate means of assessing the effects of the cognitive limitations upon driving unless severe dementia has been demonstrated.

77The appellant argues that as he does not have cognitive impairment, cognitive impairment therefore will not impair his ability to drive safely. He testifies that he lives independently and handles all of his own affairs. He submits that he has a clean driving record after driving for 46 years with the exception of one accident four years ago that was not his fault. However, on review of the extended driver record provided as part of the Registrar’s submissions, I take note of nine prior driving offences.

78I acknowledge the burden that the lack of a driver’s licence is having on the appellant. However, I also appreciate that Dr. T.-W. is a qualified neurologist, and would have the training, skills and ability to accurately diagnose cognitive impairment and assess whether there is risk to driving. The medical opinion that the appellant requires a functional driving assessment indicates concern that his medical condition will impair his ability to operate a motor vehicle safely. I appreciate the appellant’s position, but also take note that the appellant has not provided a medical opinion or any evidence inconsistent with the medical evidence which supports the Registrar’s position that his condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

79Furthermore, I take note again of inconsistency in the appellant’s testimony with reference to his prior driving offences. I also take note that the appellant reports that he has never been told he has a diagnosis of cognitive impairment, but describes cognitive testing being completed by his neurologist Dr. T.-W. and submits medical forms from three physicians all documenting the diagnosis of cognitive impairment. My assessment is that this demonstrates limited understanding of this diagnosis and limited insight into its risks while driving.

80I find the medical evidence demonstrates a clear and consistent pattern of three physicians over a five-month period all identifying the need for a functional driving assessment, which I believe clearly demonstrates that there is concern about how the appellant’s cognitive impairment will affect his ability to drive safely.

81I find this medical evidence compelling, and as such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition of cognitive impairment is likely to significantly interfere with his ability to drive safely.

Conclusion

82I find that the Registrar has discharged the onus of establishing on a balance of probabilities that the appellant suffers from three medical conditions, and that each condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

ORDER

83For the reasons set out above, pursuant to subsection 50(2) of the Act, I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.