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The Older Driver

Mindy J Fain, MDProfessor of Medicine

Chief, Geriatrics and Gerontology

Director, Arizona Reynolds Program

University of Arizona College of Medicine

The Older Driver

Rapid growthof elder driversat increased

risk forcrashes

Universal reliance

on cars for freedom &

independence

? Gold Standard

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The Myths

The older driver is an unsafe driver

We can accurately predict the unsafe driver

through valid screening tools and tests

Public policy that targets and restricts older

drivers as a group is beneficial to society as a

whole

The Older Driver

Driving is an important medical and social

issue

– Normal aging and associated disease may

compromise the ability to drive safely

– Most older drivers adjust their driving habits

– Growing apprehension exists about elder drivers

The Older Driver

Demographics

Violations, Crashes and Fatalities

Driving Skills and Aging

The Office Evaluation

The Law (Texas)

The Ethical Dilemma

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Our Aging Society

• Older Americans are the fastest growing segment of the US population

• Persons >65=13% of population

– Population > 65 will double in next 30 yrs

– Progressive shift to older median age

– Oldest-old (over 85) is fastest-growing group

The Older Driver

Older drivers = 15% of all drivers now

By 2020, 25% of all drivers will be >65 Older adults rely on driving for:

– Independence

– Mobility

– Safety

– Socialization

– Self-esteem

The Older Driver

Do you currently drive? Yes93%60-64

80%70-74

62%80-84

50%85-89

33%90+

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Older Driver: Lowest crash rate of any group

Lowest crash rate per driver

• Low Risk Driving– Fewer miles

– Shorter distances

– Familiar routes

– Avoid night driving, heavy traffic, bad weather, sunrise or sunset

– Drive slowly, cautious maneuvers

Older Driver: Second highest crash rate/mile

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Driving less miles Driving optimal miles

Per driver: lowest crash rate Per mile: one of the highest crash rates

The Older Driver

Highest Fatality Rate

Types of Violations

Left Hand Turns against oncoming traffic– Stop sign

– Traffic light

Yielding Right of Way

– Merging

Traffic Sign Violations

Driving Too Slowly

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Types of Crashes

Multiple vehicle, intersection crashes:

Older drivers havedisproportionately

more crashes at intersections

Driving Skills and Aging

• Driving is a complex but over-learned skill

• With aging, normal physiologic changes and co-morbidities compromise driving ability– Primary medical areas of concern:

• Vision

• Mobility and functional status

• Effect of chronic medical conditions

• Cognition

Age-Related Visual Changes

Decreased visual acuity, static* + dynamic

Decreased adaptation to lighting changes

Need for greater illumination

Increased light scatter

Narrowed field of vision*

Reduced ability to detect presence, rate, and relative movement of a target

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Age-Related Visual Changes

Increased prevalence of eye diseases with aging:– Macular degeneration

– Cataracts

– Glaucoma

– Retinopathy (diabetic)50% of those over75 years old are

affected

Useful Field of View = UFOV– Area over which driver can rapidly make

judgments; reductions correlates with crashes

Dynamic Visual Tests

Chronic Medical Conditions

Influences driving skills and crash rates Higher Prevalence in elder drivers

Crash Rate for Drivers Over 65/ 1,000,000 miles

Chronic medical condition

Healthy

24.311.4

Increased crash ratealso found in

younger drivers

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Medical Conditions

Arthritis Cardiopulmonary Diseases Cerebrovascular Diseases Seizure and Altered States of Consciousness Diabetes Mellitus Neurologic Disorders Sleep Disorders

Driving is a physical activity requiring:– Muscle strength and endurance– ROM of extremities, trunk and neck– Proprioception

Aging and age-related conditions (arthritis, pain, sarcopenia) may impact driving safety

Mobility and Functioning

Arthritis

Highly prevalent– Effects of Treatment (Medications)– Effects of Pain– Effects of Restriction of ROM– Effects of Decreased Strength

Turning the WheelBraking

Backing Up/Parking

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Medications

High prevalence of medication use– Elders are prescribed 30% of all meds

AnxiolyticsSedative-hypnotics

AnalgesicsAntidepressantsAntipsychotics

More common problem in elderly than commonly realized– 5%-10% of elders

– Affects cognition and motor responses

– Questioning (CAGE or direct) is recommended

Alcohol

Geriatric Assessment Clinic-

25% of referrals are still driving

The Frail Older Driver

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Geriatric Assessment Clinic: Typical Driver

– >50% had MMSE Score <24

– >25% needed help with bathing, dressing

– >33% needed help with IADLs (using the

telephone, medication management)

The Frail Older Driver

Long considered an important risk factor for crashes– Memory

– Decision making, problem solving

– Visual-spatial skills (lanes,distance)

– Verbal Processing (signs)

– Attention (distractions)

– Judgment (no restrictions)

Dementia

Yes– 50% continue driving (alone, at night, crashes)– 50% of caregivers considered them safe drivers

• 50% get lost on regular basis• 35% had at least 1 crash, or caused a crash

No– Some correlation w/ MMSE <24, clock draw, design copy,

trail making test

Are Patients with Dementia Driving?

Can We Identify the Demented Patient Who Will Crash?

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Putting it all together

Is Driving Assessment My Responsibility?

Office Approach to Older Drivers

Ask how they got to the visit today Review driving record and safe habits

(seat belt, prior crashes, self-limitations) Sensory screening Cognitive screening Functional status Musculoskeletal problems Medications Higher risk medical problems

Office Approach to Older Drivers

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The Office Approach

AMA’s Physician’s Plan for Older Drivers’ Safety– Be alert to red flags

– Assess driving-related abilities* (tool)

– Treat underlying causes

– Refer (driver rehab)

– Counsel on safe driving

– Follow-up

The Office Approach

ADReS:

Assessment of Driving-Related SkillsAMA Physician’s Guide to Assessing and Counseling Older Drivers 2003

The Snellen E chart

Visual Fields

ADReS: Vision

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Rapid Pace Walk 20 Feet (Get up and Go)

Manual Test of Range of Motion– Neck rotation, finger curl, shoulder and elbow

flexion, ankle plantar flexion, ankle dorsiflexion

Manual Test of Motor Strength (5/5)

ADReS: Mobility

Trail-making test Clock-drawing test

ADReS: Cognition

Counseling the patient who is no longer safe to drive– Explain why it is important to retire from driving– Focus on risk to self, and others– Discuss transportation options– Use economic arguments– Write a prescription: DO NOT DRIVE– Involve the family for alternative transportation and

support

Practical Approach to End Driving

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The Office Approach

What if your patient refuses assessment?– Encourage them to take the self-assessment (Am I a Safe

Driver?)

– Encourage them to drive with someone to observe them

– Counsel your patient on “Tips for Safe Driving”

– Document your concern in the chart

– Follow up at the next appointment

– Give family “How to Help the Older Driver” from AMA

– If you are urgently concerned, consider referral to Driver Rehab Specialist, local AARP resources, or your state driver licensing agency

Other Demanding Situations– The Resistant Patient

– Patient lacking decision-making capacity• Know your state law re: reporting

Remember, revoking the license may not stop the person from driving!

• Hide the car

• Change or hide the keys

• Disable the car

Practical Approach to End Driving

Know and comply with your state’s reporting laws

Reduce the impact of breaching patient confidentiality

Document

Practical Approach to End Driving

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The Law: Texas

What is Texas law regarding the older driver?

Balancing Public Safety with Individual Autonomy– Confidentiality vs. Duty to Warn– Balance between personal risks and benefits– Public’s responsibility to provide alternative

means of transportation

;Beneficence;Respect for Persons;Justice; Fidelity

The Older Driver Challenge

Who will control the older adult’s ability to drive?– Medicine– Government– Insurance Companies– Automobile Industry

Society’s Challenge

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The older driver represents a public safety issue – but the solution must balance individual autonomy with the public good.

The primary care provider has a central role, but has limited tools to guide the process.

Every provider needs to be familiar with their state’s impaired driver reporting laws.

Take Home Message