Watching Out for Older Drivers Samuel C. Durso, MD, AGSF Associate Professor of Medicine Division of Geriatric Medicine and Gerontology

Objectives: Learn key facts about older drivers Understand the physician’s role in screening patients who may be unsafe drivers Know how to respond to older drivers who are or may be unsafe

Key Facts Leading cause of injury-related death for 65-74-year olds; second after falls for 75- to 84-year olds Self regulation of driving behavior not enough Majority rely on driving for transportation Crash rate related to physical and mental changes Physicians can influence patients’ decisions

7 Red Flags for the Medically Impaired Driver Acute events: Counsel prior to discharge for MI, stroke or brain injury, syncope or vertigo, seizures, surgery or delirium Patient’s or family member’s concern Chronic medical illness that may affect function Medical conditions with unpredictable or episodic events

7 Red Flags (continued) Medications: especially those affecting CNS or motor function Review of systems: can reveal symptoms or conditions that impair driving performance (e.g. weakness, dizziness, palpitations, joint pain or stiffness) New medication or change; new condition or change: address effect on driving in assessment and plan for treatment

Look at the following case. What are the red flags?

Case: Mr. C. is an 80 y/o who lives alone. Driving is his main form of transportation. His daughter, who lives within 15 minutes of his home, accompanies him to your office for his first visit to establish primary care. Privately she asks you to voice an opinion and address his driving safety. Her concern stems from an incident in which he ran a stop sign while she was riding with him recently.

Case continued: Further History: He feels well and appears to be defensive about having to justify his driving. He has no history of moving violations or accidents. He drives principally to the bank, church, his daughters house and the VFW. He drives during daytime only and stays off the interstate. The daughter suspects that the traffic sign incident was not isolated. Medications: NSAID for OA of knees, back and neck, a diuretic for HTN.

Case continued: PMH: Diet controlled diabetes, a mild cataract but good vision. Ten years ago he had an MI, but no angina. Social: Retired crane operator. High school grad. WWII vet. Smokes 0.5 pack per day, has a few beers at VFW. His last license renewal was three years ago. ROS: negative for angina, dizziness or history of loss of consciousness.

What have we learned from the history?

The Exam: Assessment of Driving Related Skills (ADReS) Focus on three key skills: Vision Motor function Cognitive function

The Key Skills in Focus Vision Near and far vision, and fields Motor function muscle strength and endurance range of motion of neck, trunk and extremities proprioception

The Key Skills in Focus (continued) Cognition Memory Visual perception, visual processing, and visuospatial skills Selective and divided attention Executive skills

Physical Exam: Reveals normal vital signs with exception of occasional premature beat. General build stocky, muscular, slightly kyphotic. He has small cataracts but corrected vision is 20/40 bilaterally. Hears finger rub bilaterally. Neck has decreased rotation. Musculoskeletal exam reveals good strength and ROM, but has painful weight bearing on right knee associated with mild limp. Mini-mental is 28/30, missing the precise date and 1 of 3 on immediate recall. Clock drawing on next slide.

Asked to show 11:20

Freund Clock Scoring for Driving Competency Any incorrect element signals a need for intervention: All 12 hrs in correct order, starting with 12 at the top Only the numbers 1-12 included without duplications or omissions All numbers are equally spaced All are equally spaced from edge of circle One hand points to the eleven One hand points to the four There are only two clock hands

How do we address the patient? Use direct language Reassure the patient that safety is paramount Goal is to help patient drive safely as long as possible Reassure that you can not “take his license away” If you recommend retirement from driving, you will refer him/her to the DMV

What if patient refuses assessment? Encourage the patient to take self-assessment Counsel on Successful Aging Tips and Tips for Safe Driving Document your concern, patient’s refusal and counseling Follow-up at next appointment If family concerned, give How to Help the Older Driver

What do you want to know before dispensing advice? Department of Motor Vehicle law Local resources for driving skills evaluation and driving rehabilitation Alternatives to driving

Role Play

Summary Recognize red flags Assess physical and cognitive function Correct treatable problems Counsel and document Refer when appropriate Follow-up with patient

AMA Ethical Opinion Physicians should assess patient’s physical and mental impairment Tactful discussion before reporting Must use best judgment Report medical condition that impairs driving safety Report minimal amount necessary Work with state medical societies to create statutes that uphold patient and community interests and safeguard good faith reporting

References Physician’s Guide to Assessing and Counseling Older Drivers http://www.ama-assn.org/ama/pub/category/10791.html