Assessing and Counseling Older Drivers Identifying and Assessing the Medically Impaired Driver

AMA House of Delegates Recommended that drivers receive a physician’s certificate of medical fitness to drive Recommended that prior to licensure, applicants undergo an exam to determine physical and mental capacity to drive Section on ophthalmology issued ”Visual Standards for Operating a Motor Vehicle.”

AMA Committee to Study Problems of Motor Vehicle Accidents (1930’s-1950’s) 1939 report classified conditions influencing driving as: –Permanent deficiencies –Transitory deficiencies –Brief or self-inflicted deficiencies This report stated that alcohol causes impairment at a blood level of 0.05%.

Report “Age per se should not be a limitation once the individual reaches licensing age, rather the functional capacity and ability of each individual should be the determining factor.”

“Too Old” to drive? Numerical age is not the problem Impaired function is the limiting factor AMA report, 1963

Physician’s Guide to Assessing and Counseling Older Drivers Provides physicians with the tools necessary for assessing older patients for medical fitness to drive.

What functional abilities are important to driving? Vision Cognition Motor function

Physician’s Plan for Older Driver Safety Screen to determine if patient is potentially at risk Assess driving related functional skills (ADReS) Treat underlying causes of functional decline Refer for further evaluation and/or adaptive training Counsel on safe driving behavior and alternative options Follow-Up for signs of depression, isolation and compliance

How can physicians screen patients for medically impaired driving? Be alert to Red Flags: Any medical condition, medication or symptom that can impair driving skills

Red Flags Acute events Patient’s or family member’s concern Medical history –Chronic medical conditions –Unpredictable/Episodic events Medications Review of systems

Prescription & OTC drugs alcohol antihistamines antidepressants benzodiazepenes opiod analgesics muscle relaxants antipsychotics

If Red Flags are present Ask health risk assessment/social history questions –How did you get here today? –Has another treating physician brought up driving issues? Gather additional information –Do other drivers on the road cause you distress? –Have you had any recent problems when you drive? Understand your patient’s mobility needs

How can physicians assess for deficits in function? Assessment of Driving Related Skills ADReS is a brief, function-based, in- office assessment of driving-related skills ADReS does not assess patient’s performance on driving task ADReS does not predict crash risk

Assessment of Driving Related Skills Motor Function Rapid pace walk Manual test of motor strength Manual test of range of motion Vision Visual fields by confrontation testing Snellen E Chart Cognition Trail-Making Test, Part B Clock Drawing Test

Interpreting ADReS results Recommended scoring limits to evaluate patient’s performance The goal is to identify and correct any functional deficits that may impair driving performance Recommendations are subject to state reporting laws and DMV requirements

Three courses of action If patient performs well, continue driving without further work-up or treatment If patient performs poorly, pursue medical treatment and necessary evaluation If patient’s poor performance can not be medically corrected, refer patient to a Driver Rehabilitation Specialist

Targeted clinical assessment Functional on-road assessment Prescribing and training clients in the use of adaptive equipment Counseling and advising on driving concerns and mobility alternatives Certified Driver Rehabilitation Specialists have expertise in:

Physicians can help maximize older driver safety Continue medical treatment & preventive care Counsel patients on health and driving Identify at-risk patients & help manage deficits Discuss driving retirement Abide by state reporting laws

Legal considerations Protecting the patient –Case law illustrates that failure to advise patients on medical conditions and medications is negligent behavior –Case law also illustrates the health care system can be liable for breaching confidentiality Protecting the public –Legal precedents demonstrates that physicians may be held liable for third-party injuries

Legal protection for patient reporting Immunity- exempts physicians from liability for civil damages Anonymity/Legal protection- protects physicians from civil actions for damages caused by reporting in good faith

Policy Issues Impaired function determines driving safety not age. On the road test essential to see how patient compensates for impairments No immunity for physicians who report their concerns in many states. National need for legislation to allow good faith reporting by physicians and other health professionals.

olderdrivers American Medical Association National Highway Traffic Safety Administration