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

2. 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

3. Key Facts
Leading cause of injury-related death for 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

4. 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

5. 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

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

7. 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.

8. 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.

9. 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.

10. What have we learned from the history?

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

12. 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

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

14. 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.

15. Asked to show 11:20

16. 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

17. 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

18. 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

19. 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

20. Role Play

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

22. 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

23. References Physician’s Guide to Assessing and Counseling Older Drivers