Keeping Older Drivers Safe and Out of the News
Driver, 86, loses license after mistaking the gas pedal for the brake and runs over man in Costco parking lot.
74-year-old driver with health problems plows into an El Cajon Carl's Jr., killing a man inside.
CHP Officers spend 40 minutes pursuing elderly motorist from Encinitas to University City. Driver did not notice the six squad cars and police helicopter following him the entire way.
75-year-old driver with a bad hip mistook the gas for the brake and drove off a cliff at Cabrillo National Monument, resulting in his death.
On average, men outlive their ability to drive safely by 6 years, and women by 10 years (1). With individuals 65 years old and older the fastest growing demographic in the United States today, the problem of elder driving safety is exploding. By 2020, there will be more than 40 million licensed drivers over the age of 65 in the United States (2). Our challenge is to identify — before tragedies occur — when alternative transportation options should be employed.
The age at which driving becomes unsafe is variable, with many individuals continuing to drive safely into their ninth decade. Older adults have positive driving attributes like experience, being more likely to follow the laws and less likely to take risks; however, as a group, they have rates of death per distance driven and per population as high as teenage boys (see figures 1 and 2), due mainly to declining vision, impaired cognitive function, general frailty, and chronic diseases with their associated medications (3, 4). In addition, in crashes of the same intensity, older adults have three to four times the risk of death in crashes as 20 year olds due to decreased muscle mass and osteoporosis (see figures 3 and 4).
AMA has recognized the role of physicians in identifying which older adults should no longer be driving and developed guidelines that provide tools and practice management aids, including sample letters, screening tests, management guidelines, and charting aids. The screening tests suggested by AMA are blunt but identify three areas of concern: vision (acuity and fields), frailty (gait speed, range of motion, and strength), and cognition (Trail-Making B and Clock Drawing) (see table 1). The bluntness of these tools stems from the paucity of data linking failure (as a group) on these tests directly to the outcomes of interest: citations, crashes, injuries, and deaths. There is, however, more than sufficient evidence on each of these tests with the relevant outcomes to support their inclusion (5–12).
In addition to the seven tests, the screening process should also cover targeted history to include a history of loss of consciousness, seizures, dementia [all reportable to the California Department of Motor Vehicles (DMV)], medication history to include drugs that interfere with cognition, and especially patient or family concerns about their ability to drive safely. Since driving involves rapid decision-making, especially under stressful conditions that cannot be duplicated in the office, family concerns remain the most effective screen.
Table 1 describes the individual screens used in testing for age-related driving disorders (ARDDS). For patients who pass all seven screens, management should focus on restricting medications to their lowest necessary doses; on strict avoidance of alcohol while driving; and counseling on safe driving. Seniors should be retested periodically or with health changes. These screening tests may identify problems associated with temporary or correctable changes in function. In those cases, referral and evaluation, with treatment, may result in enough improvement in function to resume driving.
The algorithm in figure 5 outlines the management plan for patients who fail one of the tests. If the vision or frailty tests are failed, assess whether the diagnosis has been made and whether there is a reversible component. If the deficit is permanent, and the patient wishes to continue driving, consultation with an occupational therapist with advanced training in driver assessment may help in deciding if this is a safe option. Known as Certified Driving Rehabilitation Specialists (CDRS), these health professionals can take drivers on the road and provide both safety assessments as well as rehabilitation of driving skills. Currently, CDRS programs exist at Sharp Memorial, Tri-City Hospitals and Scripps Encinitas has one in development.
The failure of the dementia testing requires further evaluation to confirm the diagnosis and determine the level of dementia. The DMV feels that some individuals with early dementia are able to continue driving safely; however, they want to be aware of these individuals and conduct testing and monitoring. As with patients exhibiting frailty and impaired vision, a CDRS can be very helpful in providing guidance for patients with mild dementia.
The DMV mandates reporting of drivers with dementia, a loss of consciousness, or seizures. Reporting can be done through the Confidentiality and Morbidity Report (CMR) form or through the DMV's DS 699: Request for Driver Reexamination. Physicians can also report drivers with other health issues — such as substance abuse, vision deficits, frailty, and medication side effects — that may potentially impair their driving. Physicians who report are protected from liability by Health and Safety Code 103900. Especially once families have expressed concern, physicians who choose not to report could face potential liability in the event of an accident. Lawsuits by third parties injured in an accident would often not be covered by malpractice policies.
Once DMV has been notified, whether by an Emergency Department, treating physician, or law enforcement, a detailed medical questionnaire (Driving Medical Evaluation, or DME) is sent to the patient. Physicians traditionally dread filling out these forms, but irrelevant sections may simply be lined out rather than completed in detail. The legal consensus is that no liability attaches to filling out the DME, unless deliberately and provably false statements are made.
The most helpful questions for the DMV hearing officer are: "In your opinion, does your patient's medical condition affect safe driving?" and "Do you currently advise against driving?" Physicians may hesitate to answer these questions, but no liability attaches to answering them. Our medical opinion carries great weight, but the ultimate decision and liability rests with DMV.
Patients may be reluctant to bring driving concerns to their physician's attention. Driving is a sensitive issue for many older adults who depend on driving for independence. Driving cessation in this population has been associated with a three-fold decrease in out-of-home activity and a two-and-a-half-fold increase in depressive symptoms (13, 14). Thus, ARDDS (age-related driving disorders screening) should be conducted in a supportive environment where options for continued mobility can be given to patients who should no longer be driving.
UC San Diego has been training professionals on ARDDS since 2004, through funding from the California Office of Traffic Safety. Our team is a unique partnership of preventive medicine physicians in the Department of Family and Preventive Medicine, led by Dr. Linda Hill, and trauma surgeons in the Division of Trauma, lead by Dr. Raul Coimbra. Over 1,000 patients have been screened for ARDDS in both in- and outpatient settings. We have found both settings to be valuable: Outpatient settings capture the majority of older adults, and primary care physicians are ideally suited to screen and counsel on this issue. Inpatient settings provide access to persons whose health may have suddenly changed and where driving is either temporarily or permanently unsafe. Screening is well accepted, and satisfaction level is high in both settings.
Addressing driving retirement requires effort on many levels. The availability of alternative transportation methods for older adults is a problem that must be addressed by society through increasing public transportation options. SANDAG has a centralized transportation website for older adults and individuals with disabilities. The government has a role through the DMV in helping to identify unsafe drivers during re-licensing; however, the healthcare system must also play a crucial role as physicians screen and identify patients. Society, older adults, and their families depend on physicians to help them through this transition.
Table 1: Description of the seven tests used in age-related driving disorders (ARDDS) screening, adapted from the AMA Physician's Guide to Assessing and Counseling Older Drivers.
Figures 1-4 have been extracted from Traffic Safety (15).