Transcript Driving and the Elderly

Driving and the Elderly
Dr. James L. Silvius BA (Oxon)
MD FRCPC
Geriatric Medicine
October 15, 2002
Conflicts of Interest
• None
Objectives
• Understand changes related to aging
that may impact on ability to drive
• Understand changes related to disease
that may impact on ability to drive
• Understand societal implications of
driving/not driving
Case 1
• H.N. - 74 y.o. male, presenting for
assessment of ability to drive
• “Dementia”
– slow short term memory loss
– MMSE 25/30
• No driving problems, may get “lost” in
unfamiliar places
Case 2
• E.B. - 74 y.o. male for drivers license
renewal
• Good physical health, some “arthritis”
• Recent diarrhea
• Smoker, physical evidence for COPD
• Refused MMSE
Case 2 - continued
• Wife:
– alcohol use history
– spousal abuse
– other changes
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decreased hygiene
financial management changes
inappropriate voiding
“living in the past”
Case 2 - continued
• Wife
– driving problems:
• running stop signs
• changing lanes inappropriately
• recently refused to allow her in car
• She doesn’t drive
• “Please give him his license”
Statutes - Section 14(1)
• Motor Vehicle Administration Act
– Any person who
• holds an operators license, and
• is making application for an operator’s license
shall disclose forthwith to the Registrar any
disease or disability which may be
expected to interfere with the safe
operation of a motor vehicle
Statutes - Section 14(2)
– A physician may, without acquiring any
liability by doing so, report to the Registrar
any medical information relative to the health
of a person holding or applying for an
operator’s license when the physician
believes that the condition in relation to which
the information is given may adversely affect
that person’s operation of a motor vehicle.
Alberta Requirements
• Mandatory review, physical exam and
structured report
– 75th birthday
– 80th birthday
– q2years after age 80
Why is Driving an Issue?
• More older drivers
• Group over age 70 fastest segment
– demographics
– more women
– driving longer into older age
Why is Driving an Issue?
Why is Driving an Issue?
• Older drivers:
– drive less
• age 65, 11,000 km/yr.
• age 80, 4,000 km/yr.
– shorter distances
– lower speeds
– less at night
– avoid busy times on road
Why is Driving an Issue?
Why is Driving an Issue?
• Errors:
– right of way
– traffic sign violations
• MVA’s
– more common at intersections
– involve multiple vehicles
Why is Driving an Issue?
• More likely to have serious injury
– <age 70, 10%
– >age 80, 15%
– longer recovery times, less complete
• More likely fatal
– age <70, 1.2%
– age >80, 4%
Age-Related Changes
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Psychomotor slowing
Visual acuity changes
Light perception changes
Visual field changes
Motor strength declines
Medical Conditions
• Multiple conditions, affect young and old
• Prevalence higher in elderly
• Determining Medical Fitness to Drive,
6th Ed., 2000 - CMA
Musculoskeletal System
• Osteoarthritis and Rheumatoid Arthritis
– Joint movements/Pain
• C-spine
• Hand function
• Foot/leg function
Neurological System
• TIA
– medical/neurological assessment
– no functional loss
– underlying cause treated
• CVA
– 1 month preclusion, then as above
• For elderly, need physical, cognitive,
functional assessment
Neurological System
• Syncope
– as for any age
– single episode, no recurrence, explained,
no preclusion
– those with recurrent faints/unexplained
falls, driving precluded pending explanation
Neurological System
• Seizures
– as for those of any age
– single seizure, no diagnosis on
investigation, no recurrence, preclusion for
3 months
– diagnosis epilepsy, preclusion for 12
months seizure free
Neurological System
• Parkinson’s Disease
– disease
• mobility changes
• cognitive changes
– treatment
• dopamine agonists
• (any agents?)
• effects on sleep
Neurological System
• Peripheral Neuropathy
– no preclusion
Sleep Disorders
• Obstructive sleep apnea
– no preclusion if compliant with treatment
• Narcolepsy
– as per younger drivers
• Medication Use
– any medications affecting psychomotor
function
Metabolic Disorders
• Diabetes
– NIDDM, no preclusion
– IDDM, preclusion if severe hypoglycemic
episodes in 6 months
• Thyroid disease
– hypothyroidism common, no preclusion
once treated
– hyperthyroidism, no preclusion once
treated
Cardiovascular Disease
• Cardiac arrhythmia
– Atrial fib/flutter most common, no
preclusion
– other arrhythmias, preclusion depends on
type
– sinus node disease, no preclusion if no
associated cerebral ischemia
– 1st degree block, RBBB, LAHB, LPHB no
preclusion
– LBBB, bifascicular block, Mobitz 1 no
preclusion if no assoc. cerebral ischemia
Cardiovascular Disease
• Valvular heart disease
– aortic stenosis, no cerebral ischemia,
functional class 1-2, no preclusion
– other valves, no cerebral ischemia, no
preclusion
• CHF - no preclusion class 1,2
• Hypertension, no contraindications;
complications may affect safe driving
Sensory Systems
• Vision
– Cataracts, glaucoma, ARMD, corneal
disease common
– standards relate only to visual acuity and
visual fields; above may impact these
• Hearing
– no standards
Respiratory System
• COPD
– no preclusion unless on oxygen, then road
test on oxygen required
Renal Disease
• No restrictions
Dementia
• Different perspectives:
– Preclusion once diagnosis made
– Preclusion based on disease stage
– Where is point reached where driving not
appropriate?
Dementia
• Canadian Consensus Conference on
Dementia
– for affected individuals, consider risk
associated as disease progresses
– driving difficulties may indicate other
cognitive or functional problems
– affected individuals and their families
should plan at an early stage for eventual
cessation
Dementia
• National Safety Code
– dementia is progressive and irreversible
• memory
• intellect
• personality
– MMSE recommended, score <24 a
preclusion pending further assessment
Societal Implications
• Physicians:
– have obligation to assist older individuals
to maintain independence
– recognize that loss of independence
associated with
• decreased QOL
• increased isolation
• depression
Societal Implications
• Older drivers:
– have obligation to be capable of safe
driving
• Assessment
– structured history and physical when
questions arise
– Cognitive assessment
– Collateral history
Societal Implications
• Legal obligations
– physicians may report
– issues of confidentiality
– protected disclosure
• public interest - MD as custodian of public trust
• private interest of patient at risk
– forseeability
Assessment
• As noted for medical illness
• Cognitive loss assessment more limited
– Issue of road tests
– DriveAble
Conclusions
• Strategies for license removal
– physical more acceptable
– cognitive more difficult
• early preparation
• letter to Driver Records
– pertinent information
• DriveAble or other structured assessment
• notification of individual
Address for Reporting
Driver Records
Traffic Safety Board
Main Floor, Twin Atria
4999 - 98 Avenue
Edmonton, Alberta
T6B 2X3
Phone 780-427-8230
Fax 780-422-6612
Case 1
• Assessment performed
• Stable cognition over 2 years, probable
Minimal Cognitive Impairment
• Driver Records contacted
• License given, annual review
requirement placed
• Wife as “co-pilot”
Case 2
• Reporting to Driver Records based on
collateral and refusal of assessment
• Individual stopped alcohol intake,
sought second assessment
• Second assessment declared him fit
• Complaint re: community MD and self to
College, dismissed