Transcript To Drive or Not To Drive - Delaware Academy of Family Physicians

Driving and Older Adults
Melissa Morgan-Gouveia, MD
30th Annual DAFP Geriatric Symposium
September 1, 2016
Disclosures
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No financial disclosures
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I am a current member of the ABIM Geriatric Medicine
Specialty Board
To protect the integrity of Board Certification, ABIM enforces
strict confidentiality and ownership of exam content.
As a member of the Geriatric Medicine Specialty Board, I
agree to keep exam information confidential.
As is true for any ABIM candidate who has taken an exam for
Certification, I have signed the Pledge of Honesty in which I
have agreed not to share ABIM exam questions with others.
No exam questions will be disclosed in my presentation
Objectives
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Review statistics related to older adults and driving
Review medical conditions and medications that can
impair driving ability
Describe methods of evaluating driving ability
Discuss strategies for having conversations about
driving with patients and their caregivers
Provide resources for patients and caregivers
Driving and Older Adults
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The number of drivers age 70 and older is growing
– Licensed drivers ≥ 70 increased 38% between 1997 & 2014
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Reflects both increase in population and drivers keeping licenses longer
– 24.4 million licensed drivers age 70 and older in 2014
 Representing 79% of the population age ≥ 70 and 11% of
drivers of all ages
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Older drivers involved in fewer fatal collisions than in the past
– 29% fewer people age ≥ 70 died in crashes in 2014 than 1997
Source: Insurance Institute for Highway Safety, http://www.iihs.org/iihs/topics/t/older-drivers/qanda
Crash Rates for Older Drivers
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Per capita rate of passenger vehicle crash involvements
by driver age, 2011. Source: www.iihs.org
Older drivers have low
rates of police-reported
crash involvements
Fatal crash rates begin to
increase at age 70
Crash Rates Per Mile Traveled
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Rate of passenger vehicle crash involvements
per mile traveled by driver age, 2008.
Source: www.iihs.org.
Crash rates and fatal crash
rates per mile traveled start
increasing at age 70
May be somewhat inflated
based on more city driving
(where crash rates are higher)
and less highway driving
(where rates are lower)
Fragility and Fatal Crash Rates
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Older adults have an increased
risk of death in crashes
– Increased incidence of
osteoporosis and fractures
– Increased atherosclerosis of
aorta predisposing to rupture
– Drive older model cars
Number of passenger vehicle driver deaths
per 1,000 drivers involved in police-reported crashes
by driver age, 2007-2011. Source: www.iihs.org.
Collisions and Older Drivers
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Older drivers are more likely to be involved in collisions at
intersections
Failure to yield the right of way is the most common error
Inadequate surveillance
– Looking but not seeing > failing to look
– Affected by vision impairment, decreased range of head
movement, ability to process multiple sources of information
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Misjudge length of gap between vehicles or another
vehicle’s speed
Driving Safety and Older Drivers
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Higher incidence of seat belt use
– 79% vs. 66% for adults aged 18-64
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Drive when conditions are safer
– Avoid night driving, driving in ice and snow
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Lower incidence of impaired driving
– 8% of fatally injured passenger vehicle drivers 70 years and older
in 2014 had blood alcohol concentrations ≥0.08%, compared with
20% for drivers ages 60-69 and 38% for drivers ages 16-59
http://www.cdc.gov/motorvehiclesafety/older_adult_drivers/
http://www.iihs.org/iihs/topics/t/older-drivers/fatalityfacts/olderpeople/2014
Importance of Driving
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Driving is essential for many older adults to remain
independent and engaged in their community
– Transportation to employment or volunteer work
– Access to nutrition, medical care, social activities
– May be only means of transportation in some rural and
suburban areas
Impact of Driving Cessation
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Loss of independence
Decreased social integration
Decreased out of home activities
Increased anxiety and depression symptoms
Increased risk of nursing home placement
Chihuri, S, et al. Driving Cessation and Health Outcomes in Older Adults. J Am Geriatr Soc 64:332–341, 2016.
Prevention of Driving Disability
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Primary Prevention
– Assess older driver and intervene to prevent driving disability
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Secondary Prevention
– Address issues that have already caused loss of driving skills and
attempt to restore those skills through treatment and rehabilitation
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Tertiary Prevention
– Identify when irreversible loss of driving skills has occurred and
recommend alternatives to avoid harm when driving is no longer
an option
American Geriatrics Society & A. Pomidor, Ed. (2016)
How do you assess driving ability?
“A moment such as this was—and is—awkward. I dreaded conversations
about driving. Driving safety wasn’t something I could treat with a
prescription or with how-to medical advice. It was a big, messy issue that
sprawled beyond the confines of the office into the realm of public safety.
Like most of my peers, I had little experience in assessing safe driving,
whether for the elderly or for patients of any age. It wasn’t covered in medical
school or residency training. The only driving-related question we were
trained to ask—Do you wear a seat belt?—was buried in a general office-visit
checklist, somewhere between Have you ever injected drugs? and Do you
have a gun in the house? None of my professors or mentors had ever told me
that I might bear some responsibility for deciding whether a patient should be
behind the wheel.”
Reisman, A. Surrendering the keys: A doctor tries to get an impaired elderly patient to stop driving. Health Affairs. 2011. 30:356-359.
Driving Assessment
American Geriatrics Society &
A. Pomidor, Ed. (2016, January).
Clinician’s guide to assessing and
counseling older drivers, 3rd edition.
(Report No. DOT HS 812 228).
Washington, DC: National Highway
Traffic Safety Administration.
Available at:
GeriatricsCareOnline.org or
http://www.nhtsa.gov/Driving+Safe
ty/Older+Drivers
Is my patient at risk for unsafe driving?
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Screen for red flags
– Older adult driver’s or caregiver’s concerns
– Recent adverse driving events or behaviors
– Medical conditions (acute and chronic)
– Medications that can affect driving ability
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Do not make assumptions about whether a person is driving
Age alone is not a red flag for driving safety
Goal of screening to optimize driving safety
Medical Conditions that Impair Driving
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Vision Impairments
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Cataracts
Macular Degeneration
Glaucoma
Diabetic retinopathy
Visual field cuts
Low visual acuity
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Cardiovascular
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Unstable coronary syndromes
Arrhythmias
CHF
Valvular disease
Respiratory
– Obstructive sleep apnea
– COPD
Medical Conditions that Impair Driving
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Neurologic
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Seizures
Dementia
Multiple sclerosis
Parkinson’s disease
Stroke
Peripheral neuropathy
Traumatic brain injury
Spinal cord injury
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Psychiatric
– Anxiety and depression
– Psychosis
– Alcohol and substance abuse
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Metabolic
– Diabetes
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Musculoskeletal
– Osteoarthritis
Medications that Impair Driving Ability
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Anticholinergics
Anticonvulsants
Antidepressants
Antihistamines
Antihypertensives
Antiparkinsonians
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Antipsychotics
Benzodiazepines and other
sedative/hypnotics
Muscle relaxants
Narcotic analgesics
Stimulants
*Providers should always counsel patients of any age about possible
effects of medications on driving and document this counseling.
Dementia and Driving
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Diagnosis of dementia alone is not enough to
withdraw driving privileges
Many patients with mild dementia can safely drive
Dementia is progressive and patients with dementia
will eventually lose the ability to drive safely
Patients with dementia often lack cognitive abilities
to be aware of their limitations
Signs of Unsafe Driving
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Forgetting how to locate familiar places
Failing to observe traffic signs
Making slow or poor decisions in traffic
Driving at an inappropriate speed
Becoming angry or confused while driving
Alzheimer’s Association. http://www.alz.org/national/documents/topicsheet_driving.pdf
Evaluating Driving Ability
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There are numerous published assessment tools, however the
majority have not been evaluated prospectively
Martin AJ. Cochrane Database of Systematic Reviews 2013, Issue 8.
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Recent systematic review “demonstrated that a single tool
measuring cognition, vision, perception, or physical ability
individually is not sufficient to determine fitness to drive”
– Supports using different and focused assessment tools together for
specific medical conditions
– Behind-the-wheel assessment remains the gold standard for driving
evaluation
Dickerson A. E. American Journal of Occupational Therapy. 2014;68:670–680.
Screening and Assessment
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General
– Driving history
– Functional status
– Medications
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Self Assessment Tools
Clinical Assessment of Driving-Related Skills (CADReS)
– Tools for in-office assessment that evaluate vision, cognition,
and motor function
CADReS - Vision
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Visual acuity
– Snellen eye chart
– Consider referral for eye exam if either
eye acuity is worse than 20/40
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Visual fields
– Confrontation testing
– Any deficit requires further evaluation
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Contrast sensitivity
– Generally evaluated by Ophthalmology
CADReS – Cognitive Function
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Montreal Cognitive Assessment
(MoCA) www.mocatest.org
– Score of ≤ 18 should raise
concerns about driving safety
– Neither MMSE or MoCA can be
reliably used as an indicator of
driving risk in individuals who
have not been diagnosed with
cognitive impairment
Hollis AM, et al. Validity of the Mini–Mental State Examination and the
Montreal Cognitive Assessment in the prediction of driving test outcome.
J Amer Geriatr Society. 2015;63:998–992.
CADReS – Cognitive Function
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Trails Part B
– Task: Connect numbers 1-13 and
letter A-L in alternating order
– Taking > 180 seconds to
complete should prompt further
evaluation
CADReS – Cognitive Function
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Clock Draw Test
– Task: Draw face of a clock,
put on all the numbers, and
set the time to 10 minutes
after 11
– Errors signal need for further
evaluation
CADReS – Cognitive Function
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Snellgrove Maze Task
– Task: Draw line from start to end
of maze
– Performance measured by time to
complete and number of errors
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Normal < 60 seconds with 0-1 errors
Snellgrove, C. (2005). www.atsb.gov.au/publications/2005/pdf/cog_screen_old.pdf
CADReS - Motor Function
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Rapid Pace Walk
– Should take 9 sec or less to walk 10ft, turn around, & walk back
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Get Up and Go
Manual test range of motion
– Neck rotation – “Look over your shoulder like you’re backing up”
– Shoulder & elbow flexion – “Pretend you’re holding a steering
wheel… make a wide right turn, then a wide left turn”
– Finger flexion – “Make a fist”
– Dorsiflexion and plantarflexion – “stepping on the gas pedal”
Next Steps if Abnormalities on CADReS
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CADReS does not evaluate performance on actual driving task
– Study of ADReS (prior version from AMA) showed limited diagnostic
accuracy (Ott BR. J Am Geriatr Soc. 2013;61:1164–1169)
Sensitivity 81% for detecting impaired driving on road test
 Specificity 32%
 Trails Part B was more highly correlated with driving scores than other
measures
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Abnormal results generally not sufficient to recommend
driving cessation but do warrant further evaluation
– Driving cessation should be recommended with severe vision or
cognitive impairment
Next Steps if Abnormalities on CADReS
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Refer to specialist for diagnosis and treatment if indicated
(e.g. Ophthalmology)
Screen for reversible causes of mild cognitive impairment
– Always review medications!
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If possible, treat underlying disorder or adjust medications
– Interventions to improve driving safety include:
Cataract surgery
 Treatment of obstructive sleep apnea
 Discontinuation of sedating medications
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Refer to Driving Rehabilitation Specialist
Driver Rehabilitation Specialists
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Occupational therapists who undergo additional
training in driver rehabilitation
Certification from Association for Driver
Rehabilitation Specialists (ADED)
Perform driver evaluation including functional (on
road) assessment and evaluation of need for
adaptive equipment
Driver Rehabilitation Specialists
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Generally not covered by Medicare
– Cost $300-600 for evaluation, plus more for any needed
rehabilitation or adaptive equipment
– Cost prohibitive for many patients
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Not available in all areas
– Check with Occupational therapy departments at local
hospitals and rehabilitation centers
– ADED website: www.driver-ed.org
– American Occupational Therapy Association (AOTA):
https://myaota.aota.org/driver_search/index.aspx
What if driving evaluation
is not an option?
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Advise patient to continue, restrict, or cease driving
based on your evaluation and clinical judgment
Refer for specialist evaluation, such as a Memory Center
Refer to state’s Department of Motor Vehicles for driving
assessment
Patients who should no longer drive
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Make clear statement to patient and family and
document in the medical record
Written prescription “Do not drive” or letter to
patient with recommendation for driving cessation
– Families can show patient with dementia when they don’t
remember instructions not to drive
What if patient refuses to stop driving?
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Explore concerns and insight into impairments
– Ask them to define when a person would be unfit to drive
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Reinforce safety concerns
In older adults without decision making capacity, need
to engage family or caregiver to help enforce
– Take away car keys
– Disable car
– Sell car
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Report to Department of Motor Vehicles
Legal and Ethical Obligations
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6 states require physicians to report impaired drivers
– CA, DE, NJ, NV, OR, PA
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American Medical Association
– “Physicians should use their best judgment when determining when to
report impairments that could limit a patient’s ability to drive safely.
In situations where clear evidence of substantial driving impairment
implies a strong threat to patient and public safety, and where the
physician’s advice to discontinue driving privileges is ignored, it is
desirable and ethical to notify the Department of Motor Vehicles.”
Berger JT, et al. Reporting by Physicians of Impaired Drivers and Potentially Impaired Drivers.
J Gen Intern Med. 2000;15:667–672
Delaware Law
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Title 24, section 1763: “Every physician attending or
treating persons who are subject to losses of
consciousness due to disease of the central nervous
system shall report within 1 week to the Division of
Motor Vehicles the names, ages and addresses of all
such persons unless such person's infirmity is under
sufficient control to permit the person to operate a
motor vehicle with safety to person and property.”
http://delcode.delaware.gov/title24/c017/sc05/index.shtml
Pennsylvania Law
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§ 1518. Reports on mental or physical disabilities or disorders.
(a) Definition of disorders and disabilities.--The Medical Advisory Board
shall define disorders characterized by lapses of consciousness or other
mental or physical disabilities affecting the ability of a person to drive safely
for the purpose of the reports required by this section.
(b) Reports by health care personnel.--All physicians, podiatrists,
chiropractors, physician assistants, certified registered nurse practitioners and
other persons authorized to diagnose or treat disorders and disabilities
defined by the Medical Advisory Board shall report to the department, in
writing, the full name, date of birth and address of every person over 15
years of age diagnosed as having any specified disorder or disability within
ten days.
http://www.dmv.pa.gov/Information-Centers/Medical-Reporting/Pages/Medically-Impaired-Driver-Law.aspx
Reporting to DMV
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Disclose and explain to patients the responsibility to
report
Protect patient confidentiality by ensuring that only the
minimal amount of information is reported and that
reasonable security measures are used in handling that
information
Ultimately, licensing is the responsibility of the State,
and the State makes the final decision on determining
whether the patient can continue to drive
Having the Conversation About Driving
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Ask about driving!
– Don’t assume patients know if they are at risk for
medically impaired driving
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Begin conversation about driving early in the course
of progressive illnesses if possible
– Early stage dementia – Discuss progressive nature of
disease and inevitability of eventual driving cessation
– Begin planning transportation alternatives
Transportation Alternatives
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Public transportation may be limited
Social worker can assist with community resources
Department of Aging
Minimize need to drive
– Delivery of meals, medications
Patient and Caregiver Resources
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Hartford Foundation Car Safety Guides
http://www.thehartford.com/mature-marketexcellence/publications-on-aging
– We need to talk: Family conversations with older drivers
– At the Crossroads: Family conversations about
Alzheimer’s disease, dementia, and driving
– You and your car: A guide to driving wellness.
– Your road ahead: A guide to comprehensive driving
evaluations
Online Resources
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National Highway Traffic Safety Administration
http://www.nhtsa.gov/Driving+Safety/Older+Drivers
Alzheimer’s Association Dementia & Driving Resource
Center http://www.alz.org/care/alzheimers-dementiaand-driving.asp
Delaware Division of Motor Vehicles
http://www.dmv.de.gov/services/driver_services/senio
r/index.shtml#senior_top
References
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American Geriatrics Society & A. Pomidor, Ed. (2016,
January). Clinician’s guide to assessing and
counseling older drivers, 3rd edition. (Report No.
DOT HS 812 228). Washington, DC: National
Highway Traffic Safety Administration. Available at:
http://www.nhtsa.gov/Driving+Safety/Older+Drivers
Carr DB, Ott BR. The Older Adult Driver With
Cognitive Impairment: “It’s a Very Frustrating Life”.
JAMA. 2010;303(16):1632-1641.