Knowing when to ask seniors for the car keys
■ A column about treating a growing demographic
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Mr. P. is a 92-year-old man who lives with his wife of 62 years in the suburbs of the town where you practice. The couple have lived in the same home and owned a small business for 40 years. Their son, Mark, who lives 10 miles away and took over the business, brought his father to the office for your evaluation and recommendations regarding his memory and ability to continue driving.
Mr. P. has a past medical history of hypertension, peripheral vascular disease and osteoarthritis. His gait has been increasingly unsteady, and he fell twice in the last few months. Last week, he drove his wife to the hairdresser, dropped her off, became confused in the parking lot and was unable to find his way home. A police officer noted his distress and escorted him home. There had been other instances in which he could not remember where to turn, and one near-miss with a bicycle rider. Mr. P. denies any difficulties and becomes quite angry and agitated in your office. Physical exam was unremarkable except for mild rigidity in the neurological exam and an increased gait base. He scored 27 of 30 possible points in the Mini Mental State Exam, losing one point in orientation (he could not tell the date) and two points in recall.
Advising older patients and their family members about driving ability and the difficult decision to give up a driver's license is among the most sensitive topics physicians must address.
The close association between driving and independence can make the decision not to drive very difficult, and raising the matter can cause patients, such as Mr. P., to become distressed. Families seeking help often turn to physicians as trusted authorities whose advice can make a difference to the elderly patient.
The problem is becoming more common. The number of older drivers on the road is growing and bound to increase at a more rapid rate, as more baby boomers become seniors.
In 2006, there were 30 million licensed drivers age 65 and older -- an 18% increase from 1996, according to the National Highway Traffic Safety Administration. In contrast, the number of all licensed drivers increased by 13% from 1996 to 2006.
Older drivers are at higher risk for traffic fatalities than younger drivers. They are involved in significantly more motor vehicle crashes per mile driven than middle-aged drivers, according to the Physician's Guide to Assessing and Counseling Older Drivers, a publication developed by the American Medical Association with the NHTSA. The most common violations include failure to obey traffic signals, unsafe turns and passing, and failure to yield the right of way.
Physicians can commence a discussion on safe driving by noting that it is a common concern among older patients. After all, each year more than 600,000 elderly adults stop driving because of their health, according to the National Institute on Aging. Physicians also can remind their patients that aging usually leads to changes that may affect driving fitness such as decreases in visual and hearing acuity, declines in flexibility and increases in reaction time. Another adjustment is growing fragility, which results in longer healing time and unpredictable consequences if injuries occur.
Check for underlying medical issues
Osteoarthritic changes may make it more difficult to turn and check for the presence of other cars before changing lanes or hitting the brakes in emergencies. Patients also should be warned about the side effects of medications, including those sold over the counter. Some may make them sleepy or impair their judgment.
Initial evaluations in the physician's office should examine three key functions: vision, cognition and motor function. All can be performed relatively quickly. Vision evaluation should include visual acuity and visual fields. Visual field decline with loss of peripheral sight may lead to difficulties noticing traffic signs, cars or pedestrians. For visual acuity less than 20/40 or for any visual field deficit noticed in the clinical exam, a referral to an ophthalmologist should be recommended to assess whether cataracts, glaucoma or macular degeneration, all conditions associated with aging, may be impairing vision.
Several tools have been recommended for the evaluation of cognitive function. The Mini Mental State Exam is widely used to screen for cognitive decline. However, an educated patient with mild dementia may produce a high score and yet be an unsafe driver. The AMA/NHTSA physician guide recommends the Trail Making Test Part B (TMT-B) and one of several available versions of the clock drawing test (CDT). A completion time of longer than 180 seconds on the TMT-B or any incorrect element in the CDT signals a need for further evaluation for dementia.
Motor function assessment includes a rapid pace walk -- also called the get-up-and-go test -- and clinical evaluation of range of motion and motor strength. Abnormal range of motion, excessive loss of strength in upper or lower extremities, or a rapid pace walk that takes more than 10 seconds should be red flags for further evaluation. In Mr. P.'s case, his abnormal gate and mild rigidity would probably trigger a more detailed neurological examination.
It has been suggested, as a practical approach, that patients who are not able to perform several instrumental activities of daily living or any of the basic activities of daily living should stop driving.
However, some individuals with mild dementia can drive safely for extended periods. For those patients, as is the case with Mr. P., referral to a driver rehabilitation specialist may be appropriate. After an in-depth functional assessment, the specialist may recommend the patient continue driving with or without restrictions or the patient retire from driving. The specialist may be able to recommend adaptations to a vehicle or advise the patient to drive only during the day or along familiar routes.
Following such advice may allow a patient to continue to drive. Testing should be repeated at least every six months.
Physicians also should check state laws. Some states require the reporting of unsafe driving, and others encourage such reporting. In addition, protecting a patient's health and that of society is an ethical duty, although care must be taken not to violate confidentiality and privacy laws.
Working with a patient's family members, who are most likely to bring the unsafe driving to the physician's attention, is often the key to a successful resolution of the issue.
If the family or the patient decides that a patient should stop driving, alternative methods of transportation should be discussed, whether this is through public transportation, taxi rides or family members sharing driving responsibilities.
If the patient refuses to comply, stress to the family the need to take away the car keys and explain that you have a responsibility to report unsafe drivers.