The Impaired Older Adult Driver: When Is It Time to Stop?
Mr. C is an 84-year-old married male who lives with his wife. They have lived in the same suburban town their entire lives. They raised three sons who are now married and living in other states. The couple enjoys taking trips to visit their children and grandchildren. Mr. C suffers from osteoarthritis, coronary artery disease, a history of coronary artery stent placement1 year ago, and recently underwent cataract surgery with intraocular lens implantation in both eyes. Mrs. C suffers from macular degeneration and stopped driving 3 years ago. Mr. C drives almost daily. He takes Mrs. C to medical appointments and shopping, runs errands, and provides the means for them to attend church services, social events, and go to a local senior center.
Dr. H has been the couple’s primary care physician for more than 15 years. He receives a call from the local hospital emergency room that both Mr. and Mrs. C were involved in a car accident. Mr. C suffered minor injuries, but Mrs. C sustained a skull fracture and several broken ribs. Both were wearing seat belts. Dr. H goes to the emergency room to evaluate his patients. He finds that the local police and state troopers are there completing reports. Mr. C was leaving the parking lot of a local supermarket in the late afternoon when he turned into oncoming traffic on a four-lane highway. A truck and two cars were directly in Mr. C’s path, but were able to move to avoid a head-on collision. Unfortunately, Mr. C hit a concrete divider on the passenger side, causing significant injuries to Mrs. C. Several witnesses all reported that Mr. C appeared to turn directly into the wrong lane. The car suffered significant damage.
Mr. C is very upset and worried about his wife, but describes being “hit by a truck.” He appears to have limited memory of the accident, and Dr. H arranges for both patients to be admitted to the hospital. He orders a computed tomography scan of the head and a neurology evaluation for Mr. C. Mrs. C is already being evaluated by a neurosurgeon. She is admitted to the surgical intensive care unit. Dr. H calls the couple’s oldest son, CJ, to inform him of the accident. CJ has always been very attentive to his parents, and tells Dr. H that he was afraid something like this would happen. “I told Dad to stop driving at least a year ago, but he is too stubborn,” he said. In the past, the sons have arranged for a taxi service to take their parents shopping and to doctors’ appointments, but Mr. and Mrs. C felt it was too expensive. CJ tells Dr. H that he and his brothers will arrive there as soon as possible. “Don’t let Dad drive anymore, please.”
Dr. H has always found Mr. C to be articulate, and his cognition seemed quite intact. He wonders if he missed something during his office visits with Mr. C.
The majority of older people rely on driving as their main means of transportation.1 The number of older drivers will progressively increase as the elderly population grows. Older adults spend less time driving than younger persons, but are far more likely to be involved in a motor vehicle crash that results in serious injury or death.1,2 Motor vehicle accidents are the leading cause of accident- and injury-related deaths among those age 65-74 years. Among those age 75 and older, only falls result in a higher fatality rate, with motor vehicle injuries accounting for significant mortality. For those over the age of 85 who continue to drive, the rate of fatal car accidents is nearly 10 times higher than that for young males.3 This occurs even though older adults are far more likely to use seat belts, drive within the speed limit, avoid nighttime driving, and drink alcohol prior to driving at a minimal rate compared to younger adults.4
This tremendous increase in driving-related mortality is related to multiple factors. Older adults over the age of 75 years are involved in many more motor vehicle accidents per mile than any other age group. They are more likely to have multiple medical problems, suffer from frailty and cognitive loss, and take medications that may impair attention, perception, and reaction time.5 While the majority of older drivers reduce the amount of time and the distance that they drive, it does not compensate for the risks involved when physical and mental impairments create significant safety risks.3,4
Driving is often the main available means for an older adult to perform chores such as shopping or religious, social, or community activities. This is particularly relevant in suburban and rural areas, where public transportation is often quite limited.1 Urban areas typically offer several options for seniors. For many seniors, driving represents independence and the ability to enjoy the benefits of retirement. While many older adults realize that driving is becoming more difficult, they are still reluctant to stop on their own.2 It is common that family members and friends realize that an older adult has a problem with driving, but they often feel powerless to intervene. The role of the physician is often vital in limiting or deciding when driving should stop.6,7
There are many medical conditions common among older adults that impair the ability to drive (Table).1-5 Seizure disorders, more commonly diagnosed among young adults, have served as the model in which physicians must not only counsel patients regarding driving restrictions, but also report cases to their state Department of Motor Vehicles (DMV).6,7 Among elderly patients, disorders that impair driving ability are often slowly progressive, additive in their contribution to disability, and only partially treatable or correctable. The cumulative illnesses that impair driving among older adults tend to worsen over time.
Older adults are more likely to take the advice and recommendations of their physician seriously. It is important that the physician counsel the patient and family regarding safe driving practices early before problems arise so that advance planning for the use of alternate methods of transportation maybe explored.1,3
Education and counseling of patients regarding driving limitations should always be performed as a first step when an older adult starts to show signs of being impaired or unsafe.1-4 Some warning signs for the physician include cognitive loss, onset of Parkinson’s disease, cerebrovascular events, syncopal episodes, cardiac arrhythmias, vision and hearing impairment, and neuropathies.8 Asking direct questions about how much time the patient spends driving and about any recent problems, such as minor accidents or difficulty with parking, may lead to an open discussion of the need to limit use of a car.5 Questions regarding the stresses associated with driving and difficulties encountered may allow older adults to express their fearfulness and begin a discussion of a plan to limit or stop driving. If the physician prescribes a medication such as a sedative-hypnotic, anxiolytic, anticonvulsant, or other medication that may cause sedation and impair driving, it is vital that this be discussed with the patient and family.1,3,4
There are several screening instruments and testing batteries that have been utilized to evaluate older adults at risk for unsafe driving.3-5 These include vision and hearing screening, gait and ambulation evaluation, cognitive testing using the Mini-Mental State Examination, the Clock Drawing Test, and the Trail-Making Test Part B.9-11 Abnormalities on these tests warrant further evaluation and referral to consultants to determine if the deficits may be corrected. Information for patients and families, including a self-assessment screening for older adults, may be downloaded from the National Highway Traffic Safety Administration at the website www.nhtsa.dot.gov/PEOPLE/INJURY/olddrive/OlderDriversBook/pages/AppendixB.html.
Physician reporting of older adults who pose a danger to themselves and the public if they continue to drive has never been clearly defined or uniform across the country.6,7 In the year 2000, only six states had a mandatory reporting law for patients who were considered too medically impaired to drive. Another 25 states allowed for the voluntary reporting to the DMV by physicians of such patients, with a law allowing for the waiver of confidentiality. The remaining states have no reporting laws, but most encourage voluntary reporting if the physician wishes to do so.6 However, the action taken by the individual state varies considerably, and reporting is not a guarantee that the patient will stop driving. Working with the patient, family, and any available social networks is far more likely to lead to success in cessation of driving. Alternative transportation may be arranged, and the physician-patient relationship can remain positive.3,4
If the physician encounters a patient with progressive dementia who is clearly too impaired to drive, such as a person who presents in the moderate stage with difficulty performing activities of daily living, recognizing signs, reading words, and reacting to stimuli, it may be necessary to actively involve the family or significant others. This may involve moving the car to another location, keeping the vehicle but disabling it in order to prevent driving, and providing alternate means of transportation. Sometimes a person with advanced dementia may still enjoy sitting in his/her car or discussing different types of cars, without actually driving. The goal is always to preserve the dignity of the individual while maintaining safety and preventing a serious or fatal accident.8
Outcome of the Case Patient
Mr. C recovered quickly and was discharged from the hospital after 3 days. He went home with his son while his wife continued to recover from her multiple injuries, including a skull fracture and several vertebral compression fractures. She is found to have a subdural hematoma that required surgical evacuation. Mrs. C has a complicated course due to pain, confusion, and weakness. Mr. C comes to the hospital daily, accompanied by his sons. His sons report to Dr. H that their father will go outside wearing pajamas and no shoes unless they tell him what to wear. Mrs. C has been performing all of the major household tasks, such as bill paying, making appointments, and arranging for housekeeping. Due to her macular degeneration, she has not recognized how disorganized her husband has become. His sons report that their father is very social and presents himself well, but often forgets that he just ate breakfast.
Dr. H arranges for Mr. C to see a neurologist again. He is found to suffer from dementia of the Alzheimer’s type. Since the family car was severely damaged in the accident, the sons decided not to replace it. Mr. C has been asking about the car and getting it fixed. The sons are quite frustrated with their father, and ask Dr. H to tell Mr. C that he is not allowed to drive. Dr. H realizes that his patient should not drive, but wants to avoid confrontation and a family argument. He has the sons prepare a list of alternative transportation, including the car service they have set up, the senior center bus, and a church carpool. This is presented to Mr. C and his wife at a meeting. Mrs. C is clearly relieved that there is a solution to her husband’s driving. She was concerned about finances and paying for a taxi service, but is reassured by her sons that this is their gift. Mr. C is not happy about the arrangement, but agrees to it and will no longer have access to a car. Dr. H tells his sons that blaming their father will not help, and refers them to the Alzheimer’s Association for more information and support.
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Avenue @ 16th Street 2B49, New York, NY 10003; (212) 420-2457; fax: (212) 420-3936; e-mail: email@example.com.
1. American Medical Association, National Highway Traffic Safety Administration, U.S. Department of Transportation. Physician’s Guide to Assessing and Counseling Older Drivers. 2003. Available at: www.nhtsa.dot.gov/PEOPLE/INJURY/olddrive/OlderDriversBook. Accessed April 23, 2007.
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9. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189-198.
10. Sunderland T, Hill JL, Mellow AM, et al. Clock drawing in Alzheimer’s disease. A novel measure of dementia severity. J Am Geriatr Soc 1989;37(8):725-729.
11. Bowie CR, Harvey PD. Administration and interpretation of the Trail Making Test. Nat Protoc 2006;1(5):2277-2281.