Older Drivers: Recognition and Reduction of Risk

Alice Pomidor, MD, MPHDepartment of GeriatricsFlorida State University College of Medicine

Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

4. Briefly discuss 4. Briefly discuss Legal & Ethical Legal & Ethical Driving IssuesDriving Issues

4. Briefly discuss 4. Briefly discuss Legal & Ethical Legal & Ethical Driving IssuesDriving Issues

3. Identify 3 potential 3. Identify 3 potential risk reduction risk reduction

interventionsinterventions

3. Identify 3 potential 3. Identify 3 potential risk reduction risk reduction

interventionsinterventions

1. Recognize 3 1. Recognize 3 risk factors for risk factors for Older DriversOlder Drivers

1. Recognize 3 1. Recognize 3 risk factors for risk factors for Older DriversOlder Drivers

2. Describe2. Describe extraextra

risks associated risks associated with dementia with dementia

2. Describe2. Describe extraextra

risks associated risks associated with dementia with dementia

Objectives

South Florida Sun-Sentinel -2007

80-yr-old Boca Raton woman 80-yr-old Boca Raton woman Driving a 1990 Mercury Grand Marquis Driving a 1990 Mercury Grand Marquis Went over a concrete parking block, onto the Went over a concrete parking block, onto the sidewalk, through a metal parking sign and into sidewalk, through a metal parking sign and into the windows of the DMV office the windows of the DMV office Was there for a license renewal retestWas there for a license renewal retest

Driver crashes into license bureau

Elderly man drives with body in windshield

St. Petersburg Times - 2005 93-year-old man Apparently suffering from dementia Fatally struck a pedestrian and drove for three

miles with the man's body through his windshield

Spotted by a tollbooth attendant who called

A Familiar Story?“It’s getting very hard to drive at night. I don’t like

to go out because I don’t think it’s safe. Is there something you can do to help?”

“You have to talk to Dad about his driving when you go in. He almost hit someone the other day, and I don’t feel like he can take the children out.”

“ My neck is so sore from that fender-bender. The emergency room said to go see the doctor if the pain didn’t go away after a few days.”

Age# of

Drivers

65 + years

Over 2.2 million

85 and up 242,480 Leading cause of Leading cause of accidental death foraccidental death for

ages 65 – 74, second-ages 65 – 74, second-leading cause leading cause

over age 75over age 75

Welcome to Florida

NHTSA:NHTSA:By 2020, one inBy 2020, one in

four drivers will befour drivers will beage 65 or olderage 65 or older

Fatalities in 20011. Florida = 268

2. Texas = 2543. CA = 224

1Federal Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey. Washington, DC: U.S. Department of Transportation.

1Federal Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey. Washington, DC: U.S. Department of Transportation.

Fatalities by mileage and age

•More men than women: About 25% of women in About 25% of women in this age cohort never learned to drive.this age cohort never learned to drive.•Drive fewer miles per year: Average 5800 miles Average 5800 miles per year, compared with 9800 miles per year in per year, compared with 9800 miles per year in younger drivers.younger drivers.•MVAs slower: Accidents usually involve lower Accidents usually involve lower speeds and are more likely to involve multiple speeds and are more likely to involve multiple vehicles.vehicles.

Characteristics of Older Drivers

•Often self-restrict: Tend to avoid driving at Tend to avoid driving at night, during rush hour, through bad weather, or night, during rush hour, through bad weather, or through unfamiliar areas.through unfamiliar areas.

•Moving violations: Most frequently incurred by Most frequently incurred by missing signs and signals, crossing lines while missing signs and signals, crossing lines while passing, or making left-hand turns.passing, or making left-hand turns.

Characteristics of Older Drivers

Varies hugely between States:

8 states require no testing at the time of renewal

16 states require extra testing for older drivers, or more frequent renewals

Only California requires reporting of dementia to their Bureau of Motor Vehicles

Driving tests can be a real bear!

License Renewal

Florida Licensing

License renewal every 4-6 years, depending on driving history

In-person every third cycle (can mail it in for up to 18 years)

Written, road tests at discretion of the Department of Highway Safety & Motor Vehicles (DHSMV )

Vision testing over age 80 at in-person renewal

Risk Factors for Driving

Vision/hearing changesNeurologic changesMusculoskeletal changesComorbid chronic illness Functional changesMedications

Yours?

Static visual acuity: 20/40 or worse in 13% over age 65 20/40 or worse in 13% over age 65

Visual Changes-Acuity

Field cuts: present in 13% over age 65; 70 degrees noticed present in 13% over age 65; 70 degrees noticed

Visual Changes-Fields

Glare/light sensitivity: light scatters, can change day to light scatters, can change day to nighttime acuity from 20/50 to 20/200nighttime acuity from 20/50 to 20/200

Visual Changes-Glare

Useful Field of View: 40% loss doubles crash rate 40% loss doubles crash rate

Visual Changes-Useful Field of View

Increasedprevalences of...

Cataracts

Glaucoma

Macular degeneration

Diabetic retinopathy

Visual Changes-Eye diseases

40 dB or less in good ear for unrestricted license40 dB or less in good ear for unrestricted license(AMA Recommendation)

Hearing Changes

Perception-response time:

Similar in older & Similar in older & younger adults; younger adults;

within 2.5 seconds within 2.5 seconds allowedallowed

Classical definition:

Slows with Slows with advancing ageadvancing age

Reaction Time

Grip strength of 35 pounds or more is recommended in order to control wheel, unless adaptive equipment used

Musculoskeletal Changes

Other chronic illnesses: Seizure disorders and Seizure disorders and dementia (30% still drive with moderate dementia)dementia (30% still drive with moderate dementia)

0 1 2 3

Relative risk/odds ratio

Back pain in the past 12 months

Diabetes with neuropathy

Depression

Coronary artery disease

Stroke

Arthritis among females

Chronic Illnesses

0 0.5 1 1.5 2 2.5 3

Relative risk/odds ratio

Falls in the past 2 years

Walking < one block per day

Difficulty copying a pentagon

3 or more foot abnormalities

Nearly 50% likelihood of adverse driving event in the next year if bottom three conditions exist

Functional Decline

0 2 4 6

Relative risk/odds ratio

ACE inhibitors

Beta-blockers

NSAIDs

Benzodiazepines

Alcohol abuse

Tricyclic antidepressants

Opioid analgesics

Anticoagulants

Medications and Alcohol

Risk Recognition in Dementia

Unable to locate familiar places (gets lost)Does not observe traffic signs (esp stop signs)Drives at inappropriate speeds (usually slow)Makes poor or slow decisions in traffic (at fault 5

times more often in left hand turn crashes) Becomes angry, frustrated or confused easily

while driving3 years or more since diagnosis

Brown LB, Ott BR. Driving and dementia: a review of the literature. J Geriatr Psychiatry Neurol 2004;17: 232-240.

Driver-Specific Assessment

Driving History-who, what, when, where, why, how

Accident or “near-miss” eventsRecent changes/self-restrictionsChronic IllnessesAlcohol useMedications

Visual screening: Snellen chart, visual fieldsAuditory screening: Whisper test, audioscope.Cognitive screening: Clock-drawing test, MMSEPsychological screening: Depression scale Functional status: ADL’s, IADL’s, falls.Musculoskeletal/neurological screening: Gait

observation, feet exam, hand grip, joint range of motion, proprioception, strength

Driving Risk Assessment- Exam

Treat any Treat any reversible deficits identified above identified above..

Eliminate potentially problem Eliminate potentially problem medications

Counsel on proper use of Counsel on proper use of seat belts

CounselCounsel avoidance of suboptimal driving conditions such as lack of sleepconditions such as lack of sleep

RecommendRecommend avoidance of avoidance of driving under influence of alcohol or medications

Risk Reduction Interventions

Encourage use of driving refresher courses Encourage use of driving refresher courses (such as(such as “Drivers 55 Plus”)

Identify Identify alternative transportation

Refer toRefer to occupational therapy oror local driving school for formal evaluationfor formal evaluation

Association of Driving Rehabilitation Association of Driving Rehabilitation Specialists at Specialists at http://www.aded.net/i4a/pages/index.cfm?pageid=1

Risk Reduction Interventions

Self-Help Resources

AAA-Senior Drivers program at www.seniordrivers.org/home/toppage.cfm

AARP-Driver Safety info at www.aarp.org/life/drive

National Highway Transportation & Safety Administration (NHTSA) Older Road Users www.nhtsa.dot.gov/people/injury/olddrive

Driving “Retirement”

Begin discussions early to ease transitionIdentify a “trusted person”Many adverse consequences of driving cessation,

including: depression dependency caregiver strain social withdrawal increased risk of entry into long-term care facilities restricted mobility

When you have no other choices

Discuss alternate strategies confiscate keys park at a distance discontinue insurance disable or sell car have safe copilot (controversial) provide picture ID grind keys down

Section 322.126 (2), (3), Florida Statutes, provides that "Any physician, person, or agency having knowledge of any licensed driver’s or applicant’s mental or physical disability to drive...is authorized to report such knowledge to the Department of Highway Safety and Motor Vehicles... The reports authorized by this section shall be confidential... No civil or criminal action may be brought against any physician, person, or agency who provides the information required herein.“ www.hsmv.state.fl.us

Reporting

All citizen complaints are evaluatedIf validated, re-examination at the driver

license office or a medical report is requiredDrivers have 30 days to submit a required

report or their driving privilege is revoked until they do so

If the evaluator does not find any substance or validity to the complaint, no further action is taken

DHSMV Actions

If report indicates further review is needed, case is referred to the Medical Advisory Board

Board may: request additional testing recommend restrictions recommend revocation of the driver’s license

Drivers may be required to complete an on-road test as a condition of licensure or reinstatement

Further DHSMV Actions

Florida At Risk Driver Council (FADAC)

Reviewed current status of older drivers in Florida

Recommendations issued February 2004

Ken Brummel-Smith, MD, chairperson

4 pilot programs going