Banner-Physician's Guide to Assessing and Counseling Older Drivers

Chapter 1
Safety and the Older Driver: An Overview

Mrs. Simon, a 67-year-old woman with Type II diabetes mellitus and hypertension, mentions during a routine check-up that she hit a stop sign while making a right-hand turn in her car two weeks ago. Although she was uninjured, she has felt anxious about driving since that episode. She wants to know if you think she should stop driving. What do you say?

Mr. Evans, a 72-year-old man with hypertension and congestive heart failure, comes to see you because he has felt “lightheaded every once in awhile” for the past two weeks. When listening to his heartbeat, you notice that it is irregularly irregular. You perform a careful history and physical exam and order some lab tests to determine the cause of his atrial fibrillation. When you ask Mr. Evans to schedule a follow-up appointment for the following week, he tells you that he cannot come because he is about to embark on a two-day road trip to visit his daughter and newborn grandson. What do you do?

Patients like Mrs. Simon and Mr. Evans are becoming more common in daily practice. Buoyed by the large ranks of “baby boomers” and increased life expectancy, the United States’ older population is growing nearly twice as fast as the total population.¹^,² Within this population, an increasing proportion will be licensed to drive, and these license-holders will drive more miles than older drivers do today.³

As the number of older drivers rises, patients and their families will increasingly turn to physicians for guidance on safe driving. Physicians will have the challenge of balancing their patients’ safety against their transportation needs.

This guide is intended to help you answer the questions, “Is my patient safe to drive?” and “What can I do to help my patient drive more safely?”* To these ends, we have reviewed the scientific literature and collaborated with clinicians and experts in this field to produce the following two physician tools:

An office-based assessment of medical fitness to drive. This assessment is outlined in the algorithm, Physician’s Plan for Older Drivers’ Safety (PPODS), (see Figure 1.1).
A reference list of medical conditions and medications that may impair driving, with specific recommendations for each one. This list can be found in Chapter 9.

In addition to these tools, we also present the following resources:

Information to help you navigate the legal and ethical issues regarding patient driving safety and patient reporting. This information can be found in Chapter 7.
A state-by-state list of licensing criteria, license renewal criteria, reporting laws, and DMV contact information. This information can be found in Chapter 8.
Recommended Current Procedural Terminology (CPT®) codes for assessment and counseling procedures. These codes can be found in Appendix A.
Handouts for your patients and their family members. These handouts, which are found in Appendix B, include a self-assessment of driving safety, safe driving tips, suggested driving alternatives, and a resource sheet for concerned family members.

We understand that you may feel uncomfortable talking to your patient about driving because you fear delivering bad news, not having any solutions to offer, and potentially dealing with the patient’s anger. Driving is a sensitive subject, and the loss of driving privileges can be traumatizing to your patient. While these are very real concerns, there are ways to minimize damage to the physician-patient relationship when discussing driving. We have provided sample approaches in the appropriate chapters for suggesting the need for driving assessment, rehabilitation, limitation, and retirement.

We want this information to be available to you, wherever you are. You can access this guide over the Internet from the AMA Web site at www.ama-assn.org/go/olderdrivers. Additional copies may also be ordered on the Web site or from the NHTSA Web site at www.nhtsa.dot.gov.

Before you read about the assessment strategy, you may wish to familiarize yourself with key facts about older drivers.

Older Drivers: Key Facts

Fact: Safety for older drivers is a public health issue.

Motor vehicle injuries are the leading cause of injury-related deaths among 65- to 74-year olds and are the second leading cause (after falls) among 75- to 84-year olds.⁴ Compared with other drivers, older drivers have a higher fatality rate per mile driven than any other age group except drivers under the age of 25. On the basis of estimated annual travel, the fatality rate for drivers 85 and older is 9 times higher than the rate for drivers 25 to 69 years old.¹

There are two reasons for this excess in fatalities. First, drivers 75 years and older are involved in significantly more motor vehicle crashes per mile driven than middle-aged drivers. Second, older drivers are considerably more fragile. Fragility begins to increase at ages 60 to 64 and increases steadily with advancing age.⁵ By age 80, male and female drivers are 4 and 3.1 times more likely, respectively, than 20-year olds to die as a result of a motor vehicle crash.⁶

In the year 2000, 37,409 Americans died in motor vehicle crashes.⁷ Of this number, 6,643 were people aged 65 years and older. This population represented 13% of the total US population but accounted for 18% of all traffic fatalities.⁸ As the older population in this country continues to grow, drivers alone aged 65 and older are expected to account for 16% of all crashes and 25% of all fatal crashes.⁹

Fact: Although many older drivers self-regulate their driving behavior, this is not enough to keep crash rates down.

As drivers age, they may begin to feel limited by slower reaction times, chronic health problems, and side effects from medications. Many reduce their mileage or stop driving altogether because they feel unsafe or lose their confidence. In 1990, males over the age of 70 drove, on average, 8,298 miles compared with 16,784 miles for males aged 20-24 years; for females, the figures were 3,976 miles and 11,807 miles, respectively.¹⁰

Older drivers not only drive substantially less, but also modify when and how they drive. Older drivers may reduce their mileage by eliminating long highway trips, thus driving mainly on local roads, which often contain more hazards in the form of signs, signals, traffic congestion and confusing intersections. Decreasing mileage, then, may not always proportionately decrease safety risks.¹¹ On the other hand, older drivers are more likely to wear safety belts and are less likely to drive at night, speed, tailgate, consume alcohol prior to driving, and engage in other risky behaviors.¹⁵

Despite all these self-measures, the crash rate per mile driven begins to increase at age 65.⁵ On a case-by-case level, the risk of crash depends on whether each individual driver’s decreased mileage and behavior modifications are enough to counterbalance any decline in driving ability. In some cases, decline—for example, in the form of peripheral vision loss —may occur so insidiously that the driver is not aware of it until he/she experiences a motor vehicle crash. In the case of dementia, drivers may lack the insight to realize they are unsafe to drive. In a series of focus groups conducted with older adults who had stopped driving within the past five years, 40% of the participants knew someone over the age of 65 who had problems with his or her driving but was still behind the wheel.¹² Clearly, some older drivers require outside assessment and intervention when it comes to driving safety.

Fact: The majority of older Americans rely on driving for transportation.

In a survey of 2,422 adults aged 50 years and older, 86% of survey participants reported that driving was their usual mode of transportation. Within this group, driving was the usual mode of transportation for 85% of participants aged 75 to 79, 78% of participants aged 80 to 84, and 60% of participants aged 85 and older.¹³

Driving can be crucial for performing necessary chores and maintaining ties to society. Many older adults continue to work past retirement age or engage in volunteer work or other organized activities. In many cases, driving is their preferred means of transportation. In some rural or suburban areas, driving may be their sole means of transportation.

Just as the driver’s license is a symbol of independence for adolescents, the ability to continue driving may mean continued mobility and independence for older drivers, and have a great impact on their quality of life and self-esteem.¹⁴

Fact: The crash rate for older drivers is related to physical and mental changes associated with aging.¹⁵

Compared with younger drivers, whose car crashes are often due to inexperience or risky behaviors,¹⁶ older driver crashes tend to be related to inattention or slowed perception and response.³ Older driver crashes are often multiple-vehicle events that occur at intersections and involve left-hand turns. The crash is usually caused by the older driver’s failure to heed signs and grant the right-of-way. At intersections with traffic signals, left-hand turns are a particular problem for the older driver; at stop sign-controlled intersections, older drivers may not know when to resume driving._¹⁵

Fact: Physicians can influence their patients’ decision to modify or retire from driving. They can also help their patients maintain safe driving skills.

Although most older drivers believe that they should be the ones to make the final decision about driving, they also agree that their physician should advise them. In a series of focus groups conducted with older adults who had retired from driving within the last five years, all agreed that the physician should talk to older adults about driving if there was a need. As one panelist started, “when the doctor says you can’t drive anymore, that’s definite. But when you decide for yourself, there might be questions.” While family advice alone had limited influence on the participants, most agreed that if their physician advised them to stop and their family concurred, then they would certainly stop.¹²

Figure 1.1—PPODS Chart

Physician's Plan for Older Drivers' Safety (PPPODS)

Is the patient at risk for medically impaired driving?

Perform initial screen—

Observe the patient
Be alert to red flags
- Medical conditions
- Medications and polypharmacy
- Review of systems
- Patient's or family member's concern

If screen is positive—

Ask health risk assessment/social history questions
Gather additional information

Physicians help their older patients maintain safe mobility in two ways. By providing effective treatment and preventive health care, physicians enable their patients to preserve their functional abilities later in life, prolonging their driving years. Also, better baseline health protects against serious injuries and speeds the recovery process in the event of a crash.

In addition, physicians can play a more active role in preventing motor vehicle crashes by assessing their patients for medical fitness to drive and recommending safe driving behaviors, driver rehabilitation, or driving limitations as needed. In many cases, physicians can help their patients stay on the road longer by identifying and managing medical obstacles to safe driving, such as vision problems or arthritis.

There is a crucial need for this latter intervention. To date, there has been little organized effort in the medical community to help older adults improve or maintain their driving skills. Research and clinical reviews on the assessment of older drivers have traditionally focused on screening methods to identify unsafe drivers and restrict older drivers. Physicians are in a position to identify patients at increased risk for unsafe driving or self-imposed driving cessation due to functional impairments, and treat underlying medical causes to help their patients drive safely as long as possible.

To achieve this end, primary care physicians can follow the algorithm, Physician’s Plan for Older Drivers’ Safety (PPODS) (see Figure 1.1), which recommends that physicians:

Be alert to red flags for medically impaired driving;
Assess driving-related functional abilities in those patients who are at risk for medically impaired driving;
Treat underlying causes of functional decline;
Refer patients who require further evaluation and/or adaptive training to a driver rehabilitation specialist;
Counsel patients on safe driving behavior, driving restrictions, driving cessation, and/or alternative transportation options as needed; and
Follow-up with patients who retire from driving for signs of depression and social isolation.

Figure 1.2
American Medical Association Ethical Opinion E-2.24 Impaired Drivers and Their Physicians

The purpose of this report is to articulate physicians’ responsibility to recognize impairments in patients’ driving ability that pose a strong threat to public safety and which ultimately may need to be reported to the Department of Motor Vehicles. It does not address the reporting of medical information for the purpose of punishment or criminal prosecution.

(1) Physicians should assess patients’ physical or mental impairments that might adversely affect driving abilities. Each case must be evaluated individually since not all impairments may give rise to an obligation on the part of the physician. Nor may all physicians be in a position to evaluate the extent or the effect of an impairment (eg, physicians who treat patients on a short-term basis). In making evaluations, physicians should consider the following factors: (a) the physician must be able to identify and document physical or mental impairments that clearly relate to the ability to drive; and (b) the driver must pose a clear risk to public safety.

(2) Before reporting, there are a number of initial steps physicians should take. A tactful but candid discussion with the patient and family about the risks of driving is of primary importance. Depending on the patient’s medical condition, the physician may suggest to the patient that he or she seek further treatment, such as substance abuse treatment or occupational therapy. Physicians also may encourage the patient and the family to decide on a restricted driving schedule, such as shorter and fewer trips, driving during non-rush-hour traffic, daytime driving, and/or driving on slower roadways if these mechanisms would alleviate the danger posed. Efforts made by physicians to inform patients and their families, advise them of their options, and negotiate a workable plan may render reporting unnecessary.

(3) Physicians should use their best judgement 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.

(4) The physician’s role is to report medical conditions that would impair safe driving as dictated by his or her state’s mandatory reporting laws and standards of medical practice. The determination of the inability to drive safely should be made by the state’s Department of Motor Vehicles.

(5) Physicians should disclose and explain to their patients this responsibility to report.

(6) Physicians should 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.

(7) Physicians should work with their state medical societies to create statutes that uphold the best interests of patients and community, and that safeguard physicians from liability when reporting in good faith. (I, III, IV, VII)

Issued June 2000 based on the report “Impaired Drivers and Their Physicians,” adopted December 1999.

While primary care physicians may be in the best position to perform PPODS, specialists have a responsibility to discuss driving with their patients as well. Ophthalmologists, neurologists, psychiatrists, physiatrists, orthopedic surgeons, emergency room physicians, and other specialists all manage conditions, prescribe medications, or perform procedures that may have a large impact on driving skills. When counseling their patients, physicians may wish to consult the Chapter 9 reference list of medical conditions and medications that may impair driving.

In the following chapters, we will guide you through PPODS and provide you with the tools you need to perform it. Before we begin, you may wish to review the American Medical Association’s ethical opinion regarding impaired drivers (see Figure 1.2).¹⁷ This opinion can be applied to older drivers with medical conditions that impair their driving skills and threaten their personal safety.

References

¹Traffic Safety Facts 2002: Older Population. US Department of Transportation, National Highway Traffic Safety Administration. Available at: http://www-fars.nhtsa.dot.gov/pubs/7.pdf. Accessed January 17, 2003.

²Calculated from: Population Projections of the United States by Age, Sex, Race, Hispanic, Origin, and Nativity: 1999 to 2100. Population Projections Program, Population Division, US Census Bureau, Washington, DC. Internet release date: January 13, 2000. Revised Date: February 14, 2000. Available at www.census.gov/population/projections/nation/summary/np-t.txt. Accessed January 17, 2003.

³Eberhard J. Safe mobility for senior citizens. International Association for Traffic and Safety Services Research. 1996;20(1):29-37.

⁴10 Leading Causes of Injury Deaths, United States, 1999, All Races, Both Sexes. Office of Statistics and Programming, National Center for Injury Prevention and Control, Center for Disease Control. Data source: National Center for Health Statistics Vital Statistics System.

⁵ Li G, Braver ER, Chen LH. Fragility versus excessive crash involvement as determinants of high death rates per vehicle-mile of travel among older drivers. Accident Analysis and Prevention. 2003;35(2): 227-235.

⁶Evans L. Risks older drivers face themselves and threats they pose to other road users. International Journal of Epidemiology. 2000;29:315-322.

⁷ Traffic Safety Facts 2000: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2001.

⁸Calculated from reference 7.

⁹Eberhard J. Older Drivers Up Close: They Aren’t Dangerous. Insurance Institute for Highway Safety Status Report (Special Issue: Older Drivers). 2001;36(8):1-2.

¹⁰Evans L. How Safe Were Today’s Older Drivers When They Were Younger? American Journal of Epidemiology. 1993;137(7);769-775.

¹¹Janke MK. Accidents, mileage, and the exaggeration of risk. Accident Analysis and Prevention. 1991;23:183-188.

¹²Persson D. The elderly driver: Deciding when to stop. The Gerontologist. 1993;33(1):88-91.

¹³Ritter AS, Straight A, Evans E. Understanding Senior Transportation: Report and Analysis of a Survey of Consumers Age 50+. Washington, DC: American Association for Retired Persons; 2002.

¹⁴Stutts JC. Do older drivers with visual and cognitive impairments drive less? Journal of the American Geriatrics Society. 1998;46(7):854-861.

¹⁵Preusser DF, Williams AF, Ferguson SA, Ullmer RG, Weinstein HB. Fatal crash risk for older drivers at intersections. Accident Analysis and Prevention. 1998;30(2):151-159.

¹⁶Williams AF, Ferguson SA. Rationale for graduated licensing and the risks it should address. Injury Prevention. 2002;8:ii9-ii16.

¹⁷2.24 Impaired Drivers and Their Physicians. In: American Medical Association, Council on Ethical and Judicial Affairs. Code of Medical Ethics: Current Opinions. 2002-2003 ed. Chicago, IL: American Medical Association; 2002:46-47.

* Please be aware that the information in this guide is provided to assist physicians in evaluating the ability of their older patients to operate a motor vehicle safely as part of their everyday, personal activities. Evaluating the ability of patients to operate commercial vehicles or to function as a professional driver involves more stringent criteria and is beyond the scope of this guide.

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