TY - JOUR
AU - Slomski, Anita
AB - I would rather tell a patient he has cancer than tell him he should no longer drive. At least with a cancer diagnosis there is hope.” Joanne G. Schwartzberg, MD, director of Aging and Community Health at the American Medical Association (AMA), in Chicago, was not surprised to hear that remark from a physician during an AMA training session on identifying older patients with driving impairments. “Having someone tell you to retire from driving is devastating,” says Schwartzberg. “It's a major life change with very unpleasant consequences,” such as social isolation, loss of independence, and, potentially, depression and anxiety. And physicians do not necessarily want to be the ones to raise the topic of driver fitness with their older patients, especially if they fear a long and emotional discussion or a confrontation that alienates the patient from the practice. “Doctors don't typically deal with driving issues; it's not in their comfort zone,” says David B. Carr, MD, associate professor of medicine and neurology at Washington University at St Louis and medical director of the Rehabilitation Institute of St Louis. Physicians can play an important role in screening elderly patients for problems in cognition, vision, and motor/somatosensory functions that may affect driving. Depending on the findings, physicians may refer such patients for additional evaluation and driving rehabilitation, and, when necessary, counsel patients to stop or restrict their driving. Numerous diseases and medications can affect driving ability—macular degeneration, cataracts, dementia, diabetes, arthritis, narcotic analgesics, anticonvulsants, and antiparkinson medications, to name just a few. Yet physicians may hesitate to voice concerns about a patient's driving because they do not have firsthand knowledge of how well he or she is compensating for physical and cognitive limitations behind the wheel. “All you know is that there are impairments,” says Schwartzberg, which often is not enough to judge whether an individual can drive safely. Physicians do, however, have an ethical—and, in some cases, legal—obligation to protect their patients and the public. In the 9 states with mandatory reporting laws, physicians can face criminal charges if they do not notify the state's department of motor vehicles (DMV) of drivers who are a danger to themselves and others. In states without mandated reporting, physicians have been held liable for third-party injuries, or negligence at the very least, for failing to counsel patients that their medical conditions or medications could impair their driving. At the same time, physicians play a role in preventing patients from unnecessarily surrendering their licenses by referring them to driving rehabilitation specialists who can help patients modify their cars to overcome medical limitations. First line of defense Physicians often are the first to identify unsafe drivers. Only 2 states—Illinois and New Hampshire—require older drivers to take a road test, and only 15 others have some sort of older-driver screening, such as a vision test, written test, in-person renewal, or medical certification of fitness. Research from Massachusetts Institute of Technology's (MIT’s) AgeLab, in Cambridge, finds that many older individuals prefer that their physicians be the ones to approach them about potential driving problems. In focus groups and in a large national survey, 50% of older married drivers told MIT researchers that they would prefer hearing concerns about their driving first from their spouses, but 27.1% wanted their physicians to broach the subject. Among those living alone, 41% wanted the message to come from their physicians. The AMA's “Physician's Guide to Assessing and Counseling Older Drivers,” released earlier this year with support from the National Highway Traffic Safety Administration (NHTSA), includes an assessment primary care physicians can use to screen elderly patients for problems in cognition, vision, and motor/somatosensory functions that may affect driving. Called Assessment of Driving-Related Skills (ADReS), the test battery is designed to take about 10 minutes to administer during a separate office visit. ADReS uses a Snellen chart to measure a patient's far-visual acuity and confrontation testing to assess visual fields. The trail-making test, part B, evaluates working memory, visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination, and the clock-drawing test assesses long- and short-term memory, visual perception, abstract thinking, and executive skills. The rapid-pace walk provides a measure of lower limb strength, endurance, range of motion, and balance. ADReS also includes manual tests of range of motion and motor strength. A failing score does not necessarily mean that a patient is at risk for a car crash. In a 2009 study, University of Florida researchers found that while ADReS correctly identified all the individuals who ultimately failed an on-road driving test, it also flagged as potentially unsafe 33% of drivers who successfully passed a behind-the-wheel test. The researchers called for modifications of ADReS to make it a more accurate screening tool. ADReS is not intended to definitively determine which individuals should surrender their licenses, counters Carr, in large part because older adults are not a homogeneous group. “You can't march in to a group of 10 000 older adults with visual, cognitive, and motor impairments and give them a few tests that will accurately predict driving outcomes with great sensitivity and specificity,” he says. However, as a dementia specialist who evaluates cognitively impaired drivers, Carr does believe that the trail-making B test can predict crashes. “I’m very confident that with a certain score on this test, a patient is at risk for failing a road test or having an at-fault crash,” he says. Earlier this year, the American Academy of Neurology (AAN) issued an updated practice parameter on evidence-based patient demographic characteristics and cognitive tests that identify unsafe driving in patients with dementia (Iverson DJ et al. Neurology. 2010;74[16]:1316-1324). According to the AAN, clinicians can use the following to evaluate at-risk drivers: the Clinical Dementia Rating scale, a caregiver's assessment of the patient's driving ability, number of collisions or traffic violations, Mini-Mental State Examination scores of 24 or less, an aggressive or impulsive personality, and self-reports of limited driving. Adapting to limitations The AMA recommends that any abnormal ADReS scores trigger a referral to a subspecialist for further evaluation and treatment. After treatment, if the patient still has limitations that may affect driving, the next step is referral to a driving rehabilitation specialist (DRS), typically an occupational therapist with additional training in driver rehabilitation.The DRS conducts a 1½- to 2-hour on-the-road evaluation to determine how well an elderly individual compensates for medical impairments while driving. If the individual passes the road test, the DRS may recommend specific adaptations be made to the car, such as a spinner knob on the steering wheel for those with poor hand grip or loss of strength on one side of the body, an extended gear shift lever to compensate for reduced reach, or wide-angle mirrors to increase field of view for people with limited head and neck motion. When the outcome of the driving test is negative, individuals may accept more readily the recommendation to stop driving when it comes from an objective evaluator. “Having the DRS deliver the bad news protects the relationship between the patient and his doctor or his family,” says Lisa D’Ambrosio, PhD, research scientist at MIT's AgeLab. Some patients may balk at the cost of a behind-the-wheel evaluation—$300 to $400 or more and usually not covered by Medicare—or may reject the possibility that their driving is unsafe. “Driving is a very complex activity, but because we do it so often and for so many years, we don't recognize how many things we are doing cognitively and physically,” says D’Ambrosio. An individual with severe visual or motor impairment may recognize that he or she is a risk behind the wheel, but it is not always so obvious with people with early dementia or chronic diseases, she says. Absent a behind-the-wheel evaluation, primary care physicians may have to counsel patients to stop or restrict their driving, enlisting the help of family with the patient's permission. When patients voluntarily relinquish their driver's licenses at the physician's urging, many prefer that the physician write a letter stating that driving is ill advised due to changes in vision—regardless of the real impairment. “It's easier to explain to others that the reason you can't drive is because your eyes are failing rather than your brain,” says D’Ambrosio. Having a letter from a physician also helps the family reinforce the patient's agreement not to drive. But if a patient refuses to give up driving, it is “desirable and ethical” for the physician to notify the DMV if there are indications the patient is a danger to themselves and others, according to the AMA's ethical opinion. In such cases, physicians should inform their patients that they are contacting the DMV, but lack of permission should not deter them, says Schwartzberg. “It may be a breach of confidentiality [to report to the DMV], but you’ve made a decision that the public's safety outweighs the fear of being sued,” she says. The AMA's guide includes recommendations on how to prepare patients for not driving, such as developing alternatives to driving and ways to prevent the patient from being isolated when he or she cannot drive. “Retiring from driving is a gradual process, and families and patients need time to get used to it,” says Schwartzberg. “A lot of discussion has to occur.” In practice, however, physicians often lack the time and information to move the discussion beyond advice to stop driving, says Carr. He recommends that physicians refer patients and families to a social worker who can help with alternative transportation strategies. Physicians can also hand out educational materials; the Hartford insurance company and MIT's AgeLab have developed guides on how families should approach driving cessation discussions, for example. Other community resources are listed in the AMA's guide. “Physicians don't have to solve the whole problem” of getting unsafe drivers off the road, says Schwartzberg, but they are in a unique position to detect potential driving problems in their patients. How Safe Are Older Drivers? Aging individuals without cognitive impairments often voluntarily restrict their driving as they become aware that declining vision or slower reaction times make them uncomfortable driving at night or in rush hour. Because the elderly spend less time on the road and driving in adverse conditions, they have fewer collisions than younger drivers. The rates of fatal crashes among drivers aged 70 years or older declined by 37% from 1997 to 2008—a much better track record than the 23% decline in fatal crashes for middle-aged drivers, according to the Insurance Institute for Highway Safety. “The problem is that when the elderly are involved in an accident, it's likely to be fatal,” says Joanne G. Schwartzberg, MD, director of Aging and Community Health at the American Medical Association, as diseases such as osteoporosis make aging bodies more fragile. Drivers aged 65 years or older comprised 15% of all traffic fatalities in 2008, according to the National Highway Traffic Safety Administration, and the fatality rate for drivers aged 85 years or older is 9 times higher than the rate for drivers aged 25 to 69 years. The growing number of elderly drivers also increases crash risk. By 2030, older people will make up 25% of all drivers and are estimated to be involved in 25% of fatal crashes.—A. S. New In-Car Technologies Assist Older Drivers Several advanced safety technologies that may help older drivers avoid crashes are now available in luxury car models and will soon appear on less expensive cars. Among them are these: Advanced cruise control and adaptive braking. Using radar, the car automatically maintains a safe interval between vehicles and applies the brakes when it calculates that the driver does not have enough time to avoid hitting the car ahead. Lane departure prevention. An onboard camera monitors the car's distance from lane markers. An alarm sounds when the car starts drifting out of the lane, followed by the car automatically guiding the wheels back to the center of the lane. Auto park. The car identifies when a parking spot is large enough to accommodate the vehicle, and it controls the steering wheel while the driver manually controls the brake and gas pedal to parallel park. Blind-spot warning. A light appears in the car's mirror when another vehicle is in the driver's blind spot. In the near future, cars will calculate how quickly an oncoming vehicle is approaching so the driver knows when it is safe to make a left-hand turn. Driving information will also be displayed above the steering wheel so drivers will not have to take their eyes off the road. Also in the works are sophisticated collision-notification systems that transmit data on crash location andseverity—and, eventually, the driver's vital signs—so trauma teams are prepared to treat injured drivers.—A. S. Source: Bryan Reimer, PhD, research scientist, MIT AgeLab Resources for Physicians The American Medical Association's (AMA’s) “Physician's Guide to Assessing and Counseling Older Drivers” is available online athttp://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.shtml. A Web-based course on the material in the self-study physician's guide, currently being pilot-tested, will be available in 2011. The American Academy of Neurology's updated guideline, “Practice Parameter Update: Evaluation and Management of Driving Risk in Dementia: Report of the Quality Standards Subcommittee of the American Academy of Neurology,” updated in April 2010, is available online at http://www.neurology.org/cgi/reprint/74/16/1316.
TI - Older Patients: Safe Behind the Wheel?
JF - JAMA
DO - 10.1001/jama.2010.1511
DA - 2010-11-03
UR - https://www.deepdyve.com/lp/american-medical-association/older-patients-safe-behind-the-wheel-qLxboOG5TM
SP - 1884
EP - 1886
VL - 304
IS - 17
DP - DeepDyve
ER -