Transcript Pressure Ulcers - Florida State University College of Medicine

Older Drivers: Recognition and
Reduction of Risk
Alice Pomidor, MD, MPH
Department of Geriatrics
Florida 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.
Objectives
1. Recognize 3
risk factors for
Older Drivers
2. Describe extra
risks associated
with dementia
3. Identify 3 potential
risk reduction
interventions
4. Briefly discuss
Legal & Ethical
Driving Issues
Driver crashes into license bureau
South Florida Sun-Sentinel -2007
80-yr-old
Boca Raton woman
Driving a 1990 Mercury Grand Marquis
Went over a concrete parking block, onto the
sidewalk, through a metal parking sign and into
the windows of the DMV office
Was there for a license renewal retest
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.”
Welcome to Florida
Age
# of
Drivers
Fatalities in 2001
65 +
years
Over 2.2
million
2. Texas = 254
3. CA = 224
85 and up
242,480
1. Florida = 268
NHTSA:
By 2020, one in
four drivers will be
age 65 or older
Leading cause of
accidental death for
ages 65 – 74, secondleading cause
over age 75
Fatalities by mileage and age
1Federal
Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey.
Washington, DC: U.S. Department of Transportation.
Characteristics of Older Drivers
•More men than women: About 25% of women in
this age cohort never learned to drive.
•Drive fewer miles per year: Average 5800 miles
per year, compared with 9800 miles per year in
younger drivers.
•MVAs slower: Accidents usually involve lower
speeds and are more likely to involve multiple
vehicles.
Characteristics of Older Drivers
•Often self-restrict: Tend to avoid driving at
night, during rush hour, through bad weather, or
through unfamiliar areas.
•Moving violations: Most frequently incurred by
missing signs and signals, crossing lines while
passing, or making left-hand turns.
License Renewal
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
Driving tests can be a real bear!
California requires reporting of dementia to their
Bureau of Motor Vehicles
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 changes
 Neurologic changes
 Musculoskeletal changes
 Comorbid chronic illness
 Functional changes
 Medications
Yours?
Visual Changes-Acuity
Static visual acuity: 20/40 or worse in 13% over age 65
Visual Changes-Fields
Field cuts: present in 13% over age 65; 70 degrees noticed
Visual Changes-Glare
Glare/light sensitivity: light scatters, can change day to
nighttime acuity from 20/50 to 20/200
Visual Changes-Useful Field of View
Useful Field of View: 40% loss doubles crash rate
Visual Changes-Eye diseases
Increased
prevalences of...
Diabetic retinopathy
Cataracts
Glaucoma
Macular degeneration
Hearing Changes
40 dB or less in good ear for unrestricted license
(AMA Recommendation)
Reaction Time
Classical
definition:
Slows with
advancing age
Perceptionresponse time:
Similar in older &
younger adults;
within 2.5 seconds
allowed
Musculoskeletal
Changes
Grip strength of 35 pounds
or more is recommended in
order to control wheel,
unless adaptive equipment
used
Chronic Illnesses
Relative risk/odds ratio
Back pain in the past 12 months
Diabetes with neuropathy
Depression
Coronary artery disease
Stroke
Arthritis among females
0
1
2
Other chronic illnesses: Seizure disorders and
dementia (30% still drive with moderate dementia)
3
Functional Decline
Relative risk/odds ratio
Falls in the past 2 years
Walking < one block per day
Difficulty copying a pentagon
3 or more foot abnormalities
0
0.5
1
1.5
2
2.5
3
Nearly 50% likelihood of adverse driving event in
the next year if bottom three conditions exist
Medications and Alcohol
Relative risk/odds ratio
ACE inhibitors
Beta-blockers
NSAIDs
Benzodiazepines
Alcohol abuse
Tricyclic antidepressants
Opioid analgesics
Anticoagulants
0
2
4
6
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 driving
 3 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” events
 Recent changes/self-restrictions
 Chronic Illnesses
 Alcohol use
 Medications
Driving Risk Assessment- Exam
 Visual screening: Snellen chart, visual fields
 Auditory screening: Whisper test, audioscope.
 Cognitive screening: Clock-drawing test, MMSE
 Psychological 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
Risk Reduction Interventions
 Treat any reversible deficits identified above.
 Eliminate potentially problem medications
 Counsel on proper use of seat belts
 Counsel avoidance of suboptimal driving
conditions such as lack of sleep
 Recommend avoidance of driving under influence
of alcohol or medications
Risk Reduction Interventions
 Encourage use of driving refresher courses
(such as “Drivers 55 Plus”)
 Identify alternative transportation
 Refer to occupational therapy or local driving
school for formal evaluation
 Association of Driving Rehabilitation
Specialists at
http://www.aded.net/i4a/pages/index.cfm?pageid=1
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 transition
 Identify 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
Reporting
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
DHSMV Actions
 All citizen complaints are evaluated
 If validated, re-examination at the driver
license office or a medical report is required
 Drivers 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
Further 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
 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