Transcript + The Older Driver Debra Bynum, MD Division of Geriatric Medicine + Cases…  Mrs. Simon, a 67-year-old woman with type 2 diabetes mellitus and hypertension, mentions.

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The Older Driver
Debra Bynum, MD
Division of Geriatric Medicine
2010
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Cases…

Mrs. Simon, a 67-year-old woman with type 2 diabetes
mellitus and hypertension, mentions during a routine checkup that she almost hit a car while making a left-hand turn
when driving two weeks ago.

Although she was uninjured, she has been anxious about
driving since that episode. Her daughter has called your
office expressing concern about her mother’s driving
abilities. Mrs. Simons admits to feeling less confident when
driving and wants to know if you think she should stop
driving.

What is your opinion?
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Cases…

Mr. Evans, a 72-year-old man with coronary artery disease
and CHF, arrives for an office visit after fainting yesterday
and reports “light- headedness” for two weeks.You notice
that his heartbeat is irregular. You perform a careful history
and physical, and order some tests to determine the cause of
his atrial fibrillation.

When you ask him to schedule a follow-up for next week, he
tells you he cannot come because he is about to embark on a
two-day road trip to visit his daughter and newborn
grandson.

Would you address the driving issue and if so, how? What
would you communicate to the patient?
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Driving: Autonomy and Power
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ACOVE-3 Quality Indicators Pertaining
to Assessment

If a vulnerable older adult has newly diagnosed dementia,
then one of the following should occur (consistent with state
law)
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Patient advised not to drive a motor vehicle
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Referral to the Department of Motor Vehicles to test driving
ability
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Referred to a driver’s safety course that includes assessment of
driving ability
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Risk Factors for MVA in older adults…
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Poor visual acuity (<20/40)
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Poor visual contrast sensitivity
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Dementia


Visual spatial deficits
Visual attention problems

Impaired neck and trunk rotation
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Poor motor coordination and speed of movement
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Alcohol and narcotics
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Medications (antidepressants, antipsychotics, antihistamines,
benzodiazepines, muscle relaxants)
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Facts from AMA site…
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Fact #1: The number of older adult drivers is growing rapidly
and they are driving longer distances.
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
Fact #2: Driving cessation is inevitable for many and can be
associated with negative outcomes.
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
Fact #3: Many older drivers successfully self-regulate their
driving behavior.

But motor vehicle crash rates per mile driven begin to increase at
age 65 (despite overall less crashes)
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Older drivers may reduce their mileage by eliminating long
trips, but local roads may have more hazards.

Decreasing mileage may not always proportionately decrease
safety risks -- “low mileage” drivers (e.g., less than 3,000
miles per year) may actually be the group that is most “atrisk”
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Type of crashes
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Compared with younger drivers whose car crashes are often
due to inexperience or risky behaviors, older driver crashes
tend to be related to inattention or slowed speed of visual
processing.

Older driver crashes are often multiple- vehicle events that
occur at intersections and involve left-hand turns.
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Fact #5: Physicians can influence their patients’ decisions to
modify or stop driving
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Downsides to recommendation to stop
driving

Decreased activity
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Depression
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Limited access to resources (especially if person is also a
caregiver)
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Assessment of Driving-Related Skills
(ADReS)
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three key functions for safe driving are

(1) vision

(2) cognition

(3) motor/somatosensory function
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Vision
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Visual acuity
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Visual fields
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Contrast sensitivity
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Cognitive ability
• Memory—short-term, long-term, and working memory
• Visual perception, visual processing, visual search, and
visuospatial skills
• Selective and divided attention
• Executive skills (sequencing, planning, judgment, decision
making)
• Language
• Vigilance.
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Cognitive assessment
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Clock drawing
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Trails B
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recent Maryland Pilot Older Driver Study (MaryPODS) that found
an association with Trails B performance and at-fault crashes in a
cohort of older adults utilized only the practice trial of Trails B
prior to the full test.
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Motor and Somatosensory
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Rapid Pace Walk
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Manual test of range of motion
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Manual test of motor strength
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Proprioception
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ADReS: Summary
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Recommended sequence:
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Visual Fields by Confrontation Testing
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Snellen E Chart
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Rapid Pace Walk—Mark a 10-foot distance on the floor. With the patient
already standing at the 20-foot mark, have him/her walk to the 10-foot
mark, then back
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Manual Test of Range of Motion— This is performed when the patient
has returned to the examination room
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Manual Test of Motor Strength
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Clock Drawing Test
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Trail Making Test, Part B
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Recommendations:
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Visual acuity:
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20/40-20/70: consider further assessment
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20/70-20/100: recommend on road assessment
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< 20/100: needs specialty and road assessment
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Cognition
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Intervention recommended if either one abnormal
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Trail Making part B greater than 3 minutes
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This test may have greatest correlation with recent/future
crashes
Clock drawing
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Assessment of visual spatial functioning
+ Evaluating driving risk in patients
with Dementia: evidence based
review
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Recognition that MMSE has no correlation and low sensitivity
for identifying unsafe drivers
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Neurology 2010; 74: 1316-1324
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Conclusions from evidence
review…
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Clinical Dementia Rating (CDR) is established as useful for
identifying patients at increased risk for unsafe driving
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Recognition that still a significant number of patients with
CDR 0.5-1 will be found to be safe drivers with On Road
Driving Test (ORDT)
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CDR
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Categories:
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Memory
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Orientation
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Judgment and problem saving
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Community affairs
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Home and hobbies
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Personal care
Scoring 0-2 (2 more severe)
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MMSE
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If <24, MAY be helpful
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Over 24, not helpful at all
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Other indicators…
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Caregiver’s rating of marginal or unsafe driving is helpful
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Patient’s self-rating of safe is NOT useful
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Other indicators….
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History of crash in the past 1-5 years
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Traffic citation in past 2-3 years
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History of crash is likely more useful in identifying patients at
risk for future crashes than the presence of mild dementia
alone…
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Decreased mileage
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Reduced driving mileage is likely associated with
INCREASED risk of poor driving
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Self reported avoidance may be useful in identifying at risk
drivers
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The absence of self avoidance/decreased mileage is NOT
helpful in indentifying safe drivers
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Personality characteristics…
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Aggressive or impulsive personality traits may be associated
with increased risk
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Neuropsychological Predictors of
Driving Errors in Older Adults
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JAGS 2010:
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Found that the strongest predictor of age related decline in
driving performance was composite measure of cognitive
abilities
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Short term memory NOT associated with performance
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Highest predictor of problems: test components involving
visuospatial and visuomotor abilities
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Hearing Impairment and ability to
drive
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JAGS 2010:
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Older adults with poor hearing had more difficulty in driving
in presence of visual or auditory distracters than older adults
with normal hearing
+ 4 C’s: Crash History, Family Concerns,
Clinical Condition, Cognitive Function
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JAGS 2010
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4 C’s: Interview Based Screening tool to identify at-risk
drivers
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Study in JAGS evaluated effectiveness when compared to
standardized driving performance test
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4 Cs Screening Tool
Crash/Citation
Concern (family
report)
Clinical Status
(medical history)
Cognition (family
report and clinical
impressions)
1. No
crashes/citation
1. No concerns
1. Overall good
health
1. Intact cognition
2. One or more
fender benders
2. Mild concerns
(family has talked
with patient about
safety)
2. Medical
condition/mild
impact on vision,
attention, motor
(frailty, arthritis,
neuropathy)
2. Mild cognitive
decline/intact daily
function
3. Citation for
dangerous violation
3. Moderate
concerns: family
restricts patient from
driving with
passengers
3. Medical issues:
moderate impact on
vision, attention,
motor (stroke, early
alzheimers,
parkinson’s)
3. Moderate
cognitive decline:
decline in daily
functions
4.Crash or crashes
4. Extreme concerns:
family wants patient
to stop driving
immediately
4. Medical
issues/severe
impact on vision,
attention, motor
4. Severe cognitive
decline/dependenc
e on others for daily
function
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4 C’s Screening Tool
Family Concerns most highly associated with at risk driving
behavior on Road Performance Testing….
Prior crashes and clinical condition not predictive
95% of marginal or unsafe drivers had 4C score of 9-16
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Review: Possible Indicators of at –
risk driving…
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History of traffic citations
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History of crashes
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Reduced driving mileage
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Self-reported situational avoidance
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MMSE score <24
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Visuospatial difficulty on cognitive testing
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Aggressive or impulsive personality characteristics
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Hearing deficit
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4 Cs: Especially FAMILY CONCERNS
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Summary: Assessment – Who is at
risk?
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History of traffic citations
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History of crashes
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Reduced driving mileage
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Self-reported situational avoidance
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MMSE score <24
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Aggressive or impulsive personality
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Family Concerned
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Summary: Assessment
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Cognitive testing with visuspatial testing
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4 Cs screening tool
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Address family concerns strongly
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Visual and hearing assessments (visual fields)
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Manual testing of ROM and motor strength
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Rapid pace walk
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Referral to On Road Driving Assessment