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assessment of older drivers

Risk factor assessment: 1) transportation history a) caregiver's perception of driving skills (most important) [13]* b) patient's self-assessment of driving skills not useful [13] c) crashes, tickets, near misses, or getting lost driving d) driving < 60 miles/week e) use of seat belt, cell phone 2) review of medical history a) cardiac disease/arrhythmias b) diabetes c) pulmonary disorders/sleep apnea d) alcoholism e) arthritis f) visual or hearing impairment g) dementia h) history of CVA/TIA/syncope i) Parkinson's disease/neuromuscular disease j) seizure disorder 3) medication use a) opioids b) benzodiazepines c) antidepressants (TCAs or other sedating antidepressants) d) antihistamines e) glaucoma agents f) antipsychotics g) alcohol h) antidepressants (including SSRI & SNRI), sedatives or hypnotics, & NSAIDs or acetaminophen are associated with a higher risk of failing a road test [26] i) no associations of anticholinergic or antihistamines with poor performance [26] 4) evaluation of perception a) visual acuity: should be 20/40 or better (corrected) b) visual field testing: by confrontation, horizontal field should range from 100-140 degrees c) loss of central vision due to macular degeneration impairs ability of older drivers to see pedestrians [10] d) contrast sensitivity: reading progressively fainter letters off the chart (eg. Pelli-Robson chart) e) peripheral sensation, esp pinprick & position 5) evaluation of cognition a) attention: digit span, A test b) visual-spatial function 1] clock test 2] copying pentagons -> abnormal test is one of 3 independent risk factors for MVA/moving violation identified in ref 1 c) clinical dementia rating 1] 0.5 (MMSE=25): no driving impairment 2] 1.0 (MMSE=19-24): significant traffic safety problems 6) evaluation of motor response: a) trunk & neck mobility: turn to look b) strength: at least 4/5 muscle strength in right lower extremity & both upper extremities c) coordination 7) evaluation of mood - impulsivity, agression, emotional lability 8) occupational therapist can evaluate patient & vehicle [13] - adjustments or adaptive equipment (mirrors) to compensate deficits Other factors: 1) driving as a form of independence 2) cost of alternative transportation 3) history of hospitalization for critical illness [24] - most don't drive; some who do have evidence of cognitive impairment * according to ref [11], relatives of elderly living independently qualify as caregivers Management: - if in doubt regarding safety of elder driving, refer to DMV for formal driving assessment [8,11,13] - mild dementia is not necessarily a contraindication to driving [13] - occupational therapist engaged in driver safety programs can help elderly continue to drive [13,18] - driver safety course with component of 'on road' instruction* - speed of processing & reasoning training lower risk of at-fault motor vehicle accidents in older drivers [9] - older drivers with multiple (>= 4 risk factors) should be advised to stop driving [11]* - referral to health department as required by state - dementia is a reportable disorder in many states - in-person license renewal reduces incidence of hospitalized drivers with dementia age 60-69 but not 70-79 [20] - vision testing reduces incidence of hospitalized drivers with dementia age 60-60 but not 70-79 [20] - road testing reduces incidence of hospitalized drivers with dementia age >=80 [20] * seems to be procedure of choice Notes: - a policy amendment March 2017 for cognitive screening of older drivers at driver's license renewal resulted in decrease in motor vehicle collisions as drivers & an increase in road injuries as pedestrians & cyclists among older people [25]

Related

dementia & driving motor vehicle accident (MVA)

General

assessment of driving

References

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