Sex and Driving in Older Patients (Mobile Accessible

1. Sex and Driving in Older Patients (Mobile Accessible Presented by: Elizabeth Clark, MD Associate Director/Clinical GRECC, JJ Peters VAMC Associate Professor, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine

2. Educational goals • Discuss the importance of raising issues of sexuality and driving with older adults in the primary care setting • Identify patient and provider barriers to those discussions • Present approaches to effective discussions of these challenging topics

3. Older adults are sexually active • Population survey (n=3005, age range 57 – 85) • Sexual activity associated with quality of life • Predictors of reduced sexual activity • Advanced age, lack of partner, female sex, poor health of person or partner Lindau ST, et al. NEJM, 2007

4. Sexually active older adults report bothersome sexual problems • Men • Erectile dysfunction, lack of interest, early climax, performance anxiety, inability to climax • Women • Lack of interest, poor lubrication, inability to climax, finding sex not pleasurable, pain • Number of problems increased with self report of fair or poor health Lindau ST, et al. NEJM, 2007

5. Older adults engage in risky behaviors • Survey of older adults in Britain (n= 335) • 7% reported unprotected sex with more than one partner1 • 20% of all HIV/AIDS patients in US >50 • Diagnosed at later stage in older adults • Older adults may have less knowledge about HIV/AIDS • Health care workers less likely to discuss sexual concerns and “safe sex” with middle aged and older adults2 1) Gott MC, Health and Social Care in the Community, 2001 2) AgePage: HIV, AIDS and Older People, http://www.nia.nih.gov/

6. AIDS Cases are Increasing among Older Adults http://www.cdc.gov/

7. Physicians miss opportunities to discuss sexual problems with older patients • Minority of patients in large study reported having discussed sex with MD after age 50 • 38% of men, 12% of women1 • Sexual concerns as common among older women as among younger women but rarely discussed with physicians • Most older women in study would welcome discussion if subject raised by physician2 1) Lindau ST, et al., NEJM, 2007 2) Nusbaum MRH, JAGS, 2004

8. Barriers to discussing sexual concerns with patients • Physicians’ lack of knowledge • “older people asexual”, “only young people engage in sexually risky behavior” • Physicians’ attitudes • “dirty old man” • Physicians’ lack of training • Patients’ perceptions of physician disapproval Gott M, et al., Social Science and Medicine, 2003

9. PLISSIT Model for discussing sexuality • P—Permission to Speak about Sexuality offered to, and gained from the patient • LI—Begin a Limited discussion of general issues and potential problems • SS—Provide Specific Suggestions to improve sexual health • IT—Move to more Intensive Therapeutic modalities if needed to address sexual concerns Annon J, J Sex Educ Ther, 1976

10. Just do it • Ask about sexuality and sexual concerns as a routine part of the medical encounter • Be prepared for the unexpected and unfamiliar • Offer practical suggestions • Refer for specialized care when appropriate • Always promote SAFE SEX

11. Resources – Sexual Health • Sexuality in Later Life http://www.nia.nih.gov/HealthInformation/Publications/sexuality.htm • Erectile Dysfunction http://kidney.niddk.nih.gov/kudiseases/pubs/ED_ES/index.htm • HIV, AIDS and Older People http://www.nia.nih.gov/HealthInformation/Publications/hiv-aids.htm • Sexual Health http://www.cdc.gov/sexualhealth/ • Women’s Health http://www.ourbodiesourselves.org/

12. Older drivers

13. Key facts about older drivers • Safety for older drivers is a public health issue • Self-regulation of driving behavior has not kept crash rates down among older drivers • Most older Americans depend on driving for all their transportation needs • Crash rates for older drivers related to physical and cognitive changes of aging • Physicians can influence patients’ decisions to stop or modify driving, and can help them maintain their driving skills AMA, Physician’s Guide to Assessing and Counseling Older Drivers, 2003

14. In patients with early stage Alzheimer’s disease, driving performance declines over time • Prospective longitudinal study • 58 healthy controls, 21 subjects with very mild Alzheimer’s disease, 29 subjects with mild AD • Repeated on-road driving tests • Subjects with early stage AD had a faster rate of receiving a “not safe” evaluation on the driving test than healthy controls Duchek J, et al., JAGS, 2003

15. Challenges to management of cognitively impaired older driver • Drivers with dementia have twice the risk of crashes as those without • In the early stages, drivers with dementia may still be able to pass driving performance test • Others may depend on driver with dementia for transportation Carr DB and Ott BR, JAMA, 2010

16. Co-morbid conditions that can reduce driving capacity • Visual deficits • Cataracts, diabetic retinopathy, macular degeneration, glaucoma • Cognitive and neurological deficits • Dementia, MS, Parkinson’s disease, seizure disorder, CVA • Motor deficits • DJD, muscle weakness, limited neck rotation • Medical conditions • Recent MI, Class IV CHF, sleep apnea, diabetes Carr DB and Ott BR, JAMA, 2010

17. Medications that can affect driving safety • Antihistamines • Antipsychotics • Tricyclic antidepressants • Bowel/bladder antispasmodics • Benzodiazepines • Muscle relaxants • Barbiturates Carr DB and Ott BR, JAMA, 2010

18. Barriers to addressing driving issues with older patients in the primary care setting • Concerns about liability • Lack of information about reporting requirements • Defensive, angry patients • Lack of efficient, reliable tool to assess driving ability Bogner H, et al., JABFP, 2004

19. Physician reporting requirements for unsafe drivers in the tri-state area • Connecticut • MAY report presence of chronic health problem that may significantly affect driving ability • Immune from liability if acting in good faith • New Jersey • Required to report recurrent loss of consciousness • Immune from liability • New York • Permitted but not required • No immunity from liability AMA, Physician’s Guide to Assessing and Counseling Older Drivers, 2003

20. Questions to ask your older patients (or their families) about driving safety • Have you gotten lost while driving (on routes you should know)? • Have you had any accidents or tickets/warnings from the police (inappropriate speeds)? • Have you found yourself confused, frustrated, or less confident while driving? • Have you failed to observe traffic signals/signs, or need help from passengers? • Do you find yourself avoiding driving during rush hour, bad weather, or at night? AMA, Physician’s Guide to Assessing and Counseling Older Drivers, 2003

21. Tips for discussing driving limitations • Be direct. “I am concerned not only for your safety, but for other people on the road.” • Tell them that testing Driving Related Skills might help find areas that could be improved with Assistive Devices or Driver Rehabilitation Specialist • http://www.driver-ed.org/i4a/pages/index.cfm?pageid=1 AMA, Physician’s Guide to Assessing and Counseling Older Drivers, 2003

22. Tips for discussing driving limitations (Cont’d) • If reluctant for testing, assure them that you cannot take their license away. The most you can do (depending on where you live) is report them as an unsafe driver to the DMV, and recommend that they retire from driving. • If they still refuse testing, give (and document) the following counseling: • Avoid driving at night, in bad weather, and during rush hour. • Avoid left hand turns (make 3 rights instead) • Give appropriate educational resources to patient and family • Discuss alternative transportation options AMA, Physician’s Guide to Assessing and Counseling Older Drivers, 2003

23. Resources – Older Drivers • Physician’s Guide to Assessing and Counseling Older Drivers: http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Introduction.html • Alzheimer’s, Dementia, and Driving http://www.thehartford.com/alzheimers/ • Am I a Safe Driver? http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/AppndxB-AmI.html • Tips for Safe Driving http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/AppndxB-Safe.html • The Age Page: Older Drivers http://www.nia.nih.gov/HealthInformation/Publications/drivers.htm • How to Help the Older Driver http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/AppndxB-How.html • The Car Thief http://www.nytimes.com/2009/11/01/magazine/01lives-t.html

24. Conclusion • Sex and driving are important issues in the care of older patients • Barriers to effective discussion include • Patient discomfort raising these issues • Physician discomfort, lack of knowledge and inadequate communication skills • Strategies to overcome these barriers can improve safety, health and quality of life for patients and families