Assessing and Counseling Older Drivers

1. Assessing and Counseling Older Drivers Identifying and Assessing the Medically Impaired Driver

2. AMA House of Delegates • 1925 - Recommended that drivers receive a physician’s certificate of medical fitness to drive. • 1930 - Recommended that prior to licensure, applicants undergo an exam to determine physical and mental capacity to drive. • 1938 - Section on ophthalmology issued ”Visual Standards for Operating a Motor Vehicle.”

3. AMA Committee to Study Problems of Motor Vehicle Accidents (1930’s-1950’s) • 1939 report classified conditions influencing driving as: • Permanent deficiencies • Transitory deficiencies • Brief or self-inflicted deficiencies • This report stated that alcohol causes impairment at a blood level of 0.05%.

5. Report - 1963 “Age per se should not be a limitation once the individual reaches licensing age, rather the functional capacity and ability of each individual should be the determining factor.”

6. “Too Old” to drive? • Numerical age is not the problem • Impaired function is the limiting factor • AMA report, 1963

7. Physician’s Guide to Assessing and Counseling Older Drivers Provides physicians with the tools necessary for assessing older patients for medical fitness to drive.

8. What functional abilities are important to driving? • Vision • Cognition • Motor function

9. Physician’s Plan for Older Driver Safety • Screen to determine if patient is potentially at risk • Assessdriving related functional skills (ADReS) • Treatunderlying causes of functional decline • Referfor further evaluation and/or adaptive training • Counselon safe driving behavior and alternative options • Follow-Upfor signs of depression, isolation and compliance

10. Be alert to Red Flags: Any medical condition, medication or symptom that can impair driving skills How can physicians screen patients for medically impaired driving?

11. Red Flags • Acute events • Patient’s or family member’s concern • Medical history • Chronic medical conditions • Unpredictable/Episodic events • Medications • Review of systems

12. Prescription & OTC drugs • alcohol • antihistamines • antidepressants • benzodiazepenes • opiod analgesics • muscle relaxants • antipsychotics

13. If Red Flags are present • Ask health risk assessment/social history questions • How did you get here today? • Has another treating physician brought up driving issues? • Gather additional information • Do other drivers on the road cause you distress? • Have you had any recent problems when you drive? • Understand your patient’s mobility needs

14. How can physicians assess for deficits in function? Assessment of Driving Related Skills • ADReS is a brief, function-based, in-office assessment of driving-related skills • ADReS does not assess patient’s performance on driving task • ADReS does not predict crash risk

15. Motor FunctionRapid pace walk Manual test of motor strength Manual test of range of motion Vision Visual fields by confrontation testing Snellen E Chart Assessment of Driving Related Skills CognitionTrail-Making Test, Part B Clock Drawing Test

16. Interpreting ADReS results • Recommended scoring limits to evaluate patient’s performance • The goal is to identify and correct any functional deficits that may impair driving performance • Recommendations are subject to state reporting laws and DMV requirements

17. Three courses of action • If patient performs well, continue driving without further work-up or treatment • If patient performs poorly, pursue medical treatment and necessary evaluation • If patient’s poor performance can not be medically corrected, refer patient to a Driver Rehabilitation Specialist

18. Certified Driver Rehabilitation Specialists have expertise in: • Targeted clinical assessment • Functional on-road assessment • Prescribing and training clients in the use of adaptive equipment • Counseling and advising on driving concerns and mobility alternatives

19. Physicians can help maximize older driver safety • Continue medical treatment & preventive care • Counsel patients on health and driving • Identify at-risk patients & help manage deficits • Discuss driving retirement • Abide by state reporting laws

20. Legal considerations • Protecting the patient • Case law illustrates that failure to advise patients on medical conditions and medications is negligent behavior • Case law also illustrates the health care system can be liable for breaching confidentiality • Protecting the public • Legal precedents demonstrates that physicians may be held liable for third-party injuries

21. Legal protection for patient reporting Immunity- exempts physicians from liability for civil damages Anonymity/Legal protection- protects physicians from civil actions for damages caused by reporting in good faith

22. Policy Issues • Impaired function determines driving safety not age. • On the road test essential to see how patient compensates for impairments • No immunity for physicians who report their concerns in many states. • National need for legislation to allow good faith reporting by physicians and other health professionals.

23. www.ama-assn.org/go/ olderdrivers www.nhtsa.dot.gov American Medical Association National Highway Traffic Safety Administration