Elder Drivers

1. Elder Drivers

2. Goals and Objectives • Review Pennsylvania driving regulations • Review Pennsylvania reporting regulations • Discuss pertinent geriatric physiology, pathophysiology, and syndromes • Learn to manage loss of licensure • Rehabilitation • Gray areas

3. PA Driving Regulations

4. Driver Licensing Agency • Pennsylvania Department of Transportation • Driver and Vehicle Services • 1101 South Front Street • Harrisburg, PA 17104-2516 • www.dot.state.pa.us • 800-832-4600 (within state) • 717-391-6190 (out of state)

5. Licensing Requirements:Visual Acuity • Each eye with/without correction 20/40 • Both eyes with/without correction 20/40 • If one eye blind-other with/without correction 20/40 • Absolute visual acuity minimum 20/40 in better eye for unrestricted license; up to 20/100 binocular vision for a restricted license • Bioptic telescopes • Not permitted for meeting acuity standards • Permitted for driving • Must have acuity of 20/100 or better with carrier lens only • http://www.biopticdriving.org/

6. Licensing Requirements: Bioptics • Bioptic telescopes • Not permitted for meeting acuity standards • Permitted for driving • Must have acuity of 20/100 or better with carrier lens only • http://www.biopticdriving.org/

7. Licensing Requirements:Visual Fields • Minimum Field Requirement 120o both eyes • Testing device not regulated

8. Licensing Requirements: Color Vision • No requirement

9. Licensing Requirement: Hearing • Amplified or Unamplified for • Forced whisper at not less than five feet or • Worse than 40 db loss in better ear at • 500 Hz, 1000 Hz and 2000 Hz • Positive office screen • Do you have trouble hearing with background noise? • USTFP Clinical Guideline: obsolete 2006 • Hand held audiometer • Less sensitive and specific, but is often more convincing to ptnt • Does your spouse complain about your hearing? • Does the doctor notice hearing loss?

10. Road Test • Standardized • Similar to 1st time permit application drivers

11. Restricted Licences • Vision • Daytime driving only • Area • Dual mirrors • Class

12. License Renewal Procedures • Standard • Time 4 yr • Options/Conditions internet, email, in person • Vision test required? No • Road test required? No • Age-based renewal • Over 65+ every 2 yr • Over 45+ random 1650/mo submit PE/vision

13. PA Reporting Procedures: Medical • “All physicians and other persons authorized to diagnose or treat disorders and disabilities defined by the Medical Advisory Board shall report to PENNDOT in writing the full name, DOB, and address of every person 15 years of age and older, diagnosed as having any specified disorder or disability with 10 days.” Physicians must report neuromuscular conditions (eg. Parkinsons), neurospsychiatric conditions (eg. Alzheimer’s dementia), cardiovascular, cerebrovascular, convulsive, and other conditions that may impair driving ability.

14. PA Reporting Procedures: Immunity • “No civil or criminal action may be brought against any person or agency for providing the information required under this system.” • Legal protection is available • Anonymity • Reporting is not anonymous, but the identity or the reporter will be protected.

15. PA Reporting Procedures • DMV follow-up • PENNDOT sends the appropriate correspondence to the driver asking him/her to submit the necessary forms and examinations reports • Other reporting • Will accept information from courts, others DMV’s, police, emergency personnel, family members, neighbors, and caregivers. Reports must be signed in order to confirm reporter facts.

16. Predictors • No statistically significant predictors predict rates greater than 2.5 times the minimum rate at 46-55 years of age. This equals the 16-25yr old rate. Sources vary – some higher some lower • ADL’s decline predicts cessation in women • Men seldom self-select out of driving • Men ≥ 85 years old have twice the accident rate of women ≥ 85 years old. GRS pg 5

17. Physiologic Concerns • Frailty • Decreased Cardiac Reserve • Slower reflexes • Decreased oculomotor function • Useful field of view • Trail-making B • Decreased neck rotation • Decreased light sensitivity • Decline in musculoskeletal function • Frontal Lobe slowing

18. Drugs • Sedative/Hypnotics • Antihistamines • Antidepressants • Antipsychotics • Anti-epileptics • Cardiac • Rheumatologic

19. Screening • Foot abnormalities • Gait abnormalities • Folstein less than 21(21-23 intermediate) • Intersecting pentagons • Citation within a year of visit

20. Intersecting Pentagons Blocks walked daily 3 or more foot abnormalities Mini-mental 25 or less Crash Risk by Factors None 6% 1 12% 2 26% 3 47% Accepted baseline is 2.5% Screening: Marottoli 1994

21. Private On Road Testing • Moderate to severely demented drivers do worse than others • No correlation to crash / morbidity / mortality • EBM provides no cut point • Accident scenarios not represented

22. Office Screenings • The 4Cs • Crash History, Family Concerns, Clinical Condition, Cognitive Functions • Score of 9 or greater indentified 84% of patients with a poor road test score.

23. 4Cs: Score of >=9 finds 84%

24. Compare to this recent article • Predictors of failing an on-road test include: • Family has concerns about driving safety • Patient admits to self-limiting driving • At fault crash in the last 5 years • Moving violation/citations in the last 3 years

25. Compare to this recent article • Predictors of failing an on-road test include: • Aggressive or impulsive personality characteristics • Decline in IADL’s due to cognitive impairment • Poor attention • Slow processing • Visuospatial abnormalities • Executive function abnormalities

26. Office Screening • There is Currently no Reliable Office Screening Tool for Driver Risk or Cessation

27. But ask yourself: • Would you let this person drive your children to the Philadelphia Zoo?

28. Simulator Testing • All demented patients drive worse than others • Can test accident situations • No correlation to crash / morbidity / mortality

29. 4CS • But on road testing has a poor correlation with subsequent good or bad future performance • The study was a retrospective chart review • The population was enriched as a neuropsychiatric consult group • No application studies have been published

30. Vehicle Adaptations • Many • Most Common • Spinner Knob • Foot Pedal Modification • Automatic Transmission

31. HAVECO Inc • 7408 Derry St • Harrisburg, PA 17111-2661 • +1 (800) 558-7408

32. Rehabilitation • PT • OT • Driver’s Rehab • American Automobile Association • AARP • Association for Driver Rehabilitation Specialists

33. Re-testing • After resolution of medical problems • After vehicle modifications

34. Conflict Resolution • Giving bad news • Many patient’s leave their doctor over this • Referral • Second opinion • Legal issues • Resource brokering

35. Alternative Transportation • Public • Private • Family • Friends • Hired • Medical

36. Follow-up • Structured follow-up for care coordination at about one month

37. Psychiatric Follow Up Care • Grief • Isolation • Depression • Anxiety • Perhaps mortality

38. Summary • Treatment of hearing, vision, and orthopedic problems preserves driving ability • Physicians and nurse practitioners must report medically incapable drivers • There are community and private services available to assist with driving and alternate transportation

39. Websites • http://www.dmv.state.pa.us/centers/olderDriverCenter.shtml • Our Intraweb site has the link to Mummau’s

40. Bibliography • Ball, K; “Can High-Risk Older Divers Be identified Through Performance-Based Measures in a Department of Motor Vehicles Setting?”, JAGS 54:77-84, 2006, The American Geriatrics Society • Anstey, K “Predicting Driving Cessation over 5 Years in Older Adults: Psychological Well-Being and Cognitive Competence Are Stronger Predictors than Physical Health”, JAGS 54:121-126, 2006, The American Geriatrics Society • Meusser, TM. Misleading Findings on Cognitive Status Stereotype Older Drivers. JAGS 58: 797-798. The American Geriatrics Society. • O’Callaghan, S; O’Neill, DO. Comment on Article on Older Drivers in Australia. JAGS 58: 1213. The American Geriatrics Society. • Ross, LA; Anstey, K, et al. Response Letter to Drs. O’Callaghan and O’Neill. JAGS 58: 1213-1214. The American Geriatrics Society. • Dawson, JD; Uc, EY; et al. Neuropsychological Predictors of Driving Errors in Older Adults. JAGS 58: 1090-1096. The American Geriatrics Society. • Hickson, L; Wood, J; et al. Hearing Impairment Affects Older People’s Ability to Drive in the Presence of Distracters. JAGS 58: 1097-1103. The American Geriatrics Society. • O’Connor, MG; Kapust, LR; et al. The 4Cs (Crash History, Fmaily Concerns, Clinical Condition, and Cognitive Functions): A Screening Tool for the Evaluation of the At-Risk Driver. JAGS 58: 1104-1108. The American Geriatrics Society.

41. Bibliography • Pacala JT, Sullivan GM, eds. Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. New York: American Geriatrics Society; 2010. • Ross LA, Browning C, et al, “Age-Based Testing for Driver’s License Renerwal:Potential Impolications for Older Australians”, JAGS 59:281-285, 2011 The American Geriatrics Society. • Betz MF, Lowenstein SR, “Driving Patterns of Older Adults: Results from the Second Injury Control and Risk Survey”, JAGS 58:1931-1935, 2010 The American Geriatrics Society. • Sleep Disturbance and Adverse Driving Events in a Predominantly Male Cohort of Active Older Drivers”, JAGS 58:1878-1884, 2010 The American Geriatrics Society. • Wood, JM, Anstey KJ, et al, “A Multidomain Approach for Prediciting Older Driver Safety Under In-Traffic Road Conditions”, JAGS 56:986-993, 2008 The American Geriatrics Society.