The Road Less Traveled: Physician Advocacy for the Older Driver

1. The Road Less Traveled:Physician Advocacy for the Older Driver Colonel Brian Unwin, M.D. Department of Family and Community Medicine Uniformed Services University of the Health Sciences Bethesda, MD

2. Goals and Objectives Define status quo Define the multiple elements and tools involved in driving assessment Describe advocacy role(s) of the family physician in assessment of older drivers Reword first three into GOsReword first three into GOs

3. Advocacy Confidentiality vs. duty to warn the public Independence/mobility vs. dependence and immobility Accurate prediction of unsafe drivers Use office-based tools in decision making Readiness for future demographic change Societal constraints and resources, what are public goals and how do we prevent ageist policiesSocietal constraints and resources, what are public goals and how do we prevent ageist policies

4. Case Studies

5. Patient 1 75 year old male with macular degeneration has stopped driving Lifelong truck driver, excellent safety record Stops driving after not seeing traffic lights and striking a parked car Spouse does not drive Limited family support

6. Patient 2 80 year old female is upset because you are 15 minutes late Informs you she must leave before it �gets dark out.� Patient is anxious, agitated, but alert and oriented Wants refill on benzodiazepines

7. Patient 3 85 year old healthy male with complaint of episodic �weakness and shakes� No driving concerns, just drives slowly during the day for essential trips. No near misses or accidents. State requires medical report.

8. AAA World, November/December 2004 Older Driver Facts and Figures 2000 18.9 million drivers over age 65 2020 50 million drivers over age 65 2030 Number of drivers 85 and older will be four times greater than today Fatality rates of drivers age > 65 seven times higher than 25-64 year olds Don�t read this. More people on the road at increased risk of mortalityDon�t read this. More people on the road at increased risk of mortality

9. AARP Public Policy Institute, 1995 Reasons Seniors Drive TexT?TexT?

10. Adaptations by Older Drivers Co-pilots Driving slower Daytime only Familiar roads Low traffic areas No alcohol Seat belts Driver refresher courses

11. Crashes per Million Miles Traveled

12. Older driver involvement in Injury Crashes in Texas, 1975-1999. AAA Foundation for Traffic Safety. Feb 2004 Fewer Crashes, More Mortality Eliminate? Why?Eliminate? Why?

13. Ragland, Satariano, and MacLeod. The Gerontologist. 2004. 44(2); 237-244. Self-reported limitations Vision was primary reason for limitation Crime concerns greater in women than men Lower income people less likely to drive Non-medical reasons weigh heavily on the decision

14. Crash-Associated Factors in Seniors Failure to observe Failure to indicate lane changes Inadequate preparation for changing weather and road conditions Increased blind spots

15. Patient 1 75 year old male with macular degeneration has stopped driving Lifelong truck driver, excellent safety record Stops driving after not seeing traffic lights and striking a parked car Spouse does not drive Limited family support

16. Patient 2 80 year old female is upset because you are 15 minutes late Informs you she must leave before it �gets dark out.� Patient is anxious, agitated, but alert and oriented Wants refill on benzodiazepines

17. Patient 3 85 year old healthy male with complaint of episodic �weakness and shakes� No driving concerns, just drives slowly during the day for essential trips. No near misses or accidents. State requires medical report.

18. AMA Physician�s Guide to Assessing and Counseling Older Drivers

20. History: Diseases and Conditions CAD Major surgery Diabetes Arrhythmias with loss of consciousness Pacemakers Alcohol abuse Cerebrovascular disease Obstructive sleep apnea Osteoarthritis Seizure disorders Metabolic syndrome Cognitive disorders viisualviisual

21. Rethinking the History Acute Sporadic and unpredictable Examples Seizures Syncope Hypoglycemia Chronic Stable and enduring Examples CHF Diabetic Retinopathy

22. History: Medications Antihistamines Antihypertensives Muscle relaxants Narcotics Stimulants Alcohol �Recreational� drugs Anticholinergics Antiemetics Anticonvulsants Antiparkinsons Antipsychotics Benzodiazepines OTCs Strong association of benzo use with crash riskStrong association of benzo use with crash risk

23. History: Driving Do you drive now? What purposes? How many days/week do you drive? Miles driven? Co-pilot? Moving violations? Parking problems? Self-imposed limitations? Time of day Familiar vs. unfamiliar roads Busy vs. slow Accidents or near misses? visualvisual

24. History: Transportation Alternatives Public transportation? Ride share programs? Taxi? Family, friends, relatives? Cost of ownership, maintenance, insurance of a vehicle vs. cost of alternatives? Bus visualBus visual

25. Common Sense Poor judgment Poor reasoning Poor abstract thinking Poor insight

26. Essentials of Clinical Assessment Cognition Vision Visual acuity Peripheral vision Functional status Physical strength Range of motion Hearing Reaction time* Driving History

27. AMA Physician's Guide to Assessing and Counseling Older Drivers, 2003. Clinical Assessment: Vision Visual acuity Visual fields Good idea to add a clock see next, add trail marking laterGood idea to add a clock see next, add trail marking later

28. Clinical Assessment: Cognition Cognition Trail Making Test, Part A Trail Making Test, Part B (<180 sec)

29. Trail A Example

30. Trail B Example

31. Clinical Assessment: Cognition Clock Draw Test

32. Mini-Mental State Exam:

33. Recommendations from the AMA Physician�s Guide Encourage self assessment Encourage family assessment Document everything

34. Vision and Cognition: need for intervention Vision Less than 20/70 Cognition Trail Making B > 180 seconds Less than perfect clock draw

35. Physical Function: need for intervention Rapid Pace Walk (>9 sec) ROM of extremities and trunk (�abnormal�) Manual Test of Motor Strength (less than 4/5)

36. The Process Does well on all domains: keep driving Potentially correctable areas Limit driving as treatment proceeds Re-evaluate If not correctable Refer to driving rehab specialist (per the AMA Guide) or Make the Decision and report the driver and advise in driving retirement/restriction

37. Types of interventions Dementia evaluation and treatment Evaluation and treatment of depression Medication modification Consultation On the road assessment

38. AMA's Physician's Guide to Assessing and Counseling Older Drivers General Recommendations for Older Drivers Power steering, brakes and automatic transmission Regular exercise OT and/or PT consult for conditioning and assistance Pain relief Joint disease management Neuromuscular disease management

39. AMA Physician's GUide to Assessing and Counseling Older Drivers, 2003. Common Outcomes Correct the correctable Driver rehabilitation specialist Plan for alternatives Restrict, retire, or report �Good to go� Continue to monitor Collaborate to problem solve driving alternativesCollaborate to problem solve driving alternatives

40. Patient 1 75 year old male with macular degeneration has stopped driving Lifelong truck driver, excellent safety record Stops driving after not seeing traffic lights and striking a parked car Spouse does not drive Limited family support Never assessed and never discussed with physician or family or physician sonNever assessed and never discussed with physician or family or physician son

41. Findings Significant ARMD Painful ROM of right shoulder Walks to medical care and shopping Son in community for assistance Sells car and uses cab as needed Declines senior services Remained at home for next 9 years

42. Patient 2 80 year old female is upset because you are 15 minutes late Informs you she must leave before it �gets dark out.� Patient is anxious, agitated, but alert and oriented Lives alone in the community Wants refill on benzodiazepines

43. Findings MMSE 24/30, frustrated with 4 minutes on Trail Making B with errors Moving violations x2 in past year Controlled hypertension and diabetes Ongoing benzodiazepine use for GAD Corrected visual acuity 20/20 Doesn�t desire family involvement

44. Findings Refuses to admit potential for problems, and refuses driving evaluation Competent for medical decision making DMV referral Social Work Services for alternative transportation, home safety assessment Treatment for dementia started

45. Patient 3 85 year old healthy male with frequent complaint of episodic �weakness.� No driving concerns, just drives slowly during the day for essential trips. No near misses or accidents. State requires re-licensing examination

46. Findings Cognition (MMSE- 30/30) Vision correctable to 20/20 and otherwise normal. Up and Go is 13 seconds Otherwise normal physical exam Age related changes on head CT Normal lab

47. Findings Continuation of driving in daytime hours and short trips Advised older driver education classes Advised regarding driving retirement issues Social Work Consult for alternative transportation Ongoing medical monitoring

48. What is the Evidence?

49. Kantor B. JAGS. 52:1326-1330. 2004. Driver Evaluation Programs No community based study based on AMA Guidelines to date Poor MMSE and Trail Making B predictive of on the road evaluation failure Mild dementia does not automatically mean unsafe driver Multidisciplinary assessment by geriatrician, clinical geriatric nurse specialist, occupational therapist, and driving evaluatorMultidisciplinary assessment by geriatrician, clinical geriatric nurse specialist, occupational therapist, and driving evaluator

50. Is Clinical Assessment of the Older Driver �Enough?�

51. Washington Post, Dec 5, 2004. Beyond Driver Assessment Assessment relationship with safetyAssessment relationship with safety

52. Imperfection Can cars and roads become safer? What is the standard of a competent driver? How does public policy impact driver safety? What factor(s) should result in a �driving prescription�? What is the weighting of these factors? How is the decision individualized? Relevance? objectives?Relevance? objectives?

53. The �Perfect� Driver No physical limitations No medical or psychiatric co-morbidities No substance use Thoughtful Maintains the vehicle Obeys laws Knows limits

54. The �perfect� driving assessment by a physician Evidence-based �Rule driven� Sensitive, specific, practical and predictive In-office tools Knowledgeable professionals

55. Bogner HR, Straton JB. JABFP. Jan-Feb 2004. 17(1):38-43. Physician Factors Difficulty in detecting at-risk adults Liability concerns Unsure role in testing driving ability Concerns for patient defensiveness or anger towards the physician Current tests lack predictive ability

56. Patient Factors Reversible vs. irreversible conditions Recognition vs. non-recognition of problem Reliability of self-assessment Loss of independence Lack of alternatives Lack of information regarding options Social supports Self-regulation

57. �Family� Factors Nature of relationship Needs, health and driving skills Alternative transportation Coping skills Knowledge and attitudes Proximity Communication Agendas

58. Washington Post, December 5, 2004. The �Perfect� Car Swivel Head Lights Adaptive Cruise Control Tire Pressure Monitor Adaptive Steering and Traction Control Collapsible steering column Head and side airbags Rearview camera and backup assistance More to follow!

59. The �Perfect� System No left turns and perfect roads Large signs Planned communities Good public transportation Uniform laws across states Affordable driver rehabilitation

60. System Factors Event driven--not preventive To date, not viewed as a public and population health problem Current laws Political and public pressure and perceptions Enforcement Creating alternatives Designing and building safe roadways Cost

61. www.iihs.org/safety_facts/state_laws?older_drivers.htm Older Driver License Renewal Procedures No special provisions No mail-in renewals in some states Accelerated renewals Physician statement �Reaction tests� and vision screening Road and written testing

62. The �Gold Standard� Evaluation Tool: The Behind-the-Wheel Assessment Uniform across states Predictive of safe/unsafe driving Unbiased Realistic Fair Accessible Reproducible ? Chang need to add for �the behind�Assessment� ?? Chang need to add for �the behind�Assessment� ?

63. Where do we go from here? Planning for the FuturePlanning for the Future

65. Alternatives Restrictive licenses Drivers� refresher programs Public transportation Community Based Programs Shared ownership of vehicle and a designated driver Fee-based Volunteers Neighbor rides Pasadena, Ca and Howard County, Maryland

66. Advocate for Alternatives Responsible, evidence-based laws Research on the topic Safer vehicles for aging drivers Affordable, available public transportation Community planning, safe roadways Affordable, available rehabilitation User friendly public transportUser friendly public transport

67. Conclusions Driving fitness, NOT age Success = planning Biopsychosocial perspective Multidisciplinary approach Individualized assessment

68. The Army Way