Driving and the Elderly

Dr. James L. Silvius BA (Oxon) MD FRCPC

Geriatric Medicine

October 15, 2002

Conflicts of Interest

• None

Objectives

• Understand changes related to aging that may impact on ability to drive

• Understand changes related to disease that may impact on ability to drive

• Understand societal implications of driving/not driving

Case 1

• H.N. - 74 y.o. male, presenting for assessment of ability to drive

• “Dementia”– slow short term memory loss– MMSE 25/30

• No driving problems, may get “lost” in unfamiliar places

Case 2

• E.B. - 74 y.o. male for drivers license renewal

• Good physical health, some “arthritis”

• Recent diarrhea

• Smoker, physical evidence for COPD

• Refused MMSE

Case 2 - continued

• Wife:– alcohol use history– spousal abuse– other changes

• decreased hygiene• financial management changes• inappropriate voiding• “living in the past”

Case 2 - continued

• Wife– driving problems:

• running stop signs• changing lanes inappropriately• recently refused to allow her in car

• She doesn’t drive

• “Please give him his license”

Statutes - Section 14(1)

• Motor Vehicle Administration Act– Any person who

• holds an operators license, and• is making application for an operator’s license

shall disclose forthwith to the Registrar any disease or disability which may be expected to interfere with the safe operation of a motor vehicle

Statutes - Section 14(2)

– A physician may, without acquiring any liability by doing so, report to the Registrar any medical information relative to the health of a person holding or applying for an operator’s license when the physician believes that the condition in relation to which the information is given may adversely affect that person’s operation of a motor vehicle.

Alberta Requirements

• Mandatory review, physical exam and structured report– 75th birthday– 80th birthday– q2years after age 80

Why is Driving an Issue?

• More older drivers

• Group over age 70 fastest segment– demographics– more women– driving longer into older age

Why is Driving an Issue?

Why is Driving an Issue?

• Older drivers:– drive less

• age 65, 11,000 km/yr.• age 80, 4,000 km/yr.

– shorter distances– lower speeds– less at night– avoid busy times on road

Why is Driving an Issue?

Why is Driving an Issue?

• Errors:– right of way– traffic sign violations

• MVA’s– more common at intersections– involve multiple vehicles

Why is Driving an Issue?

• More likely to have serious injury– <age 70, 10%– >age 80, 15%– longer recovery times, less complete

• More likely fatal– age <70, 1.2%– age >80, 4%

Age-Related Changes

• Psychomotor slowing

• Visual acuity changes

• Light perception changes

• Visual field changes

• Motor strength declines

Medical Conditions

• Multiple conditions, affect young and old

• Prevalence higher in elderly

• Determining Medical Fitness to Drive, 6th Ed., 2000 - CMA

Musculoskeletal System

• Osteoarthritis and Rheumatoid Arthritis– Joint movements/Pain

• C-spine• Hand function• Foot/leg function

Neurological System• TIA

– medical/neurological assessment– no functional loss– underlying cause treated

• CVA– 1 month preclusion, then as above

• For elderly, need physical, cognitive, functional assessment

Neurological System• Syncope

– as for any age– single episode, no recurrence, explained,

no preclusion– those with recurrent faints/unexplained

falls, driving precluded pending explanation

Neurological System• Seizures

– as for those of any age– single seizure, no diagnosis on

investigation, no recurrence, preclusion for 3 months

– diagnosis epilepsy, preclusion for 12 months seizure free

Neurological System• Parkinson’s Disease

– disease• mobility changes• cognitive changes

– treatment• dopamine agonists• (any agents?)• effects on sleep

Neurological System• Peripheral Neuropathy

– no preclusion

Sleep Disorders

• Obstructive sleep apnea– no preclusion if compliant with treatment

• Narcolepsy– as per younger drivers

• Medication Use– any medications affecting psychomotor

function

Metabolic Disorders• Diabetes

– NIDDM, no preclusion– IDDM, preclusion if severe hypoglycemic

episodes in 6 months

• Thyroid disease– hypothyroidism common, no preclusion

once treated– hyperthyroidism, no preclusion once treated

Cardiovascular Disease• Cardiac arrhythmia

– Atrial fib/flutter most common, no preclusion

– other arrhythmias, preclusion depends on type

– sinus node disease, no preclusion if no associated cerebral ischemia

– 1st degree block, RBBB, LAHB, LPHB no preclusion

– LBBB, bifascicular block, Mobitz 1 no preclusion if no assoc. cerebral ischemia

Cardiovascular Disease• Valvular heart disease

– aortic stenosis, no cerebral ischemia, functional class 1-2, no preclusion

– other valves, no cerebral ischemia, no preclusion

• CHF - no preclusion class 1,2

• Hypertension, no contraindications; complications may affect safe driving

Sensory Systems

• Vision– Cataracts, glaucoma, ARMD, corneal

disease common– standards relate only to visual acuity and

visual fields; above may impact these

• Hearing– no standards

Respiratory System

• COPD– no preclusion unless on oxygen, then road

test on oxygen required

Renal Disease

• No restrictions

Dementia

• Different perspectives:– Preclusion once diagnosis made– Preclusion based on disease stage

– Where is point reached where driving not appropriate?

Dementia

• Canadian Consensus Conference on Dementia– for affected individuals, consider risk

associated as disease progresses– driving difficulties may indicate other

cognitive or functional problems– affected individuals and their families should

plan at an early stage for eventual cessation

Dementia

• National Safety Code– dementia is progressive and irreversible

• memory• intellect• personality

– MMSE recommended, score <24 a preclusion pending further assessment

Societal Implications

• Physicians:– have obligation to assist older individuals

to maintain independence– recognize that loss of independence

associated with • decreased QOL• increased isolation• depression

Societal Implications

• Older drivers:– have obligation to be capable of safe

driving

• Assessment– structured history and physical when

questions arise– Cognitive assessment– Collateral history

Societal Implications

• Legal obligations– physicians may report– issues of confidentiality– protected disclosure

• public interest - MD as custodian of public trust• private interest of patient at risk

– forseeability

Assessment

• As noted for medical illness

• Cognitive loss assessment more limited– Issue of road tests– DriveAble

Conclusions

• Strategies for license removal– physical more acceptable– cognitive more difficult

• early preparation• letter to Driver Records

– pertinent information

• DriveAble or other structured assessment• notification of individual

Address for Reporting

Driver RecordsTraffic Safety BoardMain Floor, Twin Atria4999 - 98 AvenueEdmonton, AlbertaT6B 2X3

Phone 780-427-8230

Fax 780-422-6612

Case 1

• Assessment performed

• Stable cognition over 2 years, probable Minimal Cognitive Impairment

• Driver Records contacted

• License given, annual review requirement placed

• Wife as “co-pilot”

Case 2

• Reporting to Driver Records based on collateral and refusal of assessment

• Individual stopped alcohol intake, sought second assessment

• Second assessment declared him fit

• Complaint re: community MD and self to College, dismissed