Assessing and Counseling Older Assessing and Counseling Older DriversDrivers

Identifying and Assessing the Medically Impaired Driver

AMA House of DelegatesAMA 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.”

AMA Committee to Study Problems of AMA Committee to Study Problems of Motor Vehicle Accidents Motor Vehicle Accidents (1930’s-1950’s)(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%.

Report - 1963Report - 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.”

““Too Old” to drive?Too Old” to drive?

Numerical age is not the problemImpaired function is the limiting

factor

AMA report, 1963

Physician’s Guide to Assessing and Physician’s Guide to Assessing and Counseling Older DriversCounseling Older Drivers

Provides physicians with the tools necessary for assessing older patients for medical fitness to drive.

What functional abilities are What functional abilities are important to driving?important to driving?

Vision Cognition Motor function

Physician’s Plan for Older Driver SafetyPhysician’s Plan for Older Driver Safety

Screen to determine if patient is potentially at risk Assess driving related functional skills (ADReS) Treat underlying causes of functional decline Refer for further evaluation and/or adaptive training Counsel on safe driving behavior and alternative

options Follow-Up for signs of depression, isolation and

compliance

How can physicians screen patients How can physicians screen patients for medically impaired driving? for medically impaired driving?

Be alert to Red Flags:

Any medical condition, medication or symptom that can impair driving skills

Red FlagsRed Flags Acute events Patient’s or family member’s concern Medical history

– Chronic medical conditions– Unpredictable/Episodic events

Medications Review of systems

Prescription & OTC drugsPrescription & OTC drugs

alcoholantihistaminesantidepressantsbenzodiazepenesopiod analgesicsmuscle relaxantsantipsychotics

If Red Flags are presentIf 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

How can physicians assess for How can physicians assess for deficits in function?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

Assessment of Driving Related SkillsAssessment of Driving Related Skills

Motor Function Rapid pace walk

Manual test of motor strength

Manual test of range of motion

Vision Visual fields by confrontation testingSnellen E Chart

Cognition Trail-Making Test, Part BClock Drawing Test

Interpreting ADReS resultsInterpreting 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

Three courses of actionThree 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

Targeted clinical assessmentFunctional on-road assessmentPrescribing and training clients in the

use of adaptive equipmentCounseling and advising on driving

concerns and mobility alternatives

Certified Driver Rehabilitation Specialists have expertise in:

Physicians can help maximize older Physicians can help maximize older driver safetydriver safety

Continue medical treatment & preventive care

Counsel patients on health and drivingIdentify at-risk patients & help manage

deficitsDiscuss driving retirement Abide by state reporting laws

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

Legal protection for patient Legal protection for patient reportingreporting

Immunity- exempts physicians from liability for civil damages

Anonymity/Legal protection- protects physicians from civil actions for damages caused by reporting in good faith

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.

www.ama-assn.org/go/ olderdriverswww.ama-assn.org/go/ olderdrivers

American Medical Association

www.nhtsa.dot.govwww.nhtsa.dot.gov

National Highway Traffic Safety Administration