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PHYSICIANS GUIDE TO

Assessing and Counseling

Older Drivers2nd edition


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The inormation in this guide is provided to assist physicians in evaluatingthe ability o their older patients to operate motor vehicles saely as part otheir everyday, personal activities. Evaluating the ability o patients to operatecommercial vehicles or to unction as proessional drivers involves morestringent criteria and is beyond the scope o this publication.

This guide is not intended as a standard o medical care, nor should it be usedas a substitute or physicians clinical judgement. Rather, this guide reects thescientifc literature and views o experts as o December 2009, and is provided

or inormational and educational purposes only. None o this guides materialsshould be construed as legal advice nor used to resolve legal problems. I legaladvice is required, physicians are urged to consult an attorney who is licensed topractice in their state.

Material rom this guide may be reproduced. However, the authors o thisguide strongly discourage changes to the content, as it has undergone rigorous,comprehensive review by medical specialists and other experts in the feld oolder driver saety.

The American Medical Association is accredited by the Accreditation Councilor Continuing Medical Education to provide continuing medical education(CME) or physicians.

The American Medical Association designates this educational activity or amaximum o 6.25AMA PRA Category 1 Credits. Physicians should only claimcredit commensurate with the extent o their participation in the activity.

Additional copies o the guide can be downloaded or ordered online at theAMAs Older Drivers Project Web site: www.ama-assn.org/go/olderdrivers.

For urther inormation about the guide,

please contact:

Joanne G. Schwartzberg, MD

Director, Aging and Community HealthAmerican Medical Association515 N. State StreetChicago, IL 60654

Physicians Guideto Assessing and

Counseling Older DriversAn AMA Continuing Education ProgramFirst Edition Original Release Date7/30/2003Second Edition2/3/2010Expiration Date2/3/2013

Accreditation StatementThe American Medical Association is accreditby the Accreditation Council or ContinuingMedical Education to provide continuing medieducation or physicians.

Designation StatementThe American Medical Association designatesthis educational activity or a maximum o 6.25

AMA PRA Category 1 CreditsTM. Physiciansshould only claim credit commensurate with thextent o their participation in the activity.

Disclosure StatementThe content o this activity does not relate toany product o a commercial interest as defnedby the ACCME; thereore, there are no relevanfnancial relationships to disclose.

Educational Activity Objectives Increase physician awareness of the safety ris

o older drivers as a public health issue

Identify patients who may be at risk for unsafdriving

Use various clinical screens to assess patientslevel o unction or driving ftness

Employ referral and treatment options forpatients who are no longer ft to drive

Practice counseling techniques for patients ware no longer ft to drive

Demonstrate familiarity with State reportinglaws and legal/ethical issues surroundingpatients who may not be sae on the road

Instructions or claimingAMA PRA

Category 1 CreditsTo acilitate the learning process, we encouragethe ollowing method or physician participatioRead the material in the Physicians Guide to

Assessing and Counseling Older Drivers, completethe CME Questionnaire & Evaluation, and themail both o them to the address provided. Toearn the maximum 6.25AMA PRA Category 1Credits , 70 percent is required to pass andreceive the credit.


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IV Acknowledgements

Acknowledgements

This Physicians Guide to Assessing andCounseling Older Drivers is the producto a cooperative agreement betweenthe American Medical Association andthe National Highway Trafc SaetyAdministration.

First edition: Primary Authors

Claire C. Wang, MDAmerican Medical Association

Catherine J. Kosinski, MSWAmerican Medical Association

Joanne G. Schwartzberg, MDAmerican Medical Association

Anne Shanklin, MA

American Medical Association

Second edition:

Principal Faculty Authors

Editor: David B. Carr, MDAssociate Proessor o Medicine andNeurology Washington University atSt. Louis Clinical Director

Planning Committee:David B. Carr, MD;

Associate Proessor o Medicine andNeurology Washington University atSt. Louis Clinical Director

Joanne G. Schwartzberg, MDDirector, Aging and Community Health,


Lela Manning, MPH, MBAProject Coordinator, American Medical

Association

Jessica Sempek, MS

Program Administrator, American MedicalAsscoiation

Citation

Carr DB; Schwartzberg JG; ManningL; Sempek J; Physicians Guide toAssessing and Counseling OlderDrivers, 2nd edition, Washington,D.C. NHTSA. 2010.

This guide benefted signifcantlyrom the expertise o the ollowingindividuals who served as reviewersin this project.

Second edition: Content Consultants

Lori C. Cohen

AARPSenior Project Manager, Driver Saety

Jami Croston, OTDWashington University at St. Louis

T. Bella Dinh-Zarr, PhD, MPHRoad Saety Director, FIA Foundation

North American Director, MAKEROADS SAFEThe Campaign or GlobalRoad Saety

John W. Eberhard, PhD

Consultant, Aging and SeniorTransportation Issues

Camille Fitzpatrick, MSN, NPUniversity o Caliornia IrvineClinical Proessor Family Medicine

Mitchell A. Garber, MD,MPH, MSME

National Transportation Saety BoardMedical Ocer

Anne Hegberg, MS, OTR/LMarionjoy Rehabilitation HospitalCertied Driver Rehabilitation Specialist

Patti Y. Horsley, MPHCenter or Injury PreventionPolicy and PracticeSDSU EPIC BranchCaliornia Department o Public Health

Linda Hunt, OTR/L, PhDPacic UniversitySchool o Occupational Therapy

Associate Proessor

Jack JoyceMaryland Motor Vehicle AdministrationDriver Saety Research OceSenior Research Associate

Karin Kleinhans OTR/LSierra Nevada Memorial HospitalCenter or Injury Prevention Policy &

PracticeOccupational Therapy Association oCaliornia

Kathryn MacLean, MSWSt. Louis University

Mangadhara R. Madineedi, MD, MSA

Harvard Medical SchoolInstructor in MedicineVA Boston Healthcare SystemDirector, Geriatrics & Extended CareService Line

Richard Marottoli, MD, MPHAmerican Geriatrics Society

John C. MorrisProessor o NeurologyWashington University School o Medicine

Germaine L. Odenheimer, MDVAMCDonald W. Reynolds Department oGeriatric Medicine

Associate Proessor

Alice Pomidor, MD, MPHFlorida State University College oMedicine

Associate Proessor, Department oGeriatrics

Kanika Mehta RankinLoyola University Chicago School o Law(2nd year) Juris Doctorate Candidate,2011

Yael Raz, MDAmerican Academy o Otolaryngology

William H. Roccaorte, MDAmerican Association or GeriatricPsychiatry

Nebraska Medical CenterDepartment o Psychiatry

Gayle San Marco, OTR/L, CDRSNorthridge Hospital Medical CenterProject Consultation, Center or InjuryPrevention Policy & Practice

Freddie Segal-Gidan, PA-C, PhDAmerican Geriatrics Society

William Shea, OTR/LFairlawn Rehabilitation Hospital

2010 American Medical Association. All rights reserved.


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Acknowledgements

Patricia E. Sokol, RN, JDSenior Poilcy Analyst, Patient Saety


Esther Wagner, MANational Highway Trac SaetyAdministration

First edition: Advisory Panel

Sharon Allison-Ottey, MDNational Medical Association

Joseph D. Bloom, MDAmerican Psychiatric Association

Audrey Rhodes Boyd, MDAmerican Academy o Family Physicians

David B. Carr, MDWashington University School o Medicine

Bonnie M. Dobbs, PhDUniversity o Alberta

Association or the Advancement oAutomotive Medicine

John Eberhard, PhDNational Highway Trac SaetyAdministration

Laurie Flaherty, RN, MSNational Highway Trac SaetyAdministration

Arthur M. Gershkoff, MDAmerican Academy o PhysicalMedicine and Rehabilitation

Brian Greenberg, MEdAmerican Association o Retired Persons

Lynne M. Kirk, MD, FACPAmerican College o Physicians American Society o Internal Medicine

Marian C. Limacher, MD, FACC,FSGCAmerican College o CardiologySociety o Geriatric Cardiology

Richard Marottoli, MD, MPHAmerican Geriatrics Society

Lylas G. Mogk, MDAmerican Academy o Ophthalmology

John C. Morris, MDAmerican Academy o NeurologyAlzheimers Association

James OHanlon, PhDTri-Counties Regional Center

Cynthia Owsley, PhD, MSPH

University o Alabama at Birmingham

Robert Raleigh, MDMaryland Department o Transportation

William Roccaorte, MDAmerican Association or GeriatricPsychiatry

Jose R. Santana Jr., MD, MPHNational Hispanic Medical Association

Melvyn L. Sterling, MD, FACP

Council on Scientic AairsAmerican Medical Association

Jane Stutts, PhDUniversity o North Carolina HighwaySaety Research Center

First edition: Review Committee

Geri Adler, MSW, PhDMinneapolis Geriatric Research EducationClinical Center

Reva Adler, MDAmerican Geriatrics Society

Elizabeth AlicandriFederal Highway Administration

Paul J. Andreason, MDFood and Drug Administration

Mike BaileyOklahoma Department o Public Saety

Robin Barr, PhDNational Institute on Aging

Arlene Bierman, MD, MSAgency or Healthcare Researchand Quality

Carol Bodenheimer, MDAmerican Academy o Physical Medicineand Rehabilitation

Jennier Bottomley, PhD, MS, PTAmerican Physical Therapy Association

Thomas A. Cavalieri, DOAmerican Osteopathic Association

Lori CohenAmerican Association o Motor Vehicle

Administrators

Joseph Coughlin, PhDGerontological Society o America

T. Bella Dinh-Zarr, PhD, MPHAAA

Barbara Du Bois, PhDNational Resources Center on Agingand Injury

Leonard Evans, PhD

Science Serving Society

Connie Evaschwick, ScD., FACHEAmerican Public Health Association

Je Finn, MAAmerican Occupational TherapyAssociation

Jaime Fitten, MDUCLA School o Medicine

Marshall Flax, MAAssociation or the Education andRehabilitation o the Blind andVisually Impaired

Linda Ford, MDNebraska Medical Association

Barbara Freund, PhDEastern Virginia Medical School

Mitchell Garber, MD, MPH, MSMENational Transportation Saety Board

Andrea Gilbert, COTA/LRehabilitation Institute o Chicago

Claudia Grimm, MSWOregon Department o Transportation

Kent Higgins, PhDLighthouse International


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VI Acknowledgements

Linda Hunt, PhD, OTR/LMaryville University

Mary Janke, PhDCaliornia Department o Motor Vehicles

Gary Kay, PhDWashington Neuropsychological Institute

Shara Lynn KelseyResearch and DevelopmentCaliornia Department o Motor Vehicles

Susan KirinichNational Highway Trac SaetyAdministration

Donald Kline, PhDUniversity o Calgary

Philip LePore, MS

New York State Oce or the Aging

Sandra Lesikar, PhDUS Army Center or Health Promotionand Preventive Medicine

William Mann, OTR, PhDUniversity o Florida

Dennis McCarthy, MEd, OTR/LUniversity o Florida

Gerald McGwin, PhDUniversity o Alabama

Michael Mello, MD, FACEPAmerican College o Emergency Physicians

Barbara Messinger-Rapport, MD, PhDCleveland Clinic Foundation

Alison Moore, MD, MPHAmerican Public Health Association

David Geen School o Medicine,University o Caliornia

Anne Long Morris, EdD, OTR/LAmerican Society on Aging

Germaine Odenheimer, MDCenter or Assessment and Rehabilitationo Elderly Drivers

Eli Peli, M.Sc., ODSchepens Eye Research Institute

Alice Pomidor, MD, MPHSociety o Teachers o Family Medicine

George Rebok, MA, PhDJohns Hopkins School o Hygiene and

Public Health

Selma SaulsFlorida Department o Highway Saety andMotor Vehicles

Susan SamsonPinellas/Pasco Area Agency on Aging

Steven Schachter, MDEpilepsy Foundation

Frank Schieber, PhDUniversity o South Dakota

Freddi Segal-Gidan, PA, PhDAmerican Geriatrics Society

Melvin Shipp, OD, MPH, DrPhUniversity o Alabama at Birmingham

Richard Sims, MDAmerican Geriatrics Society

Kristen Snyder, MDOregon Health & Science UniversitySchool o Medicine

Susan Standast, MD, MPH

American College o Preventative Medicine

Holly Stanley, MDAmerican Geriatrics Society

Loren Staplin, PhDTransanalytics and Texas TransportationInstitute

Wendy Stav, PhD, OTR, CDRSAmerican Occupational TherapyAssociationCleveland State University

Donna Stressel, OTR, CDRSAssociation o Driver RehabilitationSpecialists

Cathi A. Thomas, RN, MSBoston University Medical Center

American Parkinson Disease Association

John Tongue, MDAmerican Academy o Orthopedic Surgery

Patricia Waller, PhDUniversity o Michigan

Lisa Yagoda, MSW, ACSWNational Association o Social Workers

Patti Yanochko, MPHSan Diego State University

Richard Zorowitz, MDNational Stroke Association


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Table o Contents

Table of ContentsPreface .................................................................................................................................. IX

Chapter 1 .................................................................................................................................1Saety and the Older Driver With Functional or Medical Impairments: An Overview

Chapter 2 ...............................................................................................................................11Is the Patient at Increased Risk or Unsae Driving?

Red Flags or Further Assessment

Chapter 3 ...............................................................................................................................19Assessing Functional Ability

Chapter 4 ...............................................................................................................................33Physician Interventions

Chapter 5 ...............................................................................................................................41The Driver Rehabilitation Specialist

Chapter 6 ...............................................................................................................................49Counseling the Patient Who is no Longer Sae to Drive

Chapter 7 ...............................................................................................................................59Ethical and Legal Responsibilities o the Physician

Chapter 8 ...............................................................................................................................69State Licensing and Reporting Laws

Chapter 9 .............................................................................................................................145Medical Conditions and Medications That May Aect Driving

Chapter 10 ...........................................................................................................................187Moving Beyond This Guide: Future Plans to Meet the Transportation Needs o Older Adults

Appendix A ..........................................................................................................................197

CPT

Codes


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VIII Table o Contents

Table of Contents (continued)

Appendix B ..........................................................................................................................201

Patient and Caregiver Educational MaterialsAm I a Sae Driver? ....................................................................................................................... 203

Successul Aging Tips .................................................................................................................. 205

Tips or Sae Driving ...................................................................................................................... 207

How to Assist the Older Driver ...................................................................................................... 209

Getting By Without Driving ............................................................................................................ 213

Where Can I Find More Inormation? ............................................................................................. 215

Appendix C ..........................................................................................................................221

Continuing Medical Education Questionnaire and Evaluation

Physicians Guide to Assessing and Counseling Older Drivers ....................................................... 221

Continuing Medical Education Evaluation Form ............................................................................. 224

Index ....................................................................................................................................229


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Preace

PrefaceThe science o public health and the practice o medicine are oten deemed twoseparate entities. Ater all, the practice o medicine centers on the treatment odisease in the individual, while the science o public health is devoted to preven-

tion o disease in the population. However, physicians can actualize public healthpriorities through the delivery o medical care to their individual patients.

One o these priorities is the prevention o injury. More than 400 Americansdie each day as a result o injuries sustained rom motor vehicle crashes, frearms,poisonings, suffocation, falls, res, and drowning. The risk of injury is so greatthat most people sustain a signifcant injury at some time during their lives.

The Physicians Guide to Assessing and Counseling Older Drivers was created bythe American Medical Association (AMA), with support rom the NationalHighway Trafc and Saety Administration (NHTSA), to help physiciansaddress preventable injuriesin particular, those incurred in motor vehiclecrashes. Currently, motor vehicle injuries are the leading cause o injury-related

deaths among 65- to 74-year-olds and are the second leading cause (ater alls)among 75- to 84-year-olds. While trafc saety programs have reduced the atal-ity rate or drivers under age 65, the atality rate or older drivers has consistentlyremained high. Clearly, additional eorts are needed.

Physicians are in a leading position to address and correct this health disparity.By providing eective health care, physicians can help their patients maintaina high level of tness, enabling them to preserve safe driving skills later in lifeand protecting them against serious injuries in the event o a crash. By adoptingpreventive practicesincluding the assessment and counseling strategies outlinedin this guidephysicians can better identify drivers at risk for crashes, helpenhance their driving saety, and ease the transition to driving retirement iand when it becomes necessary.

Through the practice o medicine, physicians have the opportunity to promotethe saety o their patients and o the public. The AMA and NHTSA urge youto use the tools in this Physicians Guide to Assessing and Counseling Older Driversto forge a link between public health and medicine.

The project was supported by cooperative agreement number DTNH22-08-H-00185rom the National Highway Trac Saety Administration (NHTSA) o the Departmento Transportation. While this guide was reviewed by NHTSA, the contents o this guideare those o the authors and do not represent the opinions, policies or ocial positionso NHTSA.



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CHAPTER 1

Safety and the Older Driver

With Functional or Medical

Impairments: An Overview



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Chapter 1Saety and the Older Driver With Functional or Medical Impairments: An Overview

Patients like Mrs. Simon and Mr. Evansare becoming more common in physi-cians practices. Buoyed by the largeranks of baby boomers and increased

life expectancy, the U.S. older adultpopulation is growing nearly twice asast as the total population.1,2 Withinthis cohort o older adults, an increasingproportion will be licensed to drive, andit is expected that these license-holderswill drive more miles than older driversdo today.3

As the number o older drivers withmedical conditions expands, patientsand their amilies will increasinglyturn to physicians or guidance on saedriving. Physicians will have the chal-lenge o balancing their patients saetyagainst their transportation needs andthe saety o society.

This guide is intended to help youanswer the questions, At what level ofseverity do medical conditions impairsafe driving? What can I do to helpmy patient drive more safely?*, and inecessary to help you counsel patients

1. National Center or Statistics & Analysis.Trafc Saety Facts 2000: Older Population.DOT HS 809 328. Washington, DC: NationalHighway Trafc Saety Administration.

2. Population Projections of the United States byAge, Sex, Race, Hispanic, Origin, and Nativity:1999 to 2100. Population Projections Program,Population Division, Census Bureau Internetrelease date: January 13, 2000. Revised date:February 14, 2000. Suitland, MD: U.S.Census Bureau.

3. Eberhard, J. Sae Mobility or Senior Citizens.International Association or Trafc and SaetyServices Research. 20(1):2937.

Mrs. Simon, a 67-year-old woman

with type 2 diabetes mellitus and

hypertension, mentions during a

routine check-up that she almost

hit a car while making a let-hand

turn when driving two weeks ago.

Although she was uninjured, she

has been anxious about driving since

that episode. Her daughter has

called your oce expressing concern

about her mothers driving abilities.

Mrs. Simons admits to eeling less

condent when driving and wants

to know i you think she should stop

driving. What is your opinion?

Mr. Evans, a 72-year-old man

with coronary artery disease and

congestive heart ailure, arrives or

an oce visit ater ainting yesterday

and reports complaints o light-

headedness or the past two weeks.

When eeling his pulse, you notice

that his heartbeat is irregular. You

perorm a careul history and physi-

cal examination, and order some

laboratory tests to help determine the

cause o his atrial brillation. When

you ask Mr. Evans to schedule a

ollow-up appointment or the next

week, he tells you he cannot come

at that time because he is about to

embark on a two-day road trip to

visit his daughter and newborn

grandson. Would you address the

driving issue and i so, how?

What would you communicate to

the patient?

CHAPTER 1

Safety and the OlderDriver With Functional

or Medical ImpairmentsAn Overview

about driving cessation and alternatemeans o transportation. Mobilitycounseling and discussing alternativemodes of transportation need to take

more prominent role in the physicianofce. To these ends, we have reviewethe scientifc literature and collaboratewith clinicians and experts in this feldto produce the ollowing physician too

An ofce-based assessment omedical ftness to drive. Thisassessment is outlined in thealgorithm, Physicians Plan orOlder Drivers Saety (PPODS),presented later in this chapter.

A unctional assessment battery,the Assessment o Driving RelatedSkills (ADReS). This can be foundin Chapter 3.

A reerence table o medicalconditions and medications thatmay aect driving, with specifcrecommendations or each, canbe ound in Chapter 9.

In addition to these tools, we alsopresent the ollowing resources:

Inormation to help you navigate

the legal and ethical issues regardinpatient driving saety. Inormation

* Please be aware that the inormation in thisguide is provided to assist physicians in evaluing the ability o their older patients to operamotor vehicles saely as part o their everydaypersonal activities. Evaluating the ability opatients to operate commercial vehicles or tounction as proessional drivers involves morestringent criteria and is beyond the scope o tguide.


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2 Chapter 1Saety and the Older Driver With Functional or Medical Impairments: An Overview

on patient reporting, with a state-by-state list o licensing criteria, licenserenewal criteria, reporting laws,and Department o Motor Vehicles(DMV) contact inormation, can beound in Chapters 7 and 8.

Recommended Current ProceduralTerminology (CPT) codes or

assessment and counseling procedures.These can be ound in Appendix A.

Handouts or your patients and theiramily members. These handouts,located in Appendix B, include a sel-screening tool or driving saety, saedriving tips, driving alternatives, anda resource sheet or concerned amilymembers. These handouts can beremoved rom the guide and photo-copied or distribution to patientsand their amily members.

We understand that physicians maylack expertise in communicating withpatients about driving, discussing theneed or driving cessation (deliveringbad news), and being aware o viablealternative transportation options tooer. Physicians also may be concernedabout dealing with the patients anger,or even losing contact with the patient.Driving is a sensitive subject, and theloss o driving privileges can be stressul.While these are reasonable concerns,there are ways to minimize the impacton the doctor-patient relationship whendiscussing driving. We provide sampleapproaches in subsequent chapters inthe areas o driving assessment, rehabili-tation, restriction, and cessation.

We want this inormation to bereadily accessible to you and yourofce sta. You can locate this guideon the Internet at the AMA Web site(www.ama-assn.org/go/olderdrivers).

Additional printed copies may alsobe ordered through the Web site.

Beore you read the rest o the guide,you may wish to amiliarize yourselwith key facts about older drivers.

Older drivers: Key acts

Fact #1: The number o older adult

drivers is growing rapidly and they

are driving longer distances.

Lie expectancy is at an all-time high4and the older population is rap-

idly increasing. By the year 2030, thepopulation o adults older than 65 willmore than double to approximately 70million, making up 20 percent of thetotal U.S. population.5 In many States,including Florida and Caliornia, thepopulation o those over age 65 mayreach 20 percent in this decade Theastest growing segment o the popula-tion is the 80-and-older group, whichis anticipated to increase rom about 3million this year to 8 to 10 million overthe next 30 years. We can anticipate

many older drivers on the roadwaysover the next ew decades, and yourpatients will likely be among them.

Census projections estimate that bythe year 2020 there will be 53 millionpersons over age 65 and approximately40 million (75%) o those will belicensed drivers.6 The increase in thenumber o older drivers is due to manyactors. In addition to the general agingo the population that is occurring inall developed countries, many moreemale drivers are driving into advancedage. This will likely increase with agingcohorts such as the baby boomers.

In addition, the United States hasbecome a highly mobile society, andolder adults are using automobiles orvolunteer activities and gainul employ-ment, social and recreational needs,and cross country travel. Recent studiessuggest that older adults are driving

4. Centers or Disease Control and Prevention.2008. National Center or Health Statistics.Accessed on December 14, 2008 at;www.cdc.gov/nchs/PRESSROOM/07newsreleases/lieexpectancy.htm

5. U.S. Census Bureau, Healthy Aging, 2008.Accessed on December 14, 2008 at; www.cdc.gov/NCCdphp/publications/aag/aging.htm

6. U.S. Census Bureau. Projection of total residentpopulation by 5-year age groups and sex withspecial age categories; middle series, 20162020.Washington, DC: Population ProjectionsProgram, Population Division, U.S. CensusBureau; 2000.

more requently, while transportationsurveys reveal an increasing number omiles driven per year or each successiveaging cohort.

Fact #2: Driving cessation is inevi-

table or many and can be associated

with negative outcomes.

Driving can be crucial or perormingnecessary chores and maintaining socialconnectedness, with the latter havingstrong correlates with mental and physi-cal health.7 Many older adults continueto work past retirement age or engage involunteer work or other organized ac-tivities. In most cases, driving is the pre-erred means o transportation. In somerural or suburban areas, driving may bethe sole means o transportation. Just asthe drivers license is a symbol o inde-

pendence or adolescents, the ability tocontinue driving may mean continuedmobility and independence or olderdrivers, with great eects on their qual-ity o lie and sel-esteem.8

In a survey o 2,422 adults 50 and older,86 percent o survey participants report-ed that driving was their usual mode otransportation. Within this group, driv-ing was the usual method o transporta-tion or 85 percent o participants 75 to79, 78 percent o participants 80 to 84,and 60 percent o participants 85 andolder.9 This data also indicates that theprobability o losing the ability to driveincreases with advanced age. It is esti-mated that the average male will have6 years without the unctional ability todrive a car and the average emale willhave 10 years.10 However, our societyhas not prepared the public or driving

7. Berkman, L. F., Glass, T., Brissette, I., & See-man, T. E. From social integration to health:Durkheim in the new millennium. Soc Sci Med.51:843857.

8. Stutts, J. C. Do older drivers with visual andcognitive impairments drive less?J Am GeriatrSoc. 46(7):854861.

9. Ritter, A. S., Straight, A., & Evans, E.Understanding Senior Transportation: Reportand Analysis o a Survey o Consumers Age50+. American Association or Retired Persons,Policy and Strategy Group, Public PolicyInstitute, p. 1011.

10. Foley, D. J., Heimovitz, H. K., Guralnik, J., &Brock, D. B. Driving life expectancy of personsaged 70 years and older in the United States.Am J Public Health. 92:12841289


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cessation, and patients and physiciansare oten ill-prepared when that timecomes.

Studies o driving cessation have notedincreased social isolation, decreasedout-o-home activities,11 and an in-crease in depressive symptoms.12 These

outcomes have been well documentedand represent some o the negative con-sequences o driving cessation. It is im-portant or health care providers to usethe available resources and proessionalswho can assist with transportation toallow their patients to maintain inde-pendence. These issues will be discussedurther in subsequent chapters.

Fact #3: Many older drivers

successully sel-regulate their

driving behavior.

As drivers age, they may begin toeel limited by slower reaction times,chronic health problems, and eectsrom medications. Although transporta-tion surveys over the years documentthat the current cohort o older driv-ers is driving arther, in later lie manyreduce their mileage or stop drivingaltogether because they eel unsae orlose confdence. In 1990, males over 70drove on average 8,298 miles, comparedwith 16,784 miles or men 20 to 24; orwomen, the fgures were 3,976 milesand 11,807 miles, respectively.13 Olderdrivers are more likely to wear seat beltsand are less likely to drive at night,speed, tailgate, consume alcohol priorto driving, and engage in other riskybehaviors. 14

Older drivers not only drive substan-tially less, but also tend to modiy

11. Marottoli, R. A., de Leon, C. F. M., & Glass,T. A., et al. Consequences o driving cessation:decreased out-o-home activity levels.J GerontolSeries B Psychol Sci Soc Sci. 55:S334340.

12. Ragland, D. R., Satariano, W. A,. & MacLeod,K. E. Driving cessation and increased depressivesymptoms J Gerontol Series A Bio Sci Med Sci.60:399403.

13. Evans, L. How sae were todays older driverswhen they were younger?Am J Epidemiol.1993;137(7);769775.

14. Lyman, J. M., McGwin, G., &Sims, R.V. Factorsrelated to driving difculty and habits in olderdrivers.Accid Anal Prev. 33:413421.

when and how they drive. When theyrecognize loss o ability to see well aterdark, many stop driving at night. Thereare data that suggest older women aremore likely to self-regulate than men.15Others who understand the complexdemands o let turns at uncontrolledintersections and their own diminished

capacity orgo let-hand turns, andmake a series of right turns instead. Self-regulating in response to impairmentsis simply a continuation o the strategywe all employ daily in navigating thisdangerous environmentdriving. Eacho us, throughout lie, is expected touse our best judgment and not operatea car when we are impaired, whetherby atigue, emotional distress, physicalillness, or alcohol. Thus, sel-awareness,knowledge of useful strategies, andencouragement to use them may be

sufcient among cognitively intactolder adults; however, this remains animportant area or urther study.

Older drivers may reduce their mile-age by eliminating long highway trips.However, local roads oten have morehazards in the orm o signs, signals,trafc congestion, and conusing inter-sections. Decreasing mileage, then, maynot always proportionately decreasesafety risks.16 In fact, the low mileagedrivers (e.g., less than 3,000 miles peryear) may actually be the group that ismost at-risk.17

Despite all these sel-regulating mea-sures, motor vehicle crash rates per miledriven begin to increase at age 65.18 Ona case-by-case level, the risk of a crashdepends on whether each individualdrivers decreased mileage and behavior

15. Kostyniuk, L. P., & Molnar, L. J. Self-regulatorydriving practices among older adults: health, ageand sex eects.Accid Anal Prev. 40: 15761580.

16. Janke, M. K. Accidents, mileage, and the exag-geration of risk.Accid Anal Prev. 1991;23:183188.

17. Langford, J., Methorst, R., & Hakamies-Blomqvist, L. Older drivers do not have a highcrash riska replication of low mileage bias.Accid Anal Prev. 38(3):574578.

18. Li, G., Braver, E. R., & Chen, L. H. Exploringthe High Driver Death Rates per Vehicle-Mileo Travel in Older Drivers: Fragility versusExcessive Crash Involvement. Presented at theInsurance Institute or Highway Saety; August2001.

modifcations are sufcient to counterbalance any decline in driving ability.In some cases, declinein the orm operipheral vision loss, or examplemay occur so insidiously that the drivis not aware o it until he/she experi-ences a crash. In act, a recent studyindicated that some older adults do no

restrict their driving despite havingsignifcant visual defcits.19 Reliance odriving as the sole available means otransportation can result in an unortunate choice between poor options. Inthe case of dementia, drivers may lackthe insight to realize they are unsaeto drive.

In a series o ocus groups conductedwith older adults who had stoppeddriving within the past fve years, abo40 percent of the participants knew

someone over age 65 who had problemwith his/her driving but was still behinthe wheel.20 Clearly, some older driverequire outside assessment and intervetions when it comes to driving saety.

Fact #4: The crash rate or older

drivers is in part related to physica

and/or mental changes associated

with aging and/or disease.21

Compared with younger drivers whoscar crashes are oten due to inexperi-ence or risky behaviors,22 older drivercrashes tend to be related to inattentioor slowed speed o visual processing.23Older driver crashes are oten multiplevehicle events that occur at intersectioand involve let-hand turns. The crashusually caused by the older drivers ailto heed signs and grant the right-o-waAt intersections with trafc signals, le

19. Okonkwo, O. C., Crowe, M., Wadley, V. G.,& Ball, K. Visual attention and sel-regulatioo driving among older adults. Int Psychogeria

20:162173.20. Persson, D. The elderly driver: deciding when

stop. Gerontologist. 1993;33(1):8891.

21. Preusser, D. F., Williams, A. F., Ferguson, S. AUllmer R. G., & Weinstein, H.B. Fatal crashrisk for older drivers at intersections.Accid APrev. 30(2):151159.

22. Williams, A. F., & Ferguson, S. A. Rationalefor graduated licensing and the risks it shouldaddress. Inj Prev. 8:ii9ii16.

23. Eberhard, J. W. Sae Mobility or SeniorCitizens. International Association or Trafand Saety Sciences Research. 20(1):2937.


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To achieve these ends, primary carephysicians can ollow the algorithm,Physicians Plan or Older Drivers Saety(PPODS) (see Figure 1.1), whichrecommends that physicians:

Screen or red fags such as medicalillnesses and medications that mayimpair driving saety;

Ask about new-onset impaireddriving behaviors (see Am I a SaeDriver and How to Help the OlderDriver in the appendices);

Assess driving-related unctionalskills in those patients who are atincreased risk for unsafe driving; forthe unctional assessment battery,Assessment of Driver Related Skills(ADReS), see Chapter 3;

Treat any underlying causes o

unctional decline;Reer patients who require a driving

evaluation and/or adaptive training toa driver rehabilitation specialist;

Counsel patients on sae drivingbehavior, driving restrictions, drivingcessation, and/or alternate transporta-tion options as needed; and

Follow-up with patients who shouldadjust their driving to determine ithey have made changes, and evalu-ate those who stop driving or signs o

depression and social isolation.

While primary care physicians maybe in the best position to perorm thePPODS, other clinicians have a re-sponsibility to discuss driving with theirpatients as well. Ophthalmologists,neurologists, psychiatrists, physiatrists,orthopedic surgeons, emergency depart-ment and trauma center physicians,and other specialists all treat condi-tions, prescribe medications, or perorm

procedures that may have an impact ondriving skills. When counseling theirpatients, physicians may wish toconsult the reerence list o medicalconditions in Chapter 9.

In the ollowing chapters, we will guideyou through the PPODS and providethe tools you need to perorm it. Beorewe begin, you may wish to review theAMAs policy on impaired drivers (see

Figure 1.2).This policy can be appliedto older drivers with medical conditionsthat impair their driving skills andthreaten their personal driving saety.

Fact #6: Trac saety or older

drivers is a growing public

health issue.

Older drivers are the saest drivers asan age group when using the absolutenumber o crashes per 100 licenseddrivers per year.30 However, the crashrate per miles driven reveals an increaseat about age 65 to 70 in comparison tomiddle-aged drivers.31 In 2000, 37,409Americans died in motor vehiclecrashes.32 O this number, 6,643 were 65and older.33 Accidental injuries are theseventh leading cause o death amongolder people and motor vehicle crashes

are not an uncommon cause.34 As thenumber o older drivers continues togrow, drivers 65 and older are expectedto account or 16 percent o all crashesand 25 percent o all atal crashes.35

Motor vehicle injuries are the leadingcause o injury-related deaths among65- to 74-year-olds and are the secondleading cause (ater alls) among 75- to84-year-olds.36 Compared to other driv-

30. CDC. (1997). Behavioral Risk Factor Surveil-lance System Survey Data. Atlanta: Centers orDisease Control and Prevention

31. Ball, K., Owsley, C., Stalvey, B., Roenker, D.L., & Sloane, M. E. Driving avoidance andunctional impairment in older drivers.AccidAnal Prev. 30:313322.

32. NHTSA. FARS. Web-Based Encyclopedia.www-ars.nhtsa.dot.gov.

33. Insurance Institute or Highway Saety. (2001).Fatality Facts: Elderly (as o October 2001).(Fatality Facts contains an analysis o data romU.S. Department of Transportation FatalityAnalysis Reporting System.) Arlington, VA:Insurance Institute or Highway Saety.

34. Staats, D. O. Preventing injury in older adults.Geriatrics. 63:1217.

35. Eberhard, J. Older drivers up close: they arentdangerous. Insurance Institute or Highway SaetyStatus Report (Special Issue: Older Drivers).36(8):12.

36. CDC. (1999). 10 Leading Causes o InjuryDeaths, United States, 1999, All Races, BothSexes. Ofce o Statistics and Programming,National Center or Injury Prevention and Con-trol, Centers or Disease Control and Preven-tion. Data source: National Center or HealthStatistics Vital Statistics System. Atlanta:Centers or Disease Control and Prevention.

ers, older drivers have a higher atalityrate per mile driven than any other aggroup except drivers under 25.37 On thbasis o estimated annual travel, theatality rate or drivers 85 and older is9 times higher than the rate or driver25 to 69.38 By age 80, male and emaledrivers are 4 and 3.1 times more likely

respectively, than 20-year-olds to dieas a result o a motor vehicle crash.39There is a disproportionately higher ro poor outcomes in older drivers, duein part to chest and head injuries.40 Oer adult pedestrians are also more liketo be fatally injured at crosswalks.41

There may be several reasons or thisexcess in atalities. First, some olderdrivers are considerably more ragile.For example, the increased incidenceo osteoporosis, which can lead to

ractures, and/or atherosclerosis o theaorta which can predispose individualto rupture with chest trauma rom anairbag or steering wheel. Fragility begto increase at age 60 to 64 andincreases steadily with advancing age.A recent study noted that chronicconditions are determinants o mortaliand even minor injury.43 As noted abovolder drivers are also overrepresented i

37. NHTSA. Driver atality rates, 1975-1999.Washington, DC: National Highway TrafcSaety Administration.

38. NHTSA. National Center or Statistics &Analysis. Trafc Saety Facts 2000: OlderPopulation. DOT HS 809 328. Washington,DC: National Highway Trafc SaetyAdministration.

39. Evans, L. Risks older drivers face themselvesand threats they pose to other road users.Int J Epidemiol. 29:315322.

40. Bauza, G., Lamorte, W. W., Burke, P., &Hirsch, E. F. High mortality in elderly driversassociated with distinct injury patterns: analyo 187,869 drivers.J Trauma Inj Inect Crit Ca64:304310.

41. FHWA. (2007). Pedestrian Saety Guide andCountermeasres. PEDSAFE. 2007. WashingtDC: Federal Highway Administration. www.walkingino.org/pedsae/crashstats.cm. AccesseNovember 21, 2007.

42. Li, G., Braver, E., & Chen, L-H. Fragility verexcessive crash involvement as determinantshigh death rates per vehicle mile o travel orolder drivers.Accid Anal Prev. 35, 227235.

43. Camiloni, L., Farchi, S., Giorgi Rossi, P., ChiF., et al. Mortality in elderly injured patients:the role o comorbidities. Int J Inj Control SaProm. 15:2531.

(Continues on page 7)


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6 Chapter 1Saety and the Older Driver With Functional or Medical Impairments: An Overview

Figure 1.1 Physicians Plan or Older Drivers Saety (PPODS)

Is the patient at increased risk or unsae driving?

Perorm initial screen

Observe the patient

Be alert to red ags

Medical conditions

Medications and polypharmacy

Review o systems

Patients or amily members concern/impaired driving behaviors

At risk

Formally assess unction

Assess Driving Related Skills (ADReS)

Vision

Cognition

Motor and somatosensory skills

Medical interventions

For diagnosis andtreatment

Counsel and ollow up

Explore alternatives to driving

Monitor or depression and social isolation Adhere to state reporting regulations

Defcit not resolved

Reer to Driver Rehabilitation Specialist:Is the patient sae to drive?

No Yes

Defcit resolved

Not at risk

Health maintenance

Successul Aging Tips

Tips or Sae Driving

Mature Driving classes

Periodic ollow-up

I screen is positive

Ask health risk assessment/social history questions

Discuss alternatives to driving early in the process

Gather additional inormation


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let-hand-turn collisions, which causemore injury than more injury thanrear-end collisions.44 Finally, preliminarydata rom a Missouri study o medicallyimpaired drivers who were in crashesindicate that the average age o thevehicle was more than 10 years and thecars oten did not have air bags (personal

communication, Tom Meuser, Universityo St. Louis-Missouri). I this latter obser-vation is a contributing actor, improve-ment should occur as uture cohorts oaging drivers purchase newer vehicleswith improved crashworthiness.

44. IIHS. (2003). Fatality Facts: Older People aso November 2002. Arlington, Va: InsuranceInstitute or Highway Saety.


Figure 1.2

AMA ethical opinion

E-2.24 Impaired drivers and their physicians

The purpose o this policy is to articulate physicians responsibility to recognize

impairments in patients driving ability that pose a strong threat to public saety a

which ultimately may need to be reported to the Department o Motor Vehicles. I

does not address the reporting o medical inormation or the purpose o punish-

ment or criminal prosecution.

1. Physicians should assess patients physical or mental impairments that migh

adversely aect driving abilities. Each case must be evaluated individually sin

not all impairments may give rise to an obligation on the part o the physician

Nor may all physicians be in a position to evaluate the extent or the eect o a

impairment (e.g., physicians who treat patients on a short-term basis). In mak

ing evaluations, physicians should consider the ollowing actors: (a) the phys

cian must be able to identiy and document physical or mental impairments

that clearly relate to the ability to drive; and (b) the driver must pose a clear ris

to public saety.

2. Beore reporting, there are a number o initial steps physicians should take.

A tactul but candid discussion with the patient and amily about the risks o

driving is o primary importance. Depending on the patients medical conditiothe physician may suggest to the patient that he or she seek urther treatmen

such as substance abuse treatment or occupational therapy. Physicians also

may encourage the patient and the amily to decide on a restricted driving

schedule, such as shorter and ewer trips, driving during non-rush-hour trac

daytime driving, and/or driving on slower roadways i these mechanisms wou

alleviate the danger posed. Eorts made by physicians to inorm patients and

their amilies, advise them o their options, and negotiate a workable plan ma

render reporting unnecessary.

3. Physicians should use their best judgment when determining when to report

impairments that could limit a patients ability to drive saely. In situations whe

clear evidence o substantial driving impairment implies a strong threat to

patient and public saety, and where the physicians advice to discontinue driv

ing privileges is ignored, it is desirable and ethical to notiy the Department oMotor Vehicles.

4. The physicians role is to report medical conditions that would impair sae driv

ing as dictated by his or her States mandatory reporting laws and standards

medical practice. The determination o the inability to

drive saely should be made by the States Department o Motor Vehicles.

5. Physicians should disclose and explain to their patients this responsibility to

report.

6. Physicians should protect patient condentiality by ensuring that only the min

mal amount o inormation

is reported and that reasonable security measures are used in handling that

inormation.

7. Physicians should work with their State medical societies to create statutes

that uphold the best interests o patients and community, and that saeguard

physicians rom liability when reporting in good aith. (III, IV, VII) Issued June

2000 based on the report Impaired Drivers and Their Physicians, adopted

December 1999.


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CHAPTER 2

Is the Patient at

Increased Risk forUnsafe Driving?



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Chapter 2Is the Patient at Increased Risk or Unsae Driving?

Mr. Phillips, a 72-year-old man with

a history o hypertension, congestive

heart ailure, type 2 diabetes mel-

litus, macular degeneration, and

osteoarthritis comes to your oce or

a routine check-up. You notice that

Mr. Phillips has a great deal o trou-

ble walking to the examination room,

is aided by a cane, and has diculty

reading the labels on his medicationbottles, even with his glasses. While

taking a social history, you ask him

i he still drives, and he states that

he takes short trips to run errands,

reach appointments, and meet

weekly with his bridge club.

Mr. Bales, a 60-year-old man with

no signicant past medical history,

presents at the emergency department

with an acute onset o substernal

chest pain. He is diagnosed withacute myocardial inarction. Follow-

ing an uneventul hospital course, he

is stable and ready to be discharged.

On the day o discharge, he mentions

that he had driven himsel to the

emergency department and would

now like to drive himsel home, but

cannot nd his parking voucher.

CHAPTER 2

Is the Patient at IncreasedRisk for Unsafe Driving?

This chapter discusses the frst steps othe Physicians Plan or Older DriversSaety (PPODS). In particular, weprovide a strategy or answering thequestion, Is the patient at increasedrisk for unsafe driving? This part of theevaluation process includes your clinicalobservation, identiying red ags suchmedical illnesses and medications thatmay impair sae driving, and inquiring

about new onset driving behaviors thatmay indicate declining trafc skills.

To answer this question, rst

Observe the patient

throughout the ofce visit.

Careul observation is oten an impor-tant step in diagnosis. As you observethe patient, be alert to:

Impaired personal care such as poor

hygiene and grooming; Impaired ambulation such as difculty

walking or getting into and out ofchairs

Difculty with visual tasks; and

Impaired attention, memory, languageexpression or comprehension.

In the example above, Mr. Phillipshas difculty walking and reading hismedication labels. This raises a question

as to whether he can operate vehicleoot pedals properly or see well enoughto drive saely. His physical limitationswould not preclude driving, but maybe indicators that more assessmentis indicated.

Be alert to conditions in the

patients medical history,

examine the current list o

medications, and perorm

a comprehensive review

o systems.

When you take the patients history, bealert to red ags,45 that is, any medica

condition, medication or symptom thacan affect driving skills, either throughacute eects or chronic unctionaldefcits (see Chapter 9). For example,Mr. Evans, as described in Chapter 1,presents with lightheadedness associatewith atrial fbrillation. This is a red agand he should be counseled to ceasedriving until control o heart rate andsymptoms that impair his level o con-sciousness have resolved. Similarly, MrBales acute myocardial inarction is ared ag. Prior to discharge rom thehospital, his physician should counselhim about driving according to therecommendations in Chapter 9 (seeFigure 2.1).

Mr. Phillips does not have any acutecomplaints, but his medical historyidentifes several conditions that plachim at potential risk for unsafe drivinHis macular degeneration may prevenhim rom seeing well enough to drivesafely. His osteoarthritis may make it

difcult to operate vehicle controls ormay restrict his neck range of motionthereby diminishing visual scanningin trafc. Questions in regard to his

45. Dobbs, B. M. (2005) Medical Conditions andDriving: A Review o the Literature (1960-2000). Report # DOT HS 809 690. WahingtDC: National Highway Trafc Saety Admintration. Accessed October 11, 2007.at www.nhtsa.dot.gov/people/injury/research/Medical_Condition_Driving/pages/TRD.html.


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12 Chapter 2Is the Patient at Increased Risk or Unsae Driving?

diabetes include: Does he have anyend-organ damage such as sensory neu-ropathies, chronic cognitive decline, oructuations from stroke that may affecthis ability to operate a motor vehicle?Could any o his medications impairdriving perormance?

Most older adults have at least onechronic medical condition and manyhave multiple conditions. The mostcommon medical conditions in olderadults include arthritis, hypertension,hearing impairments, heart disease,cataracts, dizziness, orthopedic impair-ments, and diabetes.46 Some o theseconditions have been associated withdriving impairment and will be dis-cussed in more detail in subsequentchapters. Additionally, keep in mindthat many prescription and nonpre-

scription medications have the po-tential to impair driving skills, eitherby themselves or in combination withother drugs. (See Chapter 9 or a morein-depth discussion on medications anddriving.) Older patients generally takemore medications than their youngercounterparts and are more susceptibleto their central nervous system eects.Whenever you prescribe one o thesemedications or change its dosage, coun-sel your patient on its potential to aectdriving saety. You may also recommendthat your patient undergo ormalassessment o unction (see Chapter 3)while he/she is taking a new medicationthat may cause sedation. Concern maybe heightened i there are documenteddifculties in attention or visuospatialprocessing speed (e.g., such as the TrailsB test [see Chapters 3 and 4]).

The review o systems can revealsymptoms that may interere with thepatients driving ability. For example,

loss o consciousness, conusion, allingsleep while driving, eelings o aintness,memory loss, visual impairment, andmuscle weakness all have the potentialto endanger the driver.

46. Health United States: 2002; Current PopulationReports, American with Disabilities, p. 7073.

Figure 2.1

Counseling the driver in the

inpatient setting

When caring or patients in the inpatient

setting, it can be all too easy or physi-

cians to orget about driving. In a survey

o 290 stroke survivors who were inter-

viewed 3 months to 6 years post-stroke,ewer than 35% reported receiving advice

about driving rom their physicians, and

only 13% reported receiving any type o

driving evaluation. While it is possible that

many o these patients suered such ex-

tensive decits that both the patient and

physician assumed that it was unlikely or

the patient to drive again, patients should

still receive driving recommendations rom

their physician.

Counseling or inpatients may include

recommendations or permanent driving

cessation, temporary driving cessation,

or driving assessment and rehabilita-

tion when the patients condition has

stabilized. Such recommendations are

intended to promote the patients saety

and, i possible, help the patient regain

his/her driving abilities.

Figure 2.2

Health risk assessment

A health risk assessment is a series o

questions intended to identiy potentialhealth and saety hazards in the patients

behaviors, liestyle, and living environment.

A health risk assessment may include

questions about, but not limited to:

Physical activity and diet;

Use o seat belts;

Presence o smoke detectors and re

extinguishers in the home;

Presence o rearms in the home; and

Episodes o physical or emotional

abuse.

The health risk assessment is tailored to

the individual patient or patient population.

For example, a pediatrician may ask the

patients parents about car seats, while a

physician who practices in a warm-climate

area may ask about the use o hats and

sunscreen. Similarly, a physician who sees

older patients may choose to ask about

alls, injuries, and driving.

At times, patients themselves or amilymembers may raise concerns. I the am-ily of your patient asks, Is he or she safeto drive? (or if the patient expressesconcern), identiy the reason or theconcern. Has the patient had any recentcrashes or near-crashes, or is he/she los-ing confdence due to declining

unctional abilities? Inquiring aboutspecifc driving behaviors may be moreuseful than asking global questionsabout saety. A list o specifc drivingbehaviors that could indicate concernsor saety is listed in the Hartord guide,At the Crossroads.47 Physicians canrequest amily members or spouses tomonitor and observe skills in trafcwith ull disclosure and permission romthe patient. Another tactic might beidentiying a amily member who reusesto allow other amily members such

as the grandchildren to ride with thepatient due to trafc saety concerns.

Please note that age alone is not a redag! Unfortunately, the media oftenemphasize age when an older driver isinvolved in an injurious crash. Thisageism is a well-known phenomenonin our society.48 While many peopleexperience a decline in vision, cognition,or motor skills as they get older, peopleage at dierent rates and experienceunctional changes to dierent degrees.The ocus should be on unctional abili-ties and medical ftness-to-drive andnot on age per se.

Inquire about driving during

the social history/health risk

assessment.I a patients presentation and/or thepresence o red ags lead you to suspectthat he/she is potentially at risk forunsafe driving, the next step is to ask

whether he/she drives. You can do thisby incorporating the ollowing ques-tions into the social history or healthrisk assessment (see Figure 2.2):

47. The Hartord. At the Crossroads. Hartord, CT.www.thehartord.com/alzheimers/brochure.html.Accessed December 12, 2007.

48. Nelson, T. (2002). Ageism: Stereotyping andPrejudice Against Older Persons. Cambridge,MA: MIT Press.


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CHAPTER 3

Assessing Functional

Ability



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license, you may nd it helpful to offreassurance that physicians do not havthat type o legal authority. Explain thyou may advise evaluation o driving needed and/or reer him/her to a driverehabilitation specialist or the Department o Motor Vehicles (DMV).

Here is an example o how you could

suggest an evaluation to Mr. Phillips

Mr. Phillips, Im concerned about yoursaety when you drive. Your son tells methat you were in a car crash recently andthat youve had several near crashes in th

past two years. Even though your medicaconditions are well managed, they can stcause problems that can aect your drivinability. Id like you to do a ew things orme, such as walking down the hall while time you. These tests will help me decidei there are areas we need to work on toimprove your driving saety.

This is how it works: Based on what Iknow about your health and how you do these tasks, well do our best to identiy a

potential treatable or reversible conditionFor example, i youre not seeing as wellas you should, then well do what we canto improve your vision. I theres somethinwe cant improve, then we can consult a

driver rehabilitation specialist. This typeo instructor, typically an occupationaltherapist, will go out on the road with yoto watch you drive, then recommend wato make your driving saer. The goal is tokeep you on the road or as long as you asae to drive.

As revealed in the PPODS algorithm(Figure 1.1), the next step to managingMr. Phillips driving saety is a ormalassessment of the key functional abilitiesrelated to driving. Specifc inormationin Mr. Phillips driving historynamely,the crash, moving violations, or nearcrashesin addition to his medicalconditions, urther support the need or

an assessment.

In this chapter, we discuss the unctionsrelated to driving and present a brieofce test battery, theAssessment oDriving Related Skills (ADReS). Eachtest in ADReS assesses a key area ofunction. Although not all unctionaldomains that are necessary or relevantto driving are tested by the ADReSbattery, many key areas are and havebeen validated with driving outcomes.

How do you broach the issue

o a driving assessment to

your patient?Your patient may eel deensive aboutbeing assessed and may even reuseassessment or ear o being told thathe/she can no longer drive. Ater all,driving is not only the primary ormo transportation or most Americans,it also represents reedom and

independence.

In suggesting assessment to your patient,it is best to use a direct but nonconron-tational approach. Reassure your patientthat you have his/her saety in mindand emphasize that you would like toassist him/her to drive saely or as longas possible. I your patient expressesfear that you will take away my drivers

Mr. Phillips, whom you met in

Chapter 2, has been accompanied

to the clinic by his son, who is in

the examination room with him.

Mr. Phillips tells you that he is a

sae driver. You request and obtain

permission to interview the son who

voices his concern. Four months ago,

Mr. Phillips was involved in a minorcar crash, in which he was ound to

be at ault. He has also had several

near-crashes in the past two years.

However, he has never gotten lost

while driving.

In discussing Mr. Phillips trans-

portation options, you learn that he

drove himsel to this appointment.

Driving is Mr. Phillips main mode

o transportation, and he drives

almost every day. Although Mr.Phillips is certainand his son

conrmsthat amily members and

neighbors would be willing to drive

him wherever he needs to go, he has

never asked or rides. Why should

I ask or rides when I can just drive

mysel around? Besides, I dont want

to impose on my amily or riends.

CHAPTER 3

Assessing FunctionalAbility


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20 Chapter 3Assessing Functional Ability

Follow-up at the patients next ap-pointment: Would he/she be willingto complete the sel-screening? Hasthe patient put any o the tips intopractice? Does the patient have anyquestions or concerns? Would he/shebe willing to undergo ADReS?

I amily members are concernedabout the patients driving saety,you can give them a copy oHowto Assist the Older Driver, ound inAppendix B. Especially i the patienthas dementia, he/she will probablylack insight and it will likely notbe ruitul to belabor the point. It isimportant here to enlist amily mem-bers and obtain their aid in creatinga transportation plan or the patientand encouraging the patient to beevaluated by ADReS.

I you are urgently concerned aboutyour patients driving saety, you maywish to orego ADReS and reer yourpatient directly to a driver rehabilita-tion specialist (see Chapter 5) or toyour state DMV or a ocused drivingassessment. Depending on yourStates reporting laws, you may belegally responsible or reportingunsafe drivers to the DMV. (Adetailed discussion o the physicianslegal responsibilities can be ound inChapter 7. A reerence list o report-ing laws is provided in Chapter 8.)In any case, the patient should bereferred with his/her knowledge.At this point, the patient and/oramily might relent and be willingto consider an evaluation rom adriving rehabilitation specialist.

Assessment o Driving-Related

Skills (ADReS)

The three key functions for safe driving

are (1) vision, (2) cognition, and (3)motor/somatosensory unction. ADReSassesses some aspects o these threeimportant unctions to help you identiyspecifc areas o concern.

Please note that ADReS does not pre-dict crash risk! While many researchersare working to create an easy-to-usetest battery that predicts crash risk,urther research is needed. However,

Suggest that the patient take theSAFER Driving survey. Also devel-oped at the University of MichiganTransportation Research Institute,this is a Web-based tool (available atum-saerdriving.org) that requires usersto answer questions about the severityo health concerns they are expe-

riencing due to medical conditionsand medications. The Web site thencalculates the eects o these healthconcerns on critical driving skills andgives users individualized feedback onhow their driving may be declining;what to do to continue driving saelygiven these declines; and, i appro-priate, recommendations or morein-depth assessment. Research hasshown that feedback from the Website correlates positively with on-roaddriving scores and an assessment roman occupational therapist. Users alsoreport that the site is easy to use, theinormation is helpul, and that theydiscovered declines in themselveso which they were not previouslyaware.54

In the patients chart, document yourconcern regarding his/her drivingability, and support this with relevantinormation rom the patients presen-tation, medical history, medications,and reported driving history. Docu-

ment the patients reusal or urtherassessment, along with any counselingyou have provided. (Current Proce-dural Terminology [CPT] codes orcounseling can be ound in AppendixA.) Not only will this remind youto ollow-up at the next visit, butit could potentially protect you inthe event o a lawsuit. (A detailedmedicolegal discussion can be oundin Chapter 7.) In cases where the riskis very high and the patient drivesdespite your recommendations, you

might consider reerral o the patientto the DMV or urther testing.

54. Eby, D. W., Molnar, L. J., Shope, J.T., & Del-linger, A.M. Development and pilot testing oan assessment battery or older drivers. J SaetyRes 38: 535-43.

What do you do i your patient

reuses assessment?

Despite your best eorts, your patientmay reuse to have his/her unctionalabilities that are key to driving assessed.I this occurs, you have several options:

Encourage your patient to completethe sel-screening tool (Am I a SaeDriver?) ound in Appendix B. Thismay help raise your patients level oawareness and make him/her moreopen to ADReS.

Counsel your patient on the Success-ul Aging Tips and Tips or SaeDriving, both ound in Appendix B.These may raise your patients levelo awareness and encourage saedriving habits.

Suggest enrolling in a driving coursedesigned to improve trafc saety,such as the Trafc Saety Courseoered by AARP51 or those oeredby the AAA.52 Roadwise Review isa CD available rom the AAA thatassesses important unctional abili-ties for driving and provides feedbackto older adults on the presence oimpairment.53 Roadwise Review doesrequire the older adult to have acomputer and an assistant during theplaying o the CD. Give the patient a

copy of the Driving Decisions Work-book. Developed by the Universityo Michigan Transportation ResearchInstitute, this is a paper-and-pencilworkbook that provides users withindividualized feedback based on howthey answer questions. Research hasshown that workbook scores are posi-tively correlated with on-road drivingscores and several clinical tests ofunctional ability. The workbook canbe downloaded ree o charge at:http://deepblue.lib.umich.edu/bitstream/

2027.42/1321/2/94135.0001.001.pd.

51. AARP Trafc Saety Course. www.aarp.org/amilies/driver_saety/driver_saety_online_course.html. Accessed October 14, 2007.

52. AAA Foundation or Trafc Saety SeniorDriver Web site. www.seniordrivers.org/home/index.cm. Accessed October 14, 2007.

53. AAA Exchange. Checking Your Driving Abili-ties. www.aaapublicaairs.com/Main/Deault.asp?SectionID=&SubCategoryID=38&CategoryID=3&ContentID=315&. Accessed October 14,2007.


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Chapter 3Assessing Functional Ability

ptosis, which is more common in theolder population. Drivers with loss operipheral vision (e.g., glaucoma) mayhave trouble noticing trafc signs orcars and pedestrians that are about tocross their path. Although earlier studies examining the relationship betweevisual feld loss and driving perorman

were equivocal, more recent studieshave ound signifcant relationships.57

In ADReS, visual felds are measuredthrough conrontation testing.

Aspects o vision that are important sae driving58 but are not included inADReS are:

Contrast sensitivity: Older adultsrequire about three times more contrast than young adults to distinguistargets against their background. Th

defcit in contrast sensitivity is urthexacerbated by low light levels. Thuolder drivers may have problemsdistinguishing cars or pedestriansagainst background scenery, and thimay be much worse at night or duristorms.59 While contrast sensitivityhas been ound to be a valid predictof crash risk among older drivers,60most vision care specialists are notamiliar with measures o contrastsensitivity, nor is it routinely mea-sured in eye examinations. Further

research must be perormed to produstandardized, validated cut-o poinor contrast sensitivity, and urtherwork must be done to introducethis concept to proessionals ineye care centers.

57. Dobbs, B. M. (2001). Medical Conditions anDriving: Current Knowledge. Association orthe Advancement o Automotive Medicine/National Highway Trafc Saety Administra-tion, p. 24 Project DTNH22-94-G-05297.Washington, DC: National Highway TrafcSaety Administration

58. Walgreens. https://webapp.walgreens.com/ceP-harmacy/programsHTML/transportation-tech.pAccessed October 14, 2007.

59. Owsley, C., & Ball, K. Assessing visualunction in the older driver. Clin Geriatr Med1993;9(2):389401.

60. Dobbs, B. M. Medical Conditions and DrivinCurrent Knowledge. Association or the Ad-vancement o Automotive Medicine/ NationHighway Trafc Saety Administration, ProjeDTNH22-94-G-05297. Washington, DC:National Highway Trafc Saety Administra-tion. 2001: p. 1516.

To perorm ADReS, you will need aSnellen chart, tape to mark distanceson the oor, a stopwatch, and a pencil.There are two paper-and-pencil tests inADReS, one o which requires a pre-printed orm. This is included on pages2829 and may be photocopied.

Vision

Vision is the primary sense utilized indriving in comparison to other modali-ties like hearing and proprioception,and it is responsible or the majorityo driving-related sensory input.55In most States, candidates are requiredto undergo vision testing to obtaina drivers license. Several States (seeChapter 8) also require vision testingat the time o license renewal.

Aspects o vision that are important orsae driving and can be readily assessedby a physician include:

Visual acuity, and

Visual felds.

Numerous studies show that visualacuity declines between early and lateadulthood, although no consensus existson the rate o decline or decade oonset. Decline in acuity is related tophysiologic changes o the eye thatoccur with age and the increasedincidence o diseases such as cataracts,glaucoma, and macular degeneration.56While ar visual acuity is crucial tomany driving-related tasks, declinesin near visual acuity may be associ-ated with difculty seeing or readingmaps, or gauges and controls inside thevehicle. In ADReS, ar visual acuity ismeasured with a Snellen chart.

Visual felds may decline as a result othe natural aging process and medicalconditions such as glaucoma, retinitispigmentosa, and stroke. In addition,upper visual felds may be obstructed by

55. Shinar, D., & Schieber, F. (1991). Visualrequirements or saety and mobility o olderdrivers. Hum Factors. 33(5):507-519.

56. Carr, D. B. Assessing older drivers orphysical and cognitive impairment. Geriatrics.1993;48(5):46-51.

until physicians are able to test theirpatients directly for crash risk, they cantest them indirectly by assessing the unc-tions that are necessary or sae driving.Any impairment in these unctions hasthe potential to increase the patientsrisk for crash. Once they are identied,the physician is in a good position to

determine i the patient requires reerralto a specifc subspecialist (e.g., ophthal-mologist). Although cut-o scores areprovided or these tests (see Chapter 4),the ADReS battery is a tool or identiy-ing areas o concern that require addi-tional evaluation. The physician shoulduse his/her clinical judgment regardlesso the scores by utilizing all availableinormation (driving history, medicalhistory, and unctional assessment). Inaddition, not all important unctionsare tested on the ADReS battery; rather

specifc items were chosen or theirapplicability and easibility in the ofcesetting, along with their correlates withimpaired driving outcomes.

The tests in ADReS were selected by aconsensus panel o driving saety expertswho worked with the AMA, and werechosen rom among the many availableunctional tests based on their ease ouse, availability, amount o time requiredor completion, and quality o inorma-tion provided by the patients test peror-mance. The individual tests in ADReShave been validated as measures o theirparticular unction and in some caseshave been studied with relation to driv-ing. Although we are still awaiting moreevidenced-based medical studies to linkthese tests with crash risk, these screenscan detect new-onset visual, cognitive,or motor problems that may be amenableto an intervention.

The tests are presented below by

unction, ollowing a discussion o theunction and how it relates to driving.An accompanying score sheet on pages2829 can be photocopied and placedin the patients chart. On the scoresheet, the tests are presented in therecommended order o execution. CPTcodes or components o ADReS areprovided in Appendix A, and the scoresheet can serve as documentation orthese codes.


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Chapter 3Assessing Functional Ability

Cognition

Driving is a complex activity thatrequires a variety o high-level cognitiveskills. Among the cognitive skills thatare useul or driving62 are:

Memoryshort-term, long-term,and working memory;

Visual perception, visual processing,visual search, and visuospatial skills;

Selective and divided attention;

Executive skills (sequencing, plan-ning, judgment, decision making);

Language; and

Vigilance.

Both crystallized memory and workingmemory are necessary or driving. Notonly must drivers remember how to

operate their vehicle and what signs andsignals mean, they must also remembertheir current destination and how toget there.63 In addition, drivers must beable to retain certain inormation whilesimultaneously processing other inor-mationa skill called working memory.Working memory (and the other cogni-tive skills to which it contributes) tendsto decline with age, while crystallizedmemory remains relatively intact acrossthe lie span. It is unclear at presentwhether age-related memory impair-ments reect only preclinical orms oage-related diseases or whether theseoccur independent o disease processes.64

Visual perception, visual processing,and visuospatial skills are necessary forthe driver to organize visual stimuli intorecognizable forms and know wherethey exist in space. Without these skills,the driver would be unable to recognizea stop sign and determine its distancerom the car. In general, visual process-

62. Walgreens. https://webapp.walgreens.com/cePharmacy/programsHTML/transportation-tech.pd. Accessed October 14, 2007.

63. Colsher, P. L., & Wallace R. B. Geriatric assess-ment and driver unctioning. Clin Geriatr Med.1993;9(2):365375.

64. Goetz, C. G. (1999). Textbook o ClinicalNeurology, 1st ed. Philadelphia: W.B. SaundersCompany.

ADReS (continued)

Visual felds by conrontation testingThe examiner sits or stands three eet in ront o the patient, at the patients eye

level. The patient is asked to close his/her right eye, while the examiner closes h

her let eye. Each xes on the others nose.

The examiner then holds up a hand in each visual eld simultaneously with a ran

dom number (usually one or two) o ngers in each o the our quadrants, and asthe patient to state the total number o ngers. With the ngers held slightly close

to the examiner, the patient has a wider eld o view than the examiner. Provided

that the examiners visual elds are within normal limits, i the examiner can see

the ngers, then the patient should be able to see them unless he/she has a visu

eld deect.

The process is repeated or the other eye (patients let eye and examiners right

eye closed). The examiner indicates any visual eld deects by shading in the are

o deect on a visual eld representation.

Trail-making test, part BThis test o general cognitive unction also specically assesses working memory

visual processing, visuospatial skills, selective and divided attention, and psychomotor coordination. In addition, numerous studies have demonstrated an associ

tion between poor perormance on the Trail-Making Test, Part B, and poor drivin

perormance.1 (See Chapter 4 or urther discussion.)

Part B involves connecting, in alternating order, encircled numbers (113) and

encircled letters (AL) randomly arranged on a page. This test is scored by overa

time (seconds) required to complete the connections accurately. The examiner

points out and corrects mistakes as they occur; the eect o mistakes, then, is to

increase the time required to complete the test. This test usually takes

3 to 4 minutes to administer.

The examiner administers the test to the patient, stating, Now I will give you a

paper and pencil. On the paper are the numbers 1 through 13 and the letters A

through L, scattered across the page. Starting with 1, draw a line to A, then to 2then to B, and so on, alternating back and orth between numbers and letters un

you nish with the number 13. Ill time how ast you can do this. Are you ready?

Go. The examiner records time-to-complete.2

Although not recommended in the previous version o the ADReS battery, many

neuropsychologists recommend giving the Trails A test (connecting just numbers

prior to giving the Trails B test. The rationale is at least twoold: (1) Trails A provid

an appropriate warm-up to Trails B, and allows the older adult some practice on

simpler concept; and (2) in many o the driving studies that validated Trails B, Tra

A was given rst. For clinicians who preer to conduct both tests, collaborating w

a psychologist who uses the Trails A test (stimuli) can assist with administration

and oversight in the oce setting. However, the recent Maryland Pilot Older Drive

Study (MaryPODS) that ound an association with Trails B perormance and at-a

crashes in a cohort o older adults utilized only the practice trial o Trails B prior tothe ull test. We have now included the practice trial o Trails B in the current stim

o the ADReS battery.

1. Staplin, L., Gish, K. W., & Wagner, E. K. (2003). MaryPODS revisited: updated crash analysis andimplications or screening program implementation. J Saety Res. 34:389397.

2. Staplin, L., Lococo, K. H., Stewart, J., & Decina, L. E. (1999, April). Sae Mobility or Older PeopleNotebook. NHTSA Report No. DOT HS 808 853. Washington, DC: National Highway Trafc SafetyAdministration.


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ing may slow65 and complex visuospatialskills may decline with age, while visualperception remains stable.66

During driving, many demands aremade on attention. In particular, driversmust possess selective attentiontheability to prioritize stimuli and ocus

on only the most importantin orderto attend to urgent stimuli (such astrafc signs) while not being distractedby irrelevant ones (such as roadsideads). In addition, drivers must possessdivided attention in order to ocus onthe multiple stimuli required by mostdriving tasks. Attentional functioningmay decline with age,67 with dividedattention showing more pronouncedchanges than selective attention.68The most widely studied instrumentor detection o impairment in divided

attention and selective attention thathas been correlated with crash risk inolder adult drivers has been the UsefulField of View (UFOV).69 This test isavailable or purchase and inormation isavailable on the Visual Awareness Website.70 Cost, time, and ability to bill,as well as limited studies in a primarycare setting, might be potential barriersto utilization in a physicians ofce.Another computerized set o tests thatassesses key functional abilities for driv-ing is the Driving Health Inventory

65. Owsley, C., & Ball K. Assessing visualunction in the older driver. Clin Geriatr Med.1993;9(2):389401.

66. Beers, M. H., & Berkow, R. (eds). (2000). TheMerck Manual o Geriatrics. Section 4, Chapter32: Aging and mental health. WhitehouseStation, NJ: Merck & Co., Inc..

67. Hartley, A. A. (1992). Attention. In: Craik, F.I. M., & Salthouse, T.A. (eds). The Handbooko Aging and Cognition. Pp. 350. Hillsdale, NJ:Erlbaum.

68. Madden, D. J., Turkington, T. G., Provenzale, J.M., Hawk, T. C., Hoffman, J. M., Coleman, R.E. (1997). Selective and divided visual atten-tion: age-related changes in regional cerebralblood ow measured by H215O PET. Hum BrainMapp. 5:389409.

69. Ball, K., Roenker, D.L., Wadley, V.G., et al.(2006). Can high-risk older drivers be identiedthrough perormance-based measures in aDepartment o Motor Vehicles setting?J AmGeriatr Soc. 54:7784.

70. Visual Awareness.com. http://visualawareness.com/Pages/request.html. Accessed October 14,2007.

ADReS (continued)

Clock drawing testDepending on the method o administration and scoring, the clock drawing

test (CDT) may assess a patients long-term memory, short-term memory, visual

perception, visuospatial skills, selective attention, abstract thinking, and executive

skills. Preliminary research indicates an association between specic scoring

elements o the clock drawing test and poor driving perormance.1

(See Chapter 4 or a urther discussion.)In this orm o the CDT, the examiner gives the patient a pencil and a blank sheet

o paper and says, I would like you to draw a clock on this sheet o paper. Please

draw the ace o the clock, put in all the numbers, and set the time to ten minutes

ater eleven. This is not a timed test, but the patient should be given a reasonable

amount o time to complete the drawing. The examiner scores the test by examin-

ing the drawing or each o seven specic elements ound on the ADReS score

sheet (see page 28 or score sheet).2

Rapid pace walkThis is a measure o lower limb strength, endurance, range o motion, and bal-

ance. A 10-oot path is marked on the foor with tape. The subject is asked to

walk the 10-oot path, turn around, and walk back to the starting point as quickly

as possible. I the patient normally walks with a walker or cane, he/she may use itduring this test. The total walking distance is 20 eet.

The examiner begins timing the patient when he/she picks up the rst oot, and

stops timing when the last oot crosses the nish mark. This test is scored by the

total number o seconds it takes or the patient to walk 10 eet and back.3

In addition, the examiner should indicate on the scoring sheet whether the patient

used a walker or cane. Scores greater than 9 seconds are associated with an

increased risk o at-ault motor vehicle tasks.4

1. Freund, B., Gravenstein, S., & Ferris, R. Use of the Clock Drawing Test as a Screen for Driving Compe-tency in Older Adults. Presented at the American Geriatrics Society Annual Meeting, Washington, DC;May 9, 2002; and Personal correspondence with B. Freund dated September 16, 17 and 19, 2002.

2. Ibid.

3. Staplin, L., Lococo, K. H., Stewart, J., & Decina, L. E. (1999, April). Sae Mobility or Older PeopleNotebook. NHTSA Report No. DOT HS 808 853. Washington, DC: National Highway Trafc SaetyAdministration.

4. Staplin, L., Gish, K. W., & Wagner, E. K. (2003). MaryPODS revisited: updated crash analysis andimplications or screening program implementation. J Saety Res. 34:389397.


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ties, such as range o motion and muscleunction, with driving. Driving impair-ment has been associated with theinability to reach above the shoulder.79Older adults with physical railty maybe at increased risk for a motor vehiclecrash,80,81 and studies have indicatedthey appear to be more vulnerable to

injury.82 Walking less than one block aday, impaired left knee exion, and footabnormalities have been associated withan adverse driving event.83 Anotherstudy revealed that more difcultywalking one-quarter mile in comparisonto a control group was associated withincrease crash risk.84 In ADReS, motorunction is measured through the RapidPace Walk, Manual Test of Range ofMotion, and Manual Test o MotorStrength measures.

79. Hu Hu, P. S., Trumble, D. A., & Foley, D. J., etal. (1998). Crash risks of older drivers: a paneldata analysisAccid Anal Prev. 30:569581.

80. Sims, R. V., McGwin, G., & Allman, R. M., etal. (2000). Exploratory study o incident vehiclecrashes among older drivers.J Gerontol Series ABio Sci Med Sci. 55: M2227.

81. Marottoli, R. A., Wagner, D. R.,

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