Older Drivers : Recognition and Reduction of Risk Alice Pomidor, MD, MPH
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Older Drivers : Recognition and Reduction of Risk Alice Pomidor, MD, MPH
Older Drivers: Recognition and Reduction of Risk Alice Pomidor, MD, MPH Department of Geriatrics Florida State University College of Medicine Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved. Objectives 1. Recognize 3 risk factors for Older Drivers 2. Describe extra risks associated with dementia 3. Identify 3 potential risk reduction interventions 4. Briefly discuss Legal & Ethical Driving Issues Driver crashes into license bureau South Florida Sun-Sentinel -2007 80-yr-old Boca Raton woman Driving a 1990 Mercury Grand Marquis Went over a concrete parking block, onto the sidewalk, through a metal parking sign and into the windows of the DMV office Was there for a license renewal retest Elderly man drives with body in windshield St. Petersburg Times - 2005 93-year-old man Apparently suffering from dementia Fatally struck a pedestrian and drove for three miles with the man's body through his windshield Spotted by a tollbooth attendant who called A Familiar Story? “It’s getting very hard to drive at night. I don’t like to go out because I don’t think it’s safe. Is there something you can do to help?” “You have to talk to Dad about his driving when you go in. He almost hit someone the other day, and I don’t feel like he can take the children out.” “ My neck is so sore from that fender-bender. The emergency room said to go see the doctor if the pain didn’t go away after a few days.” Welcome to Florida Age # of Drivers Fatalities in 2001 65 + years Over 2.2 million 2. Texas = 254 3. CA = 224 85 and up 242,480 1. Florida = 268 NHTSA: By 2020, one in four drivers will be age 65 or older Leading cause of accidental death for ages 65 – 74, secondleading cause over age 75 Fatalities by mileage and age 1Federal Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey. Washington, DC: U.S. Department of Transportation. Characteristics of Older Drivers •More men than women: About 25% of women in this age cohort never learned to drive. •Drive fewer miles per year: Average 5800 miles per year, compared with 9800 miles per year in younger drivers. •MVAs slower: Accidents usually involve lower speeds and are more likely to involve multiple vehicles. Characteristics of Older Drivers •Often self-restrict: Tend to avoid driving at night, during rush hour, through bad weather, or through unfamiliar areas. •Moving violations: Most frequently incurred by missing signs and signals, crossing lines while passing, or making left-hand turns. License Renewal Varies hugely between States: 8 states require no testing at the time of renewal 16 states require extra testing for older drivers, or more frequent renewals Only Driving tests can be a real bear! California requires reporting of dementia to their Bureau of Motor Vehicles Florida Licensing License renewal every 4-6 years, depending on driving history In-person every third cycle (can mail it in for up to 18 years) Written, road tests at discretion of the Department of Highway Safety & Motor Vehicles (DHSMV ) Vision testing over age 80 at in-person renewal Risk Factors for Driving Vision/hearing changes Neurologic changes Musculoskeletal changes Comorbid chronic illness Functional changes Medications Yours? Visual Changes-Acuity Static visual acuity: 20/40 or worse in 13% over age 65 Visual Changes-Fields Field cuts: present in 13% over age 65; 70 degrees noticed Visual Changes-Glare Glare/light sensitivity: light scatters, can change day to nighttime acuity from 20/50 to 20/200 Visual Changes-Useful Field of View Useful Field of View: 40% loss doubles crash rate Visual Changes-Eye diseases Increased prevalences of... Diabetic retinopathy Cataracts Glaucoma Macular degeneration Hearing Changes 40 dB or less in good ear for unrestricted license (AMA Recommendation) Reaction Time Classical definition: Slows with advancing age Perceptionresponse time: Similar in older & younger adults; within 2.5 seconds allowed Musculoskeletal Changes Grip strength of 35 pounds or more is recommended in order to control wheel, unless adaptive equipment used Chronic Illnesses Relative risk/odds ratio Back pain in the past 12 months Diabetes with neuropathy Depression Coronary artery disease Stroke Arthritis among females 0 1 2 Other chronic illnesses: Seizure disorders and dementia (30% still drive with moderate dementia) 3 Functional Decline Relative risk/odds ratio Falls in the past 2 years Walking < one block per day Difficulty copying a pentagon 3 or more foot abnormalities 0 0.5 1 1.5 2 2.5 3 Nearly 50% likelihood of adverse driving event in the next year if bottom three conditions exist Medications and Alcohol Relative risk/odds ratio ACE inhibitors Beta-blockers NSAIDs Benzodiazepines Alcohol abuse Tricyclic antidepressants Opioid analgesics Anticoagulants 0 2 4 6 Risk Recognition in Dementia Unable to locate familiar places (gets lost) Does not observe traffic signs (esp stop signs) Drives at inappropriate speeds (usually slow) Makes poor or slow decisions in traffic (at fault 5 times more often in left hand turn crashes) Becomes angry, frustrated or confused easily while driving 3 years or more since diagnosis Brown LB, Ott BR. Driving and dementia: a review of the literature. J Geriatr Psychiatry Neurol 2004;17: 232-240. Driver-Specific Assessment Driving History-who, what, when, where, why, how Accident or “near-miss” events Recent changes/self-restrictions Chronic Illnesses Alcohol use Medications Driving Risk Assessment- Exam Visual screening: Snellen chart, visual fields Auditory screening: Whisper test, audioscope. Cognitive screening: Clock-drawing test, MMSE Psychological screening: Depression scale Functional status: ADL’s, IADL’s, falls. Musculoskeletal/neurological screening: Gait observation, feet exam, hand grip, joint range of motion, proprioception, strength Risk Reduction Interventions Treat any reversible deficits identified above. Eliminate potentially problem medications Counsel on proper use of seat belts Counsel avoidance of suboptimal driving conditions such as lack of sleep Recommend avoidance of driving under influence of alcohol or medications Risk Reduction Interventions Encourage use of driving refresher courses (such as “Drivers 55 Plus”) Identify alternative transportation Refer to occupational therapy or local driving school for formal evaluation Association of Driving Rehabilitation Specialists at http://www.aded.net/i4a/pages/index.cfm?pageid=1 Self-Help Resources AAA-Senior Drivers program at www.seniordrivers.org/home/toppage.cfm AARP-Driver Safety info at www.aarp.org/life/drive National Highway Transportation & Safety Administration (NHTSA) Older Road Users www.nhtsa.dot.gov/people/injury/olddrive Driving “Retirement” Begin discussions early to ease transition Identify a “trusted person” Many adverse consequences of driving cessation, including: depression dependency caregiver strain social withdrawal increased risk of entry into long-term care facilities restricted mobility When you have no other choices Discuss alternate strategies confiscate keys park at a distance discontinue insurance disable or sell car have safe copilot (controversial) provide picture ID grind keys down Reporting Section 322.126 (2), (3), Florida Statutes, provides that "Any physician, person, or agency having knowledge of any licensed driver’s or applicant’s mental or physical disability to drive...is authorized to report such knowledge to the Department of Highway Safety and Motor Vehicles... The reports authorized by this section shall be confidential... No civil or criminal action may be brought against any physician, person, or agency who provides the information required herein.“ www.hsmv.state.fl.us DHSMV Actions All citizen complaints are evaluated If validated, re-examination at the driver license office or a medical report is required Drivers have 30 days to submit a required report or their driving privilege is revoked until they do so If the evaluator does not find any substance or validity to the complaint, no further action is taken Further DHSMV Actions If report indicates further review is needed, case is referred to the Medical Advisory Board Board may: request additional testing recommend restrictions recommend revocation of the driver’s license Drivers may be required to complete an on- road test as a condition of licensure or reinstatement Florida At Risk Driver Council (FADAC) Reviewed current status of older drivers in Florida Recommendations issued February 2004 Ken Brummel-Smith, MD, chairperson 4 pilot programs going