National highway traffic safety administration A notable data found on the data reviewed were crash involvement ratios for older age groups that did not bear out conventional wisdom about certain situations being especially risky for these drivers, such as merging, changing lanes, driving on I Highways and driving in bad weather. VERY MIXED BAG, VERY SICK AND VERY HEALTHY
On a licensed driver basis, older adults are among the safest on the road. The average annual number of crashes in the United States is 68 per 1,000 licensed drivers, while the corresponding rate for drivers aged 65 and older is only 37. The picture changes somewhat when crash rates are calculated on the basis of miles traveled. Using this measure of exposure, older adults are at increased crash risk . The increase in risk is evident for 65-74 year olds, but becomes even more pronounced with increased age.
Coincides with the increase in incidence of dementia
Council on ethical and judicial affairs
2. Ex : referrals, restrictive driving 3. Clear evidence and where the advice of to discontinue driving is ignored
First edition was published on 7/30/2003 and updated on 2/3/2010. The information on this guide is provided to assist physicians in evaluating the ability of older patients to operate motor vehicle safely as part of their everyday personal activities. Is not intended as a standard of medical care, nor should it be used as a substitute for physicians clinical judgment. It reflects the scientific literature and views of experts as of December 2009.
You may counsel your patient about driving when you Prescribe a new medication or change doses, treat Unstable medical condition or work up a new onset
The specific functional deficits related to crashes in the older adult were attention and cognition
The interpretation of Trail Making is very simple: a time of greater than 180 seconds is a failure. However, screening tests for dementia can result in false positives due to depression, visual impairment or metabolic disorders such as hypoglycemia. Medications can also interfere with cognitive function on a temporary basis . But if other false positives don ’t exist, dementia is likely and the patient may need to be reported to the DMV with or without further testing.
Not timed. Assess LTM, STM, visual perception, visuospatial skills , selective attention and executive skills Sensitivity and Specificity: 85% If used in combination with the three-word delayed-recall, sensitivity and specificity reach 93% Depression has little effect on clock drawing, although false positives can occur from depression or medication
2. ensure your patient understands the reasons (legal, healthy and safety).Use the term “driving retirement” vs “giving up”. Pt may benefit from the visual reinforcement of a rx with the words “Do Not Drive.” 4. . Asses pt ability to comply , transportation resources your patient has identified and look for signs of isolation or depression
Out of pocket money
Patient case. 77 yr old w/vascular dementia after stroke 3 yrs ago. MMSE 17/30.
Oct 2 2000
MENTION THE DRIVING MEDICAL EVALUATION FORM. Primarily used by Driver Safety, this five-page document assists hearing officers to evaluate the physical and/or mental condition(s) of the driver and to determine what action, if any, to take with regard to the driving privilege. :
COGNITION AND DRIVING
Carolina Osorio, MD Geriatric Psychiatry FellowUCLA Semel Institute of Neuroscience and Human Behavior March 26 2012
OBJECTIVES Understand the safety risks of older drivers Indentify conditions that may put older drivers at risk Indentify the role of the physician Demonstrate familiarity with the law as well as California DMV reporting methods and requirements
Taxonomy of Older DriverBehaviors and Crash Risk fromNHTSA Feb 2012 Identify risky behaviors, driving habits and exposure patterns that have been showed to increase the likelihood of crash involvement Crash types where older drivers were most strongly overrepresented 2002-2006 using database from FARS and NASS
Taxonomy of Older Driver Behaviors and CrashRisk from NHTSA Feb 2012 Older people were increasingly less likely to be driving the striking vehicle in a two vehicle crash High – speed two lane roadways and multilane roads with speed limits of 40-45 mph were associated with heightened older driver crash involvement In two vehicle crashes, failure to yield was the most frequently cited factor Starting at age 70, old drivers were specially likely to crash at intersections With respect to single vehicles crashes , older drivers were somewhat more likely to be identified as ill or blacking out, drowsy or asleep, using medications or drugs ( other than alcohol), and having some other physical impairments ( hearing loss)
Annual Crashes per 1,000 Licensed Vehicle Drivers by Age of Driver (Source: Cerrelli, 1998)Crashes per Million MilesTraveled by Age of Driver(Source: Cerrelli, 1998)
Percent of Persons with Dementia by Age Group 50 45 40% of Aged 35Population 30 with 25Dementia 20 15 10 5 0 65 - 70 70 - 75 75 - 80 80 - 85 85 - 90 90 - 95 Age
Problems related to age can include Reduced vision Decreased strength Medications Cognitive impairment Impaired California 3.1 M license drivers Over 65 years
Older drivers have an increased likelihood of being injured orkilled in a crash. L. Evans Traffic Safety (2004), Bloomfield Hills, MI: “Science Serving Society”
Automobile crashes are the third leading cause of death and injury in the United States with 40,000 to 50, 000 people killed in about 2 million accidents per year Drivers over age 75 had a higher rate of fatal accidents nationwide in 2001- 2002. This problem is expected to grow because by 2024, one in four U.S. drivers will be over age 65 National Older Driver Research and Training CenterPhysicians are in a unique position to anticipate the impact of physical and mental conditions on driving impairment.
The privilege of driving is a source of freedom and empowerment for many individuals. Removing this privilege has its risks. The loss of ability to be independently mobile can be a devastating psychological blow for an elderly patient. It also may restrict a patient access to meet medical and social services or to employment venues.
CEJA of the AMA report on impaired drivers andtheir physicians: I-99 Physicians have an ethical responsibility to assess patients’ physical or mental impairments that might adversely affect driving abilities Each case must be evaluated separately since not all impairments may give rise to an obligation on the part of the physician The physician must be able to identify and document physical or mental impairments that clearly relate to the ability to drive The driver must pose a clear risk to the public safety
Recommendations1. Physicians should assess patients’ physical or mental impairments3. Before reporting, there are a number of initial steps physicians should take5. Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely.7. The physicians role is to report medical conditions that would impair safe driving. The determination of the inability to drive safely should be made by the states DMV.
Recommendations1. Physicians should disclose and explain to their patients this responsibility to report3. Physician should protect patient confidentiality by ensuring that only the minimal amount of information is reported5. Physicians should work with their state medical societies to create statues that uphold the best interests of patients and community, and that safeguards physicians from liability when reporting in good faith.
AMA PHYSICIAN’S GUIDEAmerican Medical Association &National Highway Traffic SafetyAdministration (NHTSA)“Physician’s Guide to Assessingand Counseling Older Drivers”Quick screening and referral toolAvailable at:www.ama-assn.org/go/olderdrivers
Office visit Medical History: OSA are 2-6 time more likely to be involved in a MVA (Berger et al. 2000). ROS Family concerns AGE ALONE IS NOT A RED FLAGRemember to address driving safety as needed.
Assessment of driving relatedskills (ADReS) Working Memory Executive Functioning Spatial Skills Elaboration of rapid decision making
Assessment of driving related skills(ADReS)COGNITION Trail B: Lafont confirmed a high correlation between increasing age and poor attentional and executive performance, as measured by Trail-Making B, to be correlated with both crashes and driving cessation (Lafont, 2008). N = 81 sec MCI = 136 sec Dementia = 190 sec Ashendorf, 2008
Clock drawing test using Freund Scoring Criteria YES NO Only the numbers 1-12 are included Number inside the clock Numbers are spaced equally from each other Numbers are spaced equally from the edge One clock hand correctly points to 2 There are only 2 clock hands There are no intrusive marks, writing or hands indicating incorrect timeThe scoring is based on seven “principal components” whichwere derived by analyzing the clock drawing of 88 drivers 65and older against their performance on a driving simulator(Freund 2005).
Counseling the patient / familyPhysicians are influential in a patient’s decision tostop driving; in fact advice from a doctor is the mostfrequently cited reason that a patient stops driving.Persson, D. (1993)3 Transportation options: http://beverlyfoundation.org/u Reinforce driving cessation:”Driving retirement”g Follow up letterg Follow up in a month
Driving Rehabilitation Specialist One who plans develops coordinates and implements driving services for individuals with disabilities Work with people who have strokes, low vision, limb amputation www.ADED.net
What do with a difficult patient?i Encourage patient to complete the self screening toolt Counsel your pt on Successful aging tips and tips for safe drivingo Roadwise review http://www.seniordrivers.org/driving/driving.cfm?button=roadwr DOCUMENT your concerns and support this with relevant information. Document patient reactions along with any counseling you have provided.
California Code of regulations (CCR) title 17 sub-chapter 2.5“Disorders characterized by lapses of consciousness” sections2800-2812.“Reporting the local health authority” the non-communicable disease orconditions – AD- and related conditions and disorders characterized bylapses of consciousness .2802 AD and related disorders. Means those illnesses that damage the brain causing irreversible, progressive, confusion, disorientation, loss of memory and judgment2806 Disorders characterized by lapses of consciousness. Loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli inability to perform one or more ADLs the impairment of the sensory motor functions used to operate a motor vehicleEX: OSA, abnormal metabolic states (DM)
Important issues about the regulations: They are specific to physicians and surgeons per section 103900 of the Health and Safety Code The physicians who reports a patient diagnosed with a disorder characterized by lapses of consciousness, according to the Health and Safety code 103900, shall not be civilly or criminally liable to any patient for making the report.
LiabilityPhysicians are considered negligent if they do not informpatients of medications and medical conditions that canimpair driving ○ Physicians may be held liable for civil damages if they clearly failed to report an impaired driver who causes a MVC ○ Immunity is granted to the physician if the patient is reported prior to a MVC ○ Document all referrals, recommendations, conversations, and reports (e.g. copy of a driver retirement letter and “do not drive” prescription)
CaliforniaIndividuals 70 years of age and older Must renew license in-person License is renewed for five years if vision and written tests are passed and there are no signs of cognitive impairment A “limited term” license may be issued for one to two years if a medical problem exists but is not severe enough to stop driving (e.g. mild dementia) Dementia moderate-severe = DL revoked Dementia early or mild = ReexaminationIn this manner, the California DMV hopes to balance the need forpublic safety and with the perseveration of personal independence .
Reporting……. In California in 1988 , healthy and safety code section 410 added AD and related disorders to the list of conditions that physicians are required to report to their local health departments, which then forward this information to CA DMV. Based on the results of these examinations as well as a physician completed written driver medical evaluation (DME) form the DMV could allow the driver to: Continue driving unrestricted Continue driving with restrictions Revoke or suspend DL.
Safety, mobility and cost are critically importantPhysician role is difficult: caseloads, poor trainingLimited alternatives to drivingRecognize rights and feelings of older peopleMany obvious solutions may not work very wellWe started addressing this problem too late
"Above all, we must work together to ensure that older adults can remain mobile and productive even when they have to give up driving.“ Thomas Meuser, Ph.D. Research associate professor of neurology at Washington University. THANK YOU