Motor vehicle crashes are the leading cause of injury to adults 65-75 years of age, and the second leading cause of injury to those 75 years of age and older.1 Physicians and other health care professionals can play a critical role in preventing motor vehicle injuries and in helping older patients maintain their mobility through the use of preventive clinical practices. In addition, clinicians can assess health changes of older patients and provide effective medical treatment to address any functional limitations that arise and may inhibit mobility. Finally, if remediation is not possible, clinicians can help patients maintain mobility through proper counseling. This article details ways in which physicians can maximize the mobility of their older patients by assessing their patients’ functional abilities and help older patients transition from the personal automobile into other means of transportation.

CASE PRESENTATION
Mrs. C is a 75-year-old, active mother of four and grandmother of 12. She lives alone in a retirement community located just outside of a large metropolitan area. At a recent visit to her primary care physician, to which she was accompanied by her eldest daughter, she mentioned that she received a ticket for failing to yield while making a left-hand turn out of her retirement community. Mrs. C complained that the officer was rude and threatened to report her to the Division of Motor Vehicles. Mrs. C’s daughter then stated that she and her siblings had some concerns about their mother’s driving. As a family, they believed that consultation with a physician was necessary.

Mrs. C’s health history is significant for osteoarthritis and osteoporosis, although otherwise she is in good health. She complained of occasional forgetfulness, but this has not caused any significant impairment in her daily activities; she has not had any formal neuropsychological testing.

On further discussion, Mrs. C mentioned that she has run over the curb pulling into her driveway a few times, and her daughter has noticed some small unexplained dents in her mother’s car. However, Mrs. C was adamant that she is a safe and cautious driver, pointing out that this was her first ticket and she has never been involved in an accident. Is Mrs. C a risk on the road?

The issue of older driver safety is a concern for both the individual and the public. Often, patients and family members look to physicians for guidance, leaving physicians wondering what their obligations are regarding the driving safety of their older patients.

EPIDEMIOLOGY
Although younger drivers experience the highest crash rate per vehicle mile traveled, crash rates rise appreciably for adults over the age of 70.2 In 1995, the crash rate for teenagers was 2434 crashes per 100 million vehicle miles traveled (VMT). The next highest crash rate was for adults over the age of 80, with 1466 crashes per 100 million VMT. In comparison, the crash rate for an adult 16-64 years of age was 522 crashes per 100 million VMT.2

Typically, crashes involving younger drivers are due to inexperience and risky driving behavior, such as speeding and alcohol use. In contrast, older persons are generally safe and cautious drivers. They are more vigilant with seatbelt use and are less likely to speed, tailgate, or use alcohol while operating a motor vehicle.3 So, why is there an increase in crash risk for this population?

Health changes that are more prevalent with age, particularly those that affect vision, cognition, or motor function, can affect a person’s ability to drive. Most older adults have at least one chronic medical condition, and many have multiple conditions. These health implications can impair important physical functions that are necessary for driving.

A complicating factor to the higher crash risk is the increased fragility of older adults. Around the ages of 60-64 years, fragility increases and rises steadily thereafter,4 making older adults more likely than younger drivers to suffer an injury—particularly chest injuries—and suffer medical complications when involved in a crash.5 In addition, older adults are nine times more likely to die from injuries as a result of a motor vehicle accident than younger persons.6

The combination of increased crash risk and increased fragility contributes to the high motor vehicle fatality rate of older adults. In 2002, adults age 65 and older made up 16% of the population and were involved in 15% of all traffic fatalities. Projections indicate that in 25 years, older persons are expected to represent 25% of the driving age population and 25% of fatalities in motor vehicle accidents.2

ASSESSING MEDICAL FITNESS TO DRIVE
To assist physicians and other health care professionals in addressing patients’ driving safety, the American Medical Association (AMA), in cooperation with the National Highway Traffic Safety Administration (NHTSA), convened an advisory panel of physicians, researchers, and other experts in the field of older driver safety to develop a strategy for assessing medical fitness to drive that is appropriate for use in the clinical setting. This 5-step strategy, entitled Physician’s Guide to Assessing and Counseling Older Drivers,7 incorporates simple, practical, in-office tests to assess the basic functions related to driving. Physicians are encouraged to use this strategy to help prevent motor vehicle injury and to promote continuing mobility so their older patients can stay safely active.

Step 1: Screen for red flags
The first step is screening the driver for “red flags” or any medical condition, medication, or symptom that can impair driving skills (Table I). Whereas presence of a disease or condition itself does not indicate increased crash risk, the extent of functional impairment caused by disease can be a key to identifying at-risk drivers. Red flags can include acute episodes such as seizure, syncope, or stroke, or chronic conditions such as cardiovascular disease (particularly when associated with excessive fatigue and impaired cognition), neurological disease such as dementia or Parkinson’s disease, or musculoskeletal diseases such as arthritis.

Other red flags include use of prescription drugs and over-the-counter medications, as many have potentially impairing central nervous system side effects such as drowsiness, dizziness, blurred vision, or slowed reaction time. According to the National Institute on Aging (NIA), adults over the age of 65 years take more prescribed medications than any other segment of the population. The elderly may be more susceptible to drug side effects due to differences in pharmacokinetics.8 Physicians should always counsel their patients on the potential for medications to impair driving skills, particularly when beginning a new medication.

Voiced concern from family members, such as, “Mom’s car has a few unexplained dents,” or comments from patients, such as, “I have trouble driving at night,” are also indications that a patient’s driving ability may be deteriorating. These types of comments from patients and family members indicate that further assessment and discussion are necessary.

Step 2: Assessment of driving-related functions
The presence of red flags suggests a need for a more formal assessment of driving-related functions. A brief assessment can be performed in the physician’s office to determine if there is sufficient deficit to recommend further referral.

Three primary functions are necessary for driving: vision, cognition, and motor function. The recommended assessment includes seven brief, in-office exams that assess each of the three areas and can help the physician determine whether further referral is necessary. The seven exams were chosen for the functions they measure and for ease of use in an office setting (Table II). However, although the exams included in the assessment can identify functional impairment, the assessment process is not an indicator of crash risk.

Vision is the primary function related to driving. Two aspects of vision are measured by the assessment: visual acuity, which is necessary for reading road signs or locating objects in the driving pathway, and visual fields, which are necessary for noticing oncoming cars or pedestrians. The standard vision chart can be used to assess visual acuity, while confrontation testing can be used to detect any deficits in the visual field. Other visual problems, such as contrast sensitivity or glare, require more sophisticated testing by an ophthalmologist.

Driving also requires various high-level cognitive skills, such as memory, attention, visual attention, and executive function. Two cognitive exams, the Trail-Making Test, Part B and the Clock-Drawing Test, have been closely correlated with driving ability. In a recent case study, poor performance on the Clock-Drawing Test correlated with impaired driving performance and proved a better cognitive tool for predicting driving ability than the Mini-Mental State Examination.9

Finally, driving is a physical activity that requires a certain degree of flexibility, strength, endurance, and range of motion. Certain physical functions have been correlated with increased crash risk, such as limited neck range of motion,10 fewer blocks walked per day, and abnormalities of the foot.11 Three exams are recommended to assess motor functioning, including the rapid pace walk, the manual test of range of motion, and the manual test of motor strength. For details on recommended cut-off criteria for each of these exams, see the Physician’s Guide to Assessing and Counseling Older Drivers.7

Step 3: Treatment
Poor performance on any of the exams would indicate first that the physician try to remediate any functional impairment through further diagnosis and treatment. A first step may be a thorough medication review or referral to a specialist to maximize functional abilities (eg, referral to a neurologist for neurological conditions or an ophthalmologist for visual deficits).

If the physician has explored all treatment options and the level of patient functioning is still questionable, it is advised that the patient be referred to a driver rehabilitation specialist for a targeted evaluation of driving ability.

Step 4: Referral to driving specialist
A driver rehabilitation specialist (DRS), often an occupational therapist with specialized training in driver rehabilitation, is “one who plans, develops, coordinates and implements driving services for individuals with disabilities,” according to the Association for Driver Rehabilitation Specialists.

Driver rehabilitation specialists are often based in outpatient rehabilitation clinics, hospitals, or private driving schools. During a typical evaluation by a DRS, the patient will undergo a full clinical assessment of vision, cognition, and motor function, and also a review of driving history, driving needs, license status, and a complete medical history and medication review. Following the clinical assessment, if deemed appropriate, the DRS will conduct an on-road assessment of the individual’s driving abilities.

Based on the individual’s performance on the clinical and road exams, the DRS may prescribe adaptive driving equipment or training on the use of adaptive driving techniques. A variety of adaptive equipment is available depending on the person’s functional impairment. For example, an individual with limited joint mobility and diminished strength due to rheumatoid arthritis may be prescribed an extended gear shift and power steering for limited arm motion and strength, as well as a wide-angle mirror to increase field of vision due to limited neck rotation. In situations where the person has had a limb amputation, modifications can be made to the automobile to accommodate. A left foot gas pedal can be installed and an emergency brake extension inserted to accommodate for a leg amputation, or installation of hand controls for the brake and accelerator may be appropriate if the person has lost the use of both legs. Following the installation of adaptive equipment, the DRS can provide training and driving instruction on its use.

The DRS may also recommend adaptive driving techniques. In the case of an individual with glare sensitivity, it may be recommended that he/she avoid driving at night or use sunglasses when appropriate. Persons with memory impairment, yet who are still judged safe to drive, may be recommended to limit their driving to close to home.

The DRS can also provide counseling to individuals on driving retirement and can help to identify mobility alternatives, if necessary.

Step 5: Counseling and legal discussion
For many, driving is essential to freedom and autonomy, and loss of this privilege may be devastating to an individual’s self-worth. Driving cessation has been shown to be associated with an increase in depressive symptoms12 and a decrease in out-of-home activities. Because many of the nation’s elderly persons live in rural settings, far from amenities such as grocery stores or medical offices, driving retirement means having to depend on others for getting places or not going out of the home at all. Even in urban areas, public transportation is often not ergonomically designed for the elderly, making useful alternatives to the car difficult to find. For this reason, some older adults are very reluctant to give up driving.

When recommending driving cessation, it is important to involve the patient’s family members in the discussion. A recent focus group conducted by The Hartford Financial Services Group, Inc., and MIT AgeLab found that older adults preferred to be approached first by a spouse and then by a physician when it came to concerns about their driving ability.13 Involving the family will help to reaffirm the importance of the message and will demonstrate that family support is available. The patient and supportive family members should be encouraged to develop a transportation plan for getting to and from necessary errands as well as social activities. For more tips on counseling, see Table III.

Physicians must also consider their legal obligations when counseling patients on driving retirement. In some states, physicians are legally mandated to report patients with specific medical conditions, such as epilepsy or dementia, to the state driver licensing agency. This raises some concerns from physicians regarding patient confidentiality. Under the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, information may be released without consent of the patient in order to comply with state law, or to public health authorities who are authorized by law to collect or receive such information. However, it is always best that the physician discuss reporting obligations with the patient and, if possible, receive the patient’s consent to report to the licensing agency. If a state does not have a mandatory reporting law, the physician is allowed to voluntarily report drivers deemed at risk. In these cases, to reduce breach of confidentiality, the physician should provide the minimum amount of information necessary to submit a report, and it is best that the physician discuss this action with the patient. Each state has its own medical review process investigating and following up with reported drivers. Ultimately, the decision of revoking a driver’s license lies in the hands of the state.

OUTCOME OF THE CASE PATIENT
The presence of osteoarthritis and voiced concern from her children raised enough red flags for the physician to conduct a more formal assessment of Mrs. C’s vision, cognition, and motor function. Although her performance was unremarkable on her visual and cognitive exams, Mrs. C did have limited neck rotation due to her osteoarthritis, which may have been contributing to limited peripheral vision while driving. The physician referred Mrs. C to a DRS through the hospital outpatient rehabilitation center.

The DRS report indicated that Mrs. C performed well on her driving test; however, she had difficulty turning to check for oncoming traffic while merging and changing lanes. The DRS recommended installation of wide-angle mirrors and additional side mirrors to Mrs. C’s automobile.

The physician counseled Mrs. C on the importance of following the recommendations of the DRS and on the importance of seatbelt use. The physician explained that because of Mrs. C’s osteoporosis and increased fragility, she is at increased risk for injury in an accident. Although Mrs. C continues to drive, her physician also recommended that she and her children begin to explore the transportation services available through her retirement community, such as shuttles or Medi-cars.

CONCLUSION
Driving safety of the elderly will continue to become a more prominent concern, and physicians can play an important role in helping to address this issue in their clinical practices. Through the use of an in-office assessment to examine vision, cognition, and motor function, and appropriate referrals for a targeted evaluation of driving ability, physicians can help to identify those patients who may be at risk behind the wheel and help them find appropriate and safe mobility alternatives. For additional resources on older driver safety, visit the websites listed in Table IV.