Elderly drivers are safer than you think, but EPs still need to be aware of red flags for increased MVC risk

An 80-year-old man presents to your ED following his second fender-bender this year. He had his three grandchildren in the back seat this time, but fortunately nobody was seriously injured as they rear-ended the truck in front of them while traveling at low speed. Grandpa has a small forehead abrasion but an unremarkable cranial CT and no other injuries, and his adolescent grandkids are sitting at the bedside without any injuries or complaints. What is your role in assessing your patient’s capacity to continue driving in the long-term?

We’ve all heard the sensational news stories about older drivers crashing into crowds or running over innocent pedestrians. But the reality is that most older drivers are safe to stay on the roads, and as a group they pose a low risk to the community. In fact, it’s estimated that drivers aged 75 and older are responsible for only 4% of pedestrian fatalities while drivers aged 16 to 24 accounts for 26%. Older drivers do have higher motor vehicle crash (MVC) rates per mile driven and have less physiologic reserve to recover from injuries. And per capita fatal MVC rates, which are highest for those aged 16 to 25 years, rise again at age 70 (Table). But many older drivers limit their driving as they age, and such self-restriction of driving may decrease future crash risk. So who’s safe to stay on the road?  With the baby boom generation continuing to age, the volume of ED patients over the age of 65 is rapidly growing. Despite our overall brief interaction with our patients, we are uniquely positioned to intervene at critical junctures in their lives.

In 2007, there were 30 million drivers aged 65 or older, accounting for 15% of all licensed drivers. The number of older licensed drivers has increased by about 20% over the last ten years and will likely continue to grow. Advanced age itself is not a risk factor for unsafe driving; rather, it is the numerous conditions that come with aging that can affect a driver’s ability. Changes in cognition, vision, peripheral sensation, reflex time, motor strength and flexibility can all impact driving safety, as can specific medical conditions. Many medications—and combinations of medications—also affect the ability to drive. However, these conditions and medications affect individuals differently, so it has been difficult to develop simple algorithms to identify older drivers at high risk for MVCs. This has resulted in wide variation in state laws for the licensing and retesting of older drivers. Unfortunately, attempts to restrict the driving privileges of drivers considered high risk may unnecessarily curtail the driving privileges of lower risk drivers. Limiting transportation in the older population is associated with poor health and depression because a higher level of social integration—such as attendance at church and group activities—is linked to a lower mortality risk.  If we could identify drivers who may be at high risk for MVCs, the safety of individuals and the community could be improved while protecting the independence of other, safe older drivers.

Currently, most testing of older drivers occurs in physician offices or state licensing offices, with wide variation in the tests used. Ideally, the early identification of higher risk patients could allow a more gradual transition process from driving to other modes of transportation. Driver evaluation programs are available in many locations; these programs, staffed by specially-trained occupational therapists and other providers, usually include comprehensive testing of cognition, vision, and on-road driving ability. These programs can offer simple changes in driving habits or simple devices (i.e. wide angle rearview mirrors) to improve safety.

Unfortunately, most programs are not covered by health or automobile insurance and many patients cannot afford the fees, which are usually of $100 or more. However, many drivers may be open to evaluations that provide retraining or modifications to stay safe—rather than automatically revoking a license for the smallest problem—and insurance discounts might be another way to incentivize participation. 

Despite the reality that ED providers are often overstretched by expanding patient volumes, it is plausible that tinitial driver safety screening could be performed efficiently and accurately within the ED. While emergency providers cannot take primary responsibility for identifying high risk older drivers, they could help identify those drivers in need of further testing as part of a multi-step evaluation process. In the past, EDs have proved to be appropriate settings for a variety of screening and risk assessment programs, including falls, suicide, domestic violence, alcohol and drug abuse, and chronic disease and injury risk factors. Currently, the Society for Academic Emergency Medicine Geriatric Academy suggests that older patients should always have mental and functional screening as part of their emergency encounter, and the American Geriatric Society supports the development of brief driver screening tools for use in the ED.

Although a variety of factors affect driving ability, prior studies have suggested that screening for cognitive impairment may help in identifying high risk drivers, especially since those drivers with cognitive dysfunction may be least able to self-regulate. Currently there is no validated, brief screening tool to identify high risk drivers, in part because of the variety of factors that affect driving ability. Organizations like the American Medical Association, the American Automobile Association, and the AARP have developed various tools for use in physician offices or at home, but none of them is short enough to be practical in a busy ED setting. Research is currently ongoing to determine how to best adapt these tools to an ED setting, as prior surveys have demonstrated that patients do want professional, objective advice about driving and that screening for cognitive dysfunction and frailty in the ED is feasible. Identification of these potentially high risk patients, with referral for further testing, may result in a more gradual reduction in driving and in the prevention of serious injuries or death. Issues of payment and follow-up remain barriers to widespread implementation of screening, as driver programs vary in their pricing and states vary in their regulations concerning reporting of unsafe drivers by physicians or other providers. Ideally, future systems could include financial support for testing of high risk patients, with follow-up through the driver program or a primary care doctor rather than ED personnel.
So what should you do with this patient? Despite the lack of validated screening tools and interventions in the ED, here are several suggestions to help identify and intervene for high risk drivers:

• Be aware of red flags including cognitive impairment, physical limitations such as motor weakness or poor peripheral sensation, significant visual impairment, MVCs caused by medical conditions (such as syncope, seizure or dizziness), and the use of multiple medications. Also be aware of how new prescriptions—notably narcotics and other sedating drugs—might affect future driving ability and counsel patients appropriately.
• Talk with patients and their families to discuss concerns and local resources. A family member’s assessment of the patient’s driving safety may be one of the most reliable predictors of driving ability.
• Contact the patient’s primary physician to express your concerns and arrange outpatient driving assessment.
• Provide resources for the patient and their family (examples listed below) to encourage transition to safe transportation.
• Be aware of local or state laws; in some states, physicians are legally obligated to report medical conditions, such as seizures or dementia, that can affect driving ability.

The importance of geriatric injury prevention will grow with the anticipated doubling of the 65 and older population between 1980 and 2030 and with ED utilization rates by older adults that are increasing faster than population growth. By implementing a brief and accurate driving screening tool in the ED, providers might be able to identify patients at higher risk for MVCs and refer them for further formalized outpatient driving assessment. As emergency providers who care for a growing volume of older patients, we will have unique opportunities and responsibilities in the coming years.

More Information:
For Providers
www.seniordrivers.org/lpp  
This AAA database of state regulations and reporting requirements for older drivers is searchable by state and type of regulation.  
www.aota.org/driver_search/index.aspx  
The American Occupational Therapy Association web page allows users to search for local driver evaluation programs.
For patients and families
www.seniordrivers.org
General information, self-screening tools, and links to local classes and resources.
www.aarp.org/home-garden/transportation/ds_program
The AARP’s “Driver Safety Program” also has general information and links to online and local classes.
www.aota.org/Older-Driver/Consumer.aspx
The American Occupational Therapy Association site has general information, safe driving tips, and information about driver evaluation programs
www.jama.com
Read JAMA’s patient hand-out on “Older Drivers and Cognitive Impairment” from April 28, 2010

References:
    •The 2010 Statistical Abstract: Licensed Drivers and Number in Accidents by Age, 2007. U.S. Census Bureau. 2009. Available at: http://www.census.gov/compendia/statab/cats/transportation/motor_vehicle_accidents_and_fatalities.html.
    •Bedard M et al. Predicting driving performance in older adults: We are not there yet! Traffic Inj Prev 2008;9:336-41.
    •Carpenter CR, Gerson L. Geriatric Emergency Medicine In: LoCicero J, Rosenthal RA, Katlic MR, Pompei P, eds. A Supplement to New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society and John A. Hartford Foundation; 2008:45-71
    •Carr DB et al. Physician’s Guide to Assessing and Counseling Older Drivers, 2nd edition, Washington, D.C. NHTSA.  2010.
    •Eby DW, Molar LF. Driving fitness and cognitive impairment: Issues for physicians. JAMA 2010;303:1642-3.
    •Ngian VJJ, Ong BS, O’Rourke F, Nguyen HV, Chan DKY. Review of a rapid geriatric assessment model based in an emergency department. Age Ageing (2008) doi: 10.1093/ageing/afn160.
    •Roberts DC et al. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med 2008;51:769-74.
    •Tefft BC. Risks older drivers pose to themselves and to other road users. J Safety Res 2008;39:577-82.
    •Traffic Safety Facts 2007: Older Population. National Center for Statistics and Analysis, National Highway Traffic Safety Administration. 2008. Report No. DOT HS 810 992.