The Older Driver: When Is It Time to Take Away the Keys?

ABSTRACT: As the elderly population of the United States grows, it will become increasingly important to identify effective ways to determine the fitness of older adults to drive. Age alone is not an accurate predictor of driving performance. Current research indicates that crash rates among older drivers are likely related to an interaction between driver characteristics, such as physical and mental impairments; driving conditions; and the driving environment (eg, the presence of internal distractions). However, simply reducing the number of elderly drivers for safety reasons neglects the importance of mobility and independence for older adults. Physicians are thus faced with the dilemma of weighing safety concerns against the value of a driver’s license to the patient. Action at the societal level has the potential to reduce the burden of deciding whether an older driver is fit to drive, decrease the number and severity of accidents involving older drivers, and minimize injury resulting from collisions.

Key words: older driver, motor vehicle accident

The problem of the older driver has three players: the older driver, society, and the physician.¹ In this article, we will discuss their roles individually with appropriate references and offer our advice. Of course, the older driver is the key player.

We will start by presenting several cases. Each one tells a compelling story.

Andrew L. Haas, MD, an orthopaedic surgeon, was riding his bike not far from his hometown, Armonk, New York, in training for the “Ironman World Championship” in Hawaii. He stated he was in excellent condition, just 3 months away from competing with the best tri-athletes in the world, when he was struck by a 75-year-old man who turned left and drove directly into him. He fought for his life and then spent a year learning to walk again. After he had missed almost a year of work, Dr Haas had to rebuild his orthopaedic surgery practice. The elderly driver was charged with failure to yield and was fined $125. He was permitted to drive without restriction and without any assessment of his driving ability.

There are many newspaper reports of automobile accidents involving elderly drivers. In July 2003, a horrific accident occurred in Santa Monica, California, where an elderly driver sped down the length of an outdoor market, killing 10 out of 50 persons struck by his car. In July 2006, an 85-year-old man drove a car onto the patio of a Starbucks coffee shop in El Monte, California, and injured 10 people, 2 of them critically.

PROBLEMS FACING OLDER DRIVERS

Contributing factors to car accidents. Like all drivers, the older driver must execute standard driving maneuvers and overcome internal and external distractions. The older driver must accomplish this oftentimes with physical and/or mental conditions that increase the difficulty of these maneuvers, while facing a greater risk of serious injury. The National Highway Traffic Safety Administration maintains an online database containing data on severe motor vehicle crashes. Numerous examples of injuries to older drivers can be found within the database along with information such as hospitalization rates, crash details, and injury causation.²

Distractions are a major factor in crashes involving elderly drivers. Internal distractions, such as using a cell phone, adjusting controls, attending to passengers, and eating, increase the risk of crash injury to drivers of all ages.³ Drivers over 70 years of age face the highest relative risk of injury or death from crashes caused by internal distractions.³

Deteriorating physical and mental conditions contribute to the problems facing the older driver. Dementia is a particularly troublesome disorder that increases the risk of serious crashes.⁴ Other risk factors for older drivers are arthritis, reduced visual acuity, reduced concentration, slowed response/reaction time, and specific diseases such as Parkinson’s disease. Apart from these factors, older drivers must contend with the increasing numbers and speed of cars on the road.

Although older drivers pose some increased risk to occupants of other vehicles, the most serious risks are to their passengers and themselves. Older drivers experience the most serious consequences of their collisions (Figure 1). Two thirds of the deaths in crashes involving drivers 75 years and older were the drivers themselves.⁵ Differences in injury severity between men and women further complicate the matter. Female drivers aged 65 and older are more likely to sustain severe injuries than male drivers in the same age group.⁶

Some driving maneuvers become more difficult with age. Left turns across on-coming traffic present a complex and risky situation for older drivers. Accurately detecting, perceiving, and judging gaps in on-coming traffic increasingly challenge older drivers as a result of their diminishing visual capabilities, such as depth and motion perception.⁷

Predictors of driving performance. Because diminishing capabilities put older drivers and the general public at greater risk, we need to identify ways to predict driving performance. Numerous statistical tools, such as the Mini Mental State Examination, Trail Making Test Part A, Useful Field Of View test, and a composite measure of past driving incidents, have been studied to determine whether driving performance can be effectively predicted. Although associations exist between these predictors and driving performance, these tests are of limited predictive value as independent screening tools, especially considering the importance of the decision being made.⁸

Global severity of dementia is helpful to indicate the need for on-road assessment of older drivers. A study of dementia related to driving adults found that moderate to severe dementia equated to failed outcomes on assessment.⁹ Severity levels of very mild and mild resulted in pass and fail rates of 50%. Older drivers with negligible dementia passed the assessment.⁹

Identifying effective ways to determine the fitness of older adults to drive will continue to increase in importance as the elderly population grows. Results from the Second Injury Control and Risk Survey indicate that approximately 75% of adults aged 75 to 84 and 70% of adults aged 85 and older are current drivers.¹⁰ Most older drivers surveyed reported that they often limit their driving in hazardous conditions, such as during bad weather, at night, in traffic, or at high speeds.¹⁰ However, only about 15% reported limiting their driving because of medical reasons.¹⁰ The survey results also indicated that drivers who self-limit their driving are less likely to report a recent motor vehicle collision.¹⁰

Age alone is not an accurate predictor of driving performance. Current research indicates that crash rates among older drivers are likely related to an interaction between driver characteristics, driving conditions, and the driving environment.¹¹ Motor vehicle crashes that occur during the early evening result in a higher rate of injury for older drivers than for younger and middle-aged drivers.¹¹ The late afternoon and early evening effects of sundowner’s syndrome on older drivers include confusion, disorientation, and restlessness, which may contribute to involvement in motor vehicle crashes.¹¹

The presence of passengers impacts older drivers’ involvement in fatal crashes. Overall, older drivers benefit from having passengers in their vehicles.¹² Although the presence of passengers may contribute to some unsafe driving actions, such as ignoring signs and warnings, the benefits include reduction of unsafe actions, such as driving the wrong way, that pose the risk of serious injury.¹²

THE ROLE OF SOCIETY

Action at the societal level has the potential to reduce the burden of deciding whether an older driver is fit to drive, decrease the number and severity of accidents involving older drivers, and minimize injury resulting from collisions.

In Oregon, some healthcare practitioners are required by a law enacted in 2002 to report cognitively impaired drivers to the Department of Motor Vehicles. Judgment and problem solving, memory, and reaction time are among the most commonly reported cognitive impairments. Only 10% of suspended drivers eventually regain their driving privileges.¹³ Drivers over the age of 80 have the most difficulty regaining driving privileges and are six times less likely to do so compared with drivers under the age of 60.¹³ Drivers over the age of 80 years with chronic or progressive cognitive impairment accounted for more than half of the licensed drivers who lost their driving privileges under Oregon’s law.¹³

Public policy on restricted licensing has a significant effect on older drivers’ reducing or ceasing driving.¹⁴ Stringent renewal procedures and demanding medical examinations reduce the number of driving licenses among older adults.¹⁵

However, simply reducing the number of elderly drivers for safety reasons neglects the importance of mobility for older adults. Reduced mobility negatively affects their quality of life.¹⁶ The availability of safe travel options either as a driver or passenger plays a vital role in maintaining the health, well-being, and mobility of older adults.¹⁶

Appropriate planning and action in anticipation of rapidly increasing numbers of older drivers will contribute to reducing risk and injury. Taking steps such as developing or redesigning intersections as roundabouts has the potential to improve safety. Roundabouts effectively slow the speed of all vehicles and minimize collision angles, thereby reducing injury to older drivers.¹⁷

As the US population ages, people over the age of 70 account for a rapidly increasing percentage of drivers (Figure 2). Trends show that frequency and longevity of older drivers on the road continue to increase.¹⁸ For many years, crash deaths and fatal crash involvements among older drivers were on the rise, but between 1997 and 2006 these incidents steadily declined.¹⁸ The decline in fatal crash involvement rates among drivers over 70 years of age was greater than that among drivers between 35 and 54 years of age, and drivers over 80 years of age experienced an even greater decline.¹⁸

Educational programs designed to raise awareness among older drivers about safety issues contribute toward efforts to balance prolonged mobility and safety. The CarFit program strives to educate older drivers about optimally adjusting safety features of their vehicles to enhance their driving performance and safety. By focusing on items such as seat belt use and position, steering wheel distance from chest, positioning of foot to gas and brake pedals, and mirror use and position, CarFit detects opportunities to contribute to safe driving for the elderly.¹⁹ Educational programs such as CarFit have the potential to reduce serious injuries to older drivers through direct interventions and by increasing awareness for the possible need to self-limit driving.

THE ROLE OF THE PHYSICIAN

Currently, only 10 states require physicians to report to the department of motor vehicles when they diagnose a qualifying condition that may impair driving.²⁰ Another 22 states encourage physicians to report instances in which they see a problem. The lack of standardized reporting requirements results in physicians’ bearing the burden of the decision.

Older drivers can pose a significant problem for the physicians who care for them. Weighing the natural diminishment of vision, hearing, mobility, reaction time, etc, plus the many diseases of the elderly against the importance of a driver’s license to the patient, such as independence and mobility, creates a difficult dilemma. Furthermore, prescription and/or over-the-counter drugs may adversely affect the ability of older patients to operate a motor vehicle.

This is a “Hobson’s choice” for all physicians who care for elderly patients. Reporting concerns to the authorities is often accompanied by anxiety about violating Health Insurance Portability and Accountability Act (HIPAA) rules and fear of alienating the patient from the physician’s practice. Ignoring the problem could result in lawsuits if a patient who is an older driver injures or kills someone prompting the question of why the problem was not reported to the authorities.

Most primary care physicians lack confidence in their ability to accurately assess the driving fitness of older patients.²¹ Further complicating the matter is the knowledge that a driver’s license can directly impact an older adult’s quality of life. “Having someone tell you to retire from driving is devastating,” said Joanne G. Schwartzberg, MD, director of aging and community health at the American Medical Association (AMA).²² The sentiment of many physicians was captured during an AMA training session designed to help identify older patients with driving impairments by a physician who stated, “I would rather tell a patient he has cancer than tell him he should no longer drive. At least with a cancer diagnosis there is hope.”²² It is easy to agree with Dr Schwartzberg that losing a driver’s license is “a major life change with very unpleasant consequences.”²² Social isolation, loss of independence and, potentially, depression and anxiety are realities for many older adults who are unable to drive.

Discussing driver fitness with older patients has the potential to significantly impact a physician’s relationship with the patient and his or her family. Physicians often walk a delicate line between what is best for their patient and what is best for the safety of others. Addressing driving impairments through a collaborative approach that involves everyone who cares for a patient helps distribute the burden of difficult decisions.²³

Education programs provide another way for physicians to address their ability to assess driver fitness. An older driver curriculum developed by the AMA strives to increase health professionals’ confidence in assessing driver fitness and mobility planning.²⁴ According to a survey of physicians, those who were familiar with The Physician’s Guide to Assessing and Counseling Older Drivers had a stronger perceived role in assessing driver fitness and were more likely to engage in driving discussions with older patients.²⁵ Interactive, case-based workshops can contribute to improving the frequency and quality of physician reporting on older patients’ fitness to drive.²⁶

In my many years of clinical practice, I (AJF) have had these decisions to make. In some instances, I had to reluctantly report to the Pennsylvania Department of Transportation the medical fact that in my opinion this patient should not have a driver’s license. The results were I never saw the patient again and, additionally, I never received a report as to the outcome of my report from the Department of Transportation. A further consideration was the possibility of a malpractice suit for not preventing an older driver from driving, which resulted in a crash that caused serious injury or death to another party. Moreover, the HIPAA rules apply.

One of my solutions to this dilemma was to have a third party make these decisions to relieve the patient, the family and the physician of this onerous decision, namely using driving schools to evaluate the patient’s ability to drive. There are two driving schools in my area: Moss Rehab Driving Program and Bryn Mawr Rehab Adapted Driving Program. The physician completes a referral form, and the programs evaluate the patient’s ability to drive for a charge of $280 at Moss Rehab and $350 at Bryn Mawr. Some years ago, I tried to solicit support from foundations and insurance companies for a pilot program to underwrite the cost of this service. There were no takers.