Growing Senior Population Increases Attention to Safety Behind the Wheel
By Camille Fitzpatrick, AGPCNP-BC
Clinical Professor, UC Irvine
Sue and Bill Gross School of Nursing
Life expectancy remains high and the older population is rapidly increasing. By the year 2060, the population of adults 65 and older will nearly double to approximately 95 million, making up at least 20 percent of the total U.S. population. In California, the population of those older than 65 may reach 20 percent in this decade. The fastest growing segment of the population is the 80-and-older group, which is anticipated to increase to 30 million over the next 30 years.
Driving is essential for performing necessary chores and maintaining socialization. Many older adults continue to work past retirement age and do volunteer work or other organized activities. In most cases, driving is the preferred means of transportation. In some rural or suburban areas, driving is the only available means of transportation.
It is estimated that the average man will live 6 years without the functional ability to drive a car, and the average woman will have 10 years.
Some questions for primary care providers to consider:
How old is too old to drive?
Age alone is not a red flag for driving safety. We have all seen unsafe driving practices in younger patients, such as parents with many kids in the car or patients driving under the influence. The media often emphasizes age when an older driver is involved in an injurious crash.
What medicines affect our ability to drive?
The list is too long to include here. The Training, Research and Education for Driving Safety (TREDS) program at UC San Diego provides an excellent guide for medications and driving. Consider the number of medications a patient takes and their potential interactions, and remember the effect of alcohol on our patients as well.
Who should be screened for driver safety?
As a baseline at age 65, all those with a recent major health change, cognitive changes, vision changes, frailty, loss of consciousness seizures, or polypharmacy should be screened. Screening should also be conducted when a family member expresses concern over their loved one’s driving ability.
How do we screen for driver safety?
The Clinical Assessment of Driving Related Skills (CADRES) is a toolbox of practical evidence-based assessments performed in the office. These functional assessment tools are in the key areas of vision, cognition and motor and sensory function related to driving.
Let's discuss a patient.
An 81-year-old woman presents to your office one day after a syncopal episode during a two-mile walk. She plans to drive on a two-hour trip to see her granddaughter’s graduation. What do you advise?
There are four questions we need to answer:
1. In the course of evaluating patients, what is your legal obligation?
California is one of seven states requiring mandatory reporting to DMV. Title 17, California Code of Regulations: Section 2810 requires clinicians to report conditions that cause lapses of consciousness, seizures, or diseases related to Alzheimer’s (and other dementias). Disorders characterized by lapses of consciousness refer to conditions that involve marked reduction of alertness or responsiveness to external stimuli, and inability to perform one or more activities of daily living.
2. What conditions does Lapse of Consciousness (LOC) cover?
Such conditions include cardiac, neurologic (including seizures), metabolic (including hypoglycemia) and other disorders.
Our patient had a syncopal episode, which qualifies as LOC. Prior to reporting to DMV, the patient had labs drawn for dehydration and other metabolic causes, and had a resting EKG. She was advised not to drive, and a report was made to the DMV. While waiting for the DMV medical evaluation form, the patient had three-day holter monitoring and an echocardiogram.
3. What information does DMV need?
To meet DMV’s mandatory reporting, any of the following three options are acceptable:
The first option is to report to the local public health department utilizing the Confidential Morbidity Report (CMR). Public health will then forward the form to the DMV.
The second option is to report directly to the DMV using the Driver Reexamination Form. This form can also be completed by a non-medical person, such as a police officer or concerned family member or neighbor.
The third way to report an unsafe driver is to document on your letterhead and fax to the local DMV driver safety office. Be sure you tell the patient you are reporting him/her and document in the chart that you have advised against driving until DMV has completed its evaluation.
After your notification of DMV, the patient will receive a Driver Medical Evaluation Form, which they must bring to their health care provider for completion. This is a five-page form to be completed as best you can.
Two questions on the form are of particular importance to the DMV: do you currently advise against driving, and would you recommend a driving test be given by the DMV?
The patient will take the completed form to the DMV, where they will be evaluated in a formal hearing, which includes a review of your recommendations, their past driving history, and a written and eye examination. In addition, the patient may be required to take an on-the-road driving assessment. DMV may recommend further evaluation, limited license (including short distances or no night driving) and repeat testing at DMV in 6 to 12 months. DMV may also immediately revoke the license.
Our patient was stable and following medical advice, so the DMV allowed her to continue driving but required her to report any further episodes to her PCP. Additionally, she was required to return to DMV in 12 months for follow-up evaluation.
4. What resources are available to the patient?
As nurse practitioners, we have an opportunity to shift the message of negativity of driving cessation to a more positive one of “retirement” and safety. These discussions can occur at the Medicare Annual Wellness Visit, during a routine visit, or with a medication change. Resources should be available to patients and their families.
Recommended helpful patient resources include:
Resources and references for clinicians:
Camille Fitzpatrick, AGPCNP-BC, is a Professor of Nursing Science at the UC Irvine Sue and Bill Gross School of Nursing, where she coordinates the Adult Gerontology Primary Care Nurse Practitioner Program. Since 2003, Fitzpatrick’s research has focused extensively on older adult driving. Her current work in this field is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
Fitzpatrick is a long-time member of CANP’s Orange County Chapter, and served as CANP’s Education Co-Chair from 2012 to 2015. In 2014, she received CANP’s Bridging Health Care Needs award, which recognizes a nurse practitioner who is active as a catalyst for positive change in the health care system, and who demonstrate the value of the care nurse practitioners provide to their patients.