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Healthcare Providers
Doctors
The safety of older drivers has long been a concern of the American Medical Association (AMA) and the Academy of Family Physicians. As associations representing and speaking to doctors, each has developed manuals and information pages to assist medical colleagues in counseling older drivers.
The doctor's role in older-driver safety covers three areas:
- Public Health and Safety
- Medical
- Legal/Ethical16
Public Health and Safety
Older drivers are the fastest growing population behind the wheel and suffer disproportionately from a high rate of traffic fatalities. From a public-health perspective, doctors can:
- Provide preventive care for potential impairments
- Assess individuals for medical fitness to drive
- Refer patients for functional evaluation and rehabilitation
- Counsel patients on driving safety
Some states have mandated that physicians report patients to the DMV they suspect should not remain behind the wheel.
Medical
Doctors also play a medical role in the older adult's ability to drive. Doctors conduct an assessment to evaluate the capabilities of the older driver to successfully function behind the wheel in terms of vision, cognition, alertness, and physical ability to operate the vehicle's steering, speed, and safety mechanisms.
Assessment of medical fitness to drive begins with a review of medical history. The doctor searches for these red flags:
- Medical conditions that may lead to impaired driving (dementia, arthritis, foot abnormalities, cataracts)
- Medications that can affect alertness and response time (antihistamines, decongestants, sleep medications, cough medicines, antidepressants, tranquilizers, narcotic painkillers)
- Recent health events (surgery, stroke, heart attack)
During the assessment, the doctor informally observes the appearance and behavior of the person, looking for:
- Level of personal hygiene and grooming
- Ability to walk and get in and out of chairs
- Ability to accomplish visual tasks
- Sharpness of attention, memory and understanding
- Concerns of the patient and family or partner about driving capability
The second step is to determine any needed medical intervention and, if required, the course of medical treatment. The doctor will identify the cause and treat the condition or make referrals to vision specialists, driving-rehabilitation specialists, or physical or occupational therapists.
If the patient appears functionally fit, the doctor can advise the driver about health behaviors that can maintain fitness. Finally, if the patient is not able to safely operate a car despite medical intervention and driving rehabilitation, the next step is counseling the patient on driving retirement.
Legal/Ethical Aspects
The AMA's policy is that physicians counsel the patient regarding medical evidence for substantial driving impairment that threatens the patient's and the public's safety. Counseling can include providing prevention and safety information, and advising the patient to cut back on driving. As a last resort, the doctor may recommend driving retirement. If the advice to discontinue driving is ignored by the patient, the AMA considers notifying the DMV both desirable and ethical.
Even with the endorsement of the AMA, doctors may feel reluctant to report unsafe drivers, fearing it will harm the trust between the doctor and patient or, at worst, will bring about legal actions. Some states provide immunity for doctors who report unsafe drivers to state regulatory agencies. The healthcare provider has the responsibility of knowing and following the reporting laws of a state.
If there are no legal requirements, then ethically the doctor should ensure that the unsafe driver remains off the road. Their doctor's position as an authority figure can influence many older drivers. Healthcare professionals who develop partnerships with other providers or with family members may find a team approach more effective in maintaining the special doctor-patient relationship and avoiding a potentially dangerous situation for the older driver and the community.
Nurses
Nurses in general can disseminate information about health and safe driving to older patients, make appropriate referrals, and keep doctors apprised of family and patient concerns about safe vehicle operation.
Occupational Therapists
Some occupational therapists have taken advanced training to conduct both on- and off-road driving-fitness assessments and interventions and can recommend alternative solutions. Some occupational therapists are also certified driving-rehabilitation specialists.
Driver-Rehabilitation Specialists
The Association of Driver Rehabilitation Specialists offers training and certification to professionals who work to maintain and improve driving safety. The American Occupational Therapy Association also offers training and continuing education to practitioners.
Driver-rehabilitation specialists may:
- Provide clinical driving assessments
- Conduct on-road evaluations
- Follow up with training in safe driving techniques
- Recommend adaptive devices and educate older drivers on their use
Most certified rehabilitation specialists are occupational therapists whose services are paid by health insurance companies. Medicare does not reimburse for assessment and retraining courses. A listing of driving rehabilitation specialists certified by ADED is available on the World Wide Web at www.aded.net.
The assessments that a certified rehabilitation specialist might use include:
| Vision |
Near and distant
Ability to see distant road signs or nearby car gauges |
Contrast sensitivity
Ability to see gray cars on a dark road, on a cloudy day |
Color
Ability to distinguish color of traffic signal lights |
Depth perception
Ability to judge adequate distance for merging or parking |
Visual field scanning
Ability to pick out objects by glancing around |
| Physical |
Pain
Ability to move leg from gas to brake pedal, or hold the steering wheel |
Strength
Ability to move legs |
Endurance
Ability to drive 1 hour |
Joint range of motion
Ability to reach safety belt or to turn head and neck to check traffic |
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| Visual Processing |
Useful Field of Vision
Ability to see and attend to images in side vision (peripheral vision) - especially important at intersections |
Trailsmaking
A
Requires maintaining attention in sequencing written numbers Ability to maintain attention and focus |
Trailsmaking
B
Requires drawing a line between sequential numbers and letters that are scattered on a page Ability to switch attention from one focus to another |
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| Cognition |
Traffic Symbol Recognition
Ability to interpret the meaning of traffic signs |
Short Blessed Test Requires remembering current dates, sentences and counting backwards Ability to recall memories, take new directions and make judgments |
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(Adapted from Hunt, L. (June 20, 2003) "Driving Assessments." American Society on Aging Web Seminar.)
Hospital Rehabilitation Professionals
Some hospital rehabilitation centers can conduct a driving assessment based on a doctor's order. The assessment may include evaluation of:
- Strength
- Coordination
- Vision (night vision and depth perception)
- Divided attention
- Brake reaction
- Understanding of road signs
Sometimes the center conducts an on-road driving test. Costs for hospital assessments vary, but are commonly $200-$600.
16Schwartzberg, J. G. (Mar. 13, 2003) "The Physician's Role in Older Driver Safety." Presented at the Joint Conference of the American Society on Aging and the National Council on Aging.
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