As our ageing population grows, GPs are more likely to become involved in decisions about transport issues with older patients. Health and transport are intimately linked, with the decision to cease driving – the most common mode of transport – nearly always related to health conditions. In turn, those who can no longer drive are less likely to receive the services that they need and are more likely to enter nursing homes, all other things being equal.

Indeed, the humble car is one of the most important forms of gerotechnology, with evidence that older people can maintain themselves at home by driving when they can no longer do so by foot or with public transport. GPs have an important role in supporting older people to be as mobile as possible for as long as possible. The better the overall health, the more comfortable the driving, and it is likely that many medications facilitate driving, such as anti-Parkinsonian, anti-inflammatory and antidepressant medication.

One consolation in this aspect of practice is the excellent safety record of older drivers. They are less likely to be involved in motor vehicle crashes (MVCs) than any other age group, but they typically drive fewer miles each year than younger drivers.¹ An apparent increased crash risk per mile driven has been shown to be an artefact and disappears when one controls for mileage (as low mileage is intrinsically risky).² If older patients are involved in an accident, their key risk arises from their fragility, whether in a car, a bus or as a pedestrian. When they are involved in traffic accidents, older people are more likely to be seriously injured or to die.³

GPs in general are aware of the importance of driving and understand the potentially negative effects of driving cessation, such as depression and social isolation. Up to now, GPs have not been helped by the literature that has dwelt overly on driving cessation, while taking a driving history may lead to interventions to improve driving ability and comfort by optimal management of treatable conditions such as Parkinson’s disease, depression and osteoarthritis. 

As physicians in assessing driving capacity, we should be wary that we are not unnecessarily turning older people into involuntary pedestrians. This is where the need for the development of an effective protocol to guide driving assessment becomes apparent.

This process will also be likely to be assisted by improved fitness to drive regulations arising from the Traffic Medicine Programme of the Road Safety Authority in conjunction with the Royal College of Physicians of Ireland, with the participation of many groups, including the ICGP. Current regulations are minimalist and not particularly helpful.

Driving history

The GP surgery is an apt setting for opportunistic screening of driving ability. Those with illnesses that may affect driving ease or safety should be asked about driving, particularly those with conditions such as syncope, epilepsy, dementia, stroke, Parkinson’s disease or significant arthritis. Just because they look frail, do not assume that they are no longer driving. As previously stated, it may be the driving that is keeping them in their homes.

As with many areas of practice in primary care, the GP’s prior knowledge of the patient and overall impression is important, although there has traditionally been a relatively low assessment of driving in primary care.⁴ The patient’s own view of driving should be assessed, (this has been usefully operationalised by the Adelaide Self-Efficacy Scale⁵ and a questionnaire from the US Highway Traffic Safety Administration⁶). 

Questions about abnormal driving behaviours and indicators of unsafe driving – crashes, dents on the car, ‘near misses’, driving too fast or too slow, getting lost in familiar areas and tickets for traffic violations – can aid assessment. Alcohol and drug misuse are also important. A collateral history can prove very useful, while keeping in mind the conflict of interest that may arise, but family doctors can usually make a good estimate of this.⁷

Medication review can also identify medications that may impair driving ability (eg. neuroleptics,⁸ long-acting benzodiazepines⁹). It also gives the physician an opportunity to identify the need for medications that may improve driving skills such as antidepressants, NSAIDs and possibly anticholinesterases.¹⁰

Clinical exam

Although many conditions can affect ease and safety of driving, the most notable are those of the nervous system, particularly dementia, stroke and movement disorders. GPs will generally recognise the salient condition potentially affecting driving, and will be able to prioritise this.

There should be a low threshold of suspicion to perform a formal screen for cognitive impairment with older drivers, as cognitive function on its own is a poor predictor of driving ability. Other aspects such as behaviour, insight and strategic thinking are also important. 

A brief cognitive screen can be useful in forming an overall wider picture, but will not be immediately helpful in decisions on fitness to drive. Other aspects that should be assessed include vision and motor function. Assessment of visual acuity and visual fields by a Snellen’s chart and confrontational testing respectively are satisfactory, with further specialist referral if any defects are detected. 

Assessment of motor function should focus on muscle strength and gait, together with the range of motion in selected joints (namely ankle, elbow, shoulder and neck). 

Putting it all together

A mnemonic for assessing older drivers is SAFE DRIVE: Safety record, Attentional skills, Family report, Ethanol, Drugs, Reaction time, Intellectual impairment, Vision and visuospatial function and Executive functions.¹¹ There is also an algorithm recommended by the American Medical Association that can be quite useful.¹²

For patients suspected of being at risk while driving, referral to an occupational therapist with experience in driving assessment, or specialist referral, may aid the GP in his decision to refer for formal on-road driver testing.

Performance-based on-road testing by a driving rehabilitation specialist evaluating practical driving skills is the gold standard in the assessment of the older driver. It involves assessment on a predetermined test route in a dual-control vehicle, assessing road position sense, awareness of other drivers, response to road signals, etc. Unfortunately in Ireland, the cost of assessment is borne by the patient.

Ethical dilemmas

Driving is a key element of social inclusion and independence at all ages. Assessment of the older driver in clinical practice is not ideal. An easy familiarity between patient and doctor can often mask the effects of cognitive loss. Patients can often become defensive and angry at the physician when they are advised to stop driving.

Also, the current Irish provision to screen all over-70s with a medical letter presents an ethical dilemma as repeated studies have shown that more older people die on the roads with this type of population screening.

The issue of alternative transportation, specifically the lack of it, can make the decision to proceed with driving assessment quite difficult. Often a patient does not have a spouse or family member to provide transport and public transport may not be available, particularly in rural communities.¹³

The role of the physician also extends to advising patients that they are obliged to inform their insurance company of their disability, although in our experience those fully assessed have not had an increased loading on their insurance. Where patients refuse to do this and there is evidence of danger to the public, there is almost universal support among most codes of medical practice for breaking confidentiality and informing a relevant third party, such as the Gardai.

What can be done?

GPs can play an important role in helping patients to accept the decision, enforcing driving cessation and suggesting alternative transportation resources.¹⁴ Some patients and their families may benefit from medical social work referral. For those with progressive disease, driving cessation will be aided by early diagnosis disclosure and discussion of eventual driving cessation.¹⁵

Restricted licensing is a useful intervention enforced in the state of Utah and in parts of Australia for people with impaired driving ability. It enables the patient to remain on the road under some restriction, eg. driving only within daylight hours. It is important to highlight the potential of compromised driving ability as this alone may heighten a patient’s self-awareness of the problem. Practical advice such as avoiding rush hour, motorways or areas of traffic congestion may also be helpful. Discussion of alternative transportation is essential.¹⁶

Driving assessment has become an integral part of medical assessment in the GP surgery. It is an ongoing challenge for doctors to assess driving ability in the clinical setting with the growing elderly population. Individual autonomy in driving, however, must be balanced with public safety. 

References

1. Retchin SM, Anapolle J. An overview of the older driver. Clin Geriatr Med. 1993; 9: 279–295
2. Hakamies-Blomqvist L, Ukkonen T, O’Neill D. Driver ageing does not cause higher accident rates per mile. Transportation Research Part F, Traffic Psychology and Behaviour 2002; 5: 271-4
3. Millar WJ. Older drivers—a complex public health issue. Health Rep. 1999;11(2):59-71. 
4. Retchin SM, Anapolle J. An overview of the older driver. Clin Geriatr Med. 1993; 9: 279-295.
5. American Medical Association. Assessing Fitness to Drive in Older People 2003; American Medical Association, Chicago.
6. Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physician’s guide to assessing and counseling older drivers. Washington, DC: National Highway Traffic Safety Administration; 2003
7. Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physician’s guide to assessing and counseling older drivers. Washington, DC: National Highway Traffic Safety Administration; 2003
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9. Hemmelgarn B, Suissa S, Huang A, et al. Benzodiazepine use and the risk of motor vehicle crash in the elderly [see comments]. The Journal of the American Medical Association 1997; 278(1): 27-31
10. Daiello LA, Festa EK, Ott BR, et al. Cholinesterase inhibitors improve visual attention in drivers with Alzheimer’s disease. Alzheimer’s Demen 2008; 4(4S1): T498
11. Wiseman EJ, Souder E. The older driver: a handy tool to assess competence behind the wheel. Geriatrics 1996; 51: 36–45
12. American Medical Association. Assessing Fitness to Drive in Older People 2003; American Medical Association, Chicago
13. O’Hanlon A, McGee H, Barker A, et al. Health and Social Services for Older People II(HeSSOP II): Changing Profiles from 2000 to 2004. Dublin: National Council on Ageing and Older people; 2005
14. Dubinsky RM, Stein AC, Lyons K. Practice parameter: risk of driving and Alzheimer’s disease (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2000; 54: 2205-11
15. Bahro M, Silber E, Box P, et al. Giving up driving in Alzheimer’s disease –an integrative therapeutic approach. International Journal of Geriatric Psychiatry 1995; 10: 871-4
16. Freund K. Independent transportation network: alternative transportation for the elderly. Transportation News 2000; 206:3-12