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Assessing and Counseling Older Assessing and Counseling Older DriversDrivers
Identifying and Assessing the Medically Impaired Driver
AMA House of DelegatesAMA House of Delegates 1925 - Recommended that drivers receive a physician’s
certificate of medical fitness to drive. 1930 - Recommended that prior to licensure, applicants undergo
an exam to determine physical and mental capacity to drive. 1938 - Section on ophthalmology issued ”Visual Standards for
Operating a Motor Vehicle.”
AMA Committee to Study Problems of AMA Committee to Study Problems of Motor Vehicle Accidents Motor Vehicle Accidents (1930’s-1950’s)(1930’s-1950’s)
1939 report classified conditions influencing driving as:– Permanent deficiencies– Transitory deficiencies– Brief or self-inflicted deficiencies
This report stated that alcohol causes impairment at a blood level of 0.05%.
Report - 1963Report - 1963
“Age per se should not be a limitation once the individual reaches licensing age, rather the functional capacity and ability of each individual should be the determining factor.”
““Too Old” to drive?Too Old” to drive?
Numerical age is not the problemImpaired function is the limiting
factor
AMA report, 1963
Physician’s Guide to Assessing and Physician’s Guide to Assessing and Counseling Older DriversCounseling Older Drivers
Provides physicians with the tools necessary for assessing older patients for medical fitness to drive.
What functional abilities are What functional abilities are important to driving?important to driving?
Vision Cognition Motor function
Physician’s Plan for Older Driver SafetyPhysician’s Plan for Older Driver Safety
Screen to determine if patient is potentially at risk Assess driving related functional skills (ADReS) Treat underlying causes of functional decline Refer for further evaluation and/or adaptive training Counsel on safe driving behavior and alternative
options Follow-Up for signs of depression, isolation and
compliance
How can physicians screen patients How can physicians screen patients for medically impaired driving? for medically impaired driving?
Be alert to Red Flags:
Any medical condition, medication or symptom that can impair driving skills
Red FlagsRed Flags Acute events Patient’s or family member’s concern Medical history
– Chronic medical conditions– Unpredictable/Episodic events
Medications Review of systems
Prescription & OTC drugsPrescription & OTC drugs
alcoholantihistaminesantidepressantsbenzodiazepenesopiod analgesicsmuscle relaxantsantipsychotics
If Red Flags are presentIf Red Flags are present Ask health risk assessment/social history
questions– How did you get here today? – Has another treating physician brought up driving
issues?
Gather additional information– Do other drivers on the road cause you distress? – Have you had any recent problems when you drive?
Understand your patient’s mobility needs
How can physicians assess for How can physicians assess for deficits in function?deficits in function?
Assessment of Driving Related Skills
ADReS is a brief, function-based, in-office assessment of driving-related skills
ADReS does not assess patient’s performance on driving task
ADReS does not predict crash risk
Assessment of Driving Related SkillsAssessment of Driving Related Skills
Motor Function Rapid pace walk
Manual test of motor strength
Manual test of range of motion
Vision Visual fields by confrontation testingSnellen E Chart
Cognition Trail-Making Test, Part BClock Drawing Test
Interpreting ADReS resultsInterpreting ADReS results
Recommended scoring limits to evaluate patient’s performance
The goal is to identify and correct any functional deficits that may impair driving performance
Recommendations are subject to state reporting laws and DMV requirements
Three courses of actionThree courses of action
If patient performs well, continue driving without further work-up or treatment
If patient performs poorly, pursue medical treatment and necessary evaluation
If patient’s poor performance can not be medically corrected, refer patient to a Driver Rehabilitation Specialist
Targeted clinical assessmentFunctional on-road assessmentPrescribing and training clients in the
use of adaptive equipmentCounseling and advising on driving
concerns and mobility alternatives
Certified Driver Rehabilitation Specialists have expertise in:
Physicians can help maximize older Physicians can help maximize older driver safetydriver safety
Continue medical treatment & preventive care
Counsel patients on health and drivingIdentify at-risk patients & help manage
deficitsDiscuss driving retirement Abide by state reporting laws
Legal considerations
Protecting the patient– Case law illustrates that failure to advise patients
on medical conditions and medications is negligent behavior
– Case law also illustrates the health care system can be liable for breaching confidentiality
Protecting the public– Legal precedents demonstrates that physicians
may be held liable for third-party injuries
Legal protection for patient Legal protection for patient reportingreporting
Immunity- exempts physicians from liability for civil damages
Anonymity/Legal protection- protects physicians from civil actions for damages caused by reporting in good faith
Policy Issues
Impaired function determines driving safety not age.
On the road test essential to see how patient compensates for impairments
No immunity for physicians who report their concerns in many states.
National need for legislation to allow good faith reporting by physicians and other health professionals.
www.ama-assn.org/go/ olderdriverswww.ama-assn.org/go/ olderdrivers
American Medical Association
www.nhtsa.dot.govwww.nhtsa.dot.gov
National Highway Traffic Safety Administration