Carolina Osorio, MDGeriatric Psychiatry Fellow

UCLA Semel Institute of Neuroscience and Human Behavior

March 26 2012

OBJECTIVESOBJECTIVES

Understand the safety risks of older drivers

Indentify conditions that may put older drivers at risk

Indentify the role of the physician

Demonstrate familiarity with the law as well as California DMV reporting methods and requirements

DEMOGRAPHICS AND DEMOGRAPHICS AND SAFETY RISKSSAFETY RISKS

Taxonomy of Older Driver Taxonomy of Older Driver Behaviors and Crash Risk Behaviors and Crash Risk from NHTSA Feb 2012from NHTSA Feb 2012 Identify risky behaviors, driving habits

and exposure patterns that have been showed to increase the likelihood of crash involvement

Crash types where older drivers were most strongly overrepresented 2002-2006 using database from FARS and NASS

Taxonomy of Older Driver Behaviors and Taxonomy of Older Driver Behaviors and Crash Risk from NHTSA Feb 2012Crash Risk from NHTSA Feb 2012

Older people were increasingly less likely to be driving the striking vehicle in a two vehicle crash

High – speed two lane roadways and multilane roads with speed limits of 40-45 mph were associated with heightened older driver crash involvement

In two vehicle crashes, failure to yield was the most frequently cited factor

Starting at age 70, old drivers were specially likely to crash at intersections

With respect to single vehicles crashes , older drivers were somewhat more likely to be identified as ill or blacking out, drowsy or asleep, using medications or drugs ( other than alcohol), and having some other physical impairments ( hearing loss)

Annual Crashes per 1,000 Licensed Vehicle Drivers by Age of Driver (Source: Cerrelli, 1998)

Crashes per Million MilesTraveled by Age of Driver(Source: Cerrelli, 1998)

Percent of Persons with Dementia Percent of Persons with Dementia by Age Groupby Age Group

05

10

15

2025

30

35

4045

50

65 - 70 70 - 75 75 - 80 80 - 85 85 - 90 90 - 95

% of Aged Population

with Dementia

Age

Problems related to age can Problems related to age can includeinclude Reduced visionReduced vision Decreased strengthDecreased strength MedicationsMedications Cognitive impairmentCognitive impairment

California 3.1 M license drivers

Over 65 years

Impaired

Older drivers have an increased likelihood of being injured or killed in a crash.

L. Evans Traffic Safety (2004), Bloomfield Hills, MI: “Science Serving Society”

WHY IS DRIVING AN ISSUEWHY IS DRIVING AN ISSUE

Automobile crashes are the third leading cause of death and injury in the United States with 40,000 to 50, 000 people killed in about 2 million accidents per year

Drivers over age 75 had a higher rate of fatal accidents

nationwide in 2001- 2002. This problem is expected to grow because by 2024, one in four U.S. drivers will be over age 65

National Older Driver Research and Training Center

Physicians are in a unique position to anticipate the impact Physicians are in a unique position to anticipate the impact of physical and mental conditions on driving of physical and mental conditions on driving

impairment. impairment.

The privilege of driving is a source of freedom and empowerment for many individuals. Removing this privilege has its risks.

The loss of ability to be independently mobile can be a devastating psychological blow for an elderly patient. It also may restrict a patient access to meet medical and social services or to employment venues.

THE PHYSICIAN’S ROLETHE PHYSICIAN’S ROLE

CEJA of the AMA report on impaired CEJA of the AMA report on impaired drivers and their physicians: I-99drivers and their physicians: I-99

Physicians have an ethical responsibility to assess patients’ physical or mental impairments that might adversely affect driving abilities

Each case must be evaluated separately since not all impairments may give rise to an obligation on the part of the physician

The physician must be able to identify and document physical or mental impairments that clearly relate to the ability to drive

The driver must pose a clear risk to the public safety

RecommendationsRecommendations

1. Physicians should assess patients’ physical or mental impairments

2. Before reporting, there are a number of initial steps physicians should take

3. Physicians should use their best judgment when determining when to report impairments that could limit a patient’s ability to drive safely.

4. The physicians role is to report medical conditions that would impair safe driving. The determination of the inability to drive safely should be made by the states DMV.

RecommendationsRecommendations

5. Physicians should disclose and explain to their patients this responsibility to report

6. Physician should protect patient confidentiality by ensuring that only the minimal amount of information is reported

7. Physicians should work with their state medical societies to create statues that uphold the best interests of patients and community, and that safeguards physicians from liability when reporting in good faith.

AMA PHYSICIAN’S GUIDEAMA PHYSICIAN’S GUIDE

American Medical Association & National Highway Traffic Safety Administration (NHTSA)

““PhysicianPhysician’’s Guide to Assessing s Guide to Assessing and Counseling Older Driversand Counseling Older Drivers””

Quick screening and referral toolAvailable at:

www.ama-assn.org/go/olderdriverswww.ama-assn.org/go/olderdrivers

Office visit

Medical History: OSA are 2-6 time more likely to be involved in a MVA (Berger et al. 2000).

ROS

Family concerns

AGE ALONE IS NOT A RED FLAGAGE ALONE IS NOT A RED FLAG

Remember to address driving safety as needed.

Assessment of driving Assessment of driving related skills (ADReS) related skills (ADReS)

Elaboration of rapid decision making

Working Memory

Executive Functioning

Spatial Skills

Assessment of driving related Assessment of driving related skills (ADReS)skills (ADReS)COGNITION Trail B: Lafont confirmed a high correlation between increasing age

and poor attentional and executive performance, as measured by Trail-Making B, to be correlated with both crashes and driving cessation (Lafont, 2008).

N = 81 sec

MCI = 136 sec

Dementia = 190 sec

Ashendorf,

2008

Clock drawing test using Freund Scoring Criteria

The scoring is based on seven “principal components” whichwere derived by analyzing the clock drawing of 88 drivers 65and older against their performance on a driving simulator (Freund 2005).

YES NO

Only the numbers 1-12 are included

Number inside the clock

Numbers are spaced equally from each other

Numbers are spaced equally from the edge

One clock hand correctly points to 2

There are only 2 clock hands

There are no intrusive marks, writing or hands indicating incorrect time

Counseling the patient / Counseling the patient / familyfamilyPhysicians are influential in a patient’s decision tostop driving; in fact advice from a doctor is the mostfrequently cited reason that a patient stops driving.Persson, D. (1993)

1. Transportation options: http://beverlyfoundation.org/

2. Reinforce driving cessation:”Driving retirement”

3. Follow up letter

4. Follow up in a month

Driving Rehabilitation Driving Rehabilitation SpecialistSpecialist One who plans develops coordinates

and implements driving services for individuals with disabilities

Work with people who have strokes, low vision, limb amputation

www.ADED.net

What do with a difficult patient?What do with a difficult patient?

1. Encourage patient to complete the self screening tool

2. Counsel your pt on Successful aging tips and tips for safe driving

3. Roadwise review http://www.seniordrivers.org/driving/driving.cfm?button=roadwiseonline

4. DOCUMENT your concerns and support this with relevant information. Document patient reactions along with any counseling you have provided.

REPORTING REQUIREMENTS REPORTING REQUIREMENTS AND THE LAWAND THE LAW

California Code of regulations (CCR) title 17 sub-chapter 2.5California Code of regulations (CCR) title 17 sub-chapter 2.5““Disorders characterized by lapses of consciousness” sectionsDisorders characterized by lapses of consciousness” sections2800-2812.2800-2812.

“Reporting the local health authority” the non-communicable disease orconditions – AD- and related conditions and disorders characterized bylapses of consciousness .

2802 AD and related disorders. Means those illnesses that damage the brain causing irreversible, progressive, confusion, disorientation, loss of memory and judgment

2806 Disorders characterized by lapses of consciousness.

Loss of consciousness or a marked reduction of alertness or responsiveness to external stimuli

inability to perform one or more ADLs

the impairment of the sensory motor functions used to operate a motor vehicle

EX: OSA, abnormal metabolic states (DM)

Important issues about the regulations:Important issues about the regulations:

They are specific to physicians and surgeons per section 103900 of the Health and Safety Code

The physicians who reports a patient diagnosed with a disorder characterized by lapses of consciousness, according to the Health and Safety code 103900, shall not be civilly or criminally liable to any patient for making the report.

LiabilityLiability

Physicians are considered negligent if they do not informpatients of medications and medical conditions that canimpair driving

1. Physicians may be held liable for civil damages if they clearly failed to report an impaired driver who causes a MVC

2. Immunity is granted to the physician if the patient is reported prior to a MVC

3. Document all referrals, recommendations, conversations, and reports (e.g. copy of a driver retirement letter and “do not drive” prescription)

California California Individuals 70 years of age and older

Must renew license in-person

License is renewed for five years if vision and written tests are passed and there are no signs of cognitive impairment

A “limited term” license may be issued for one to two years if a medical problem exists but is not severe enough to stop driving (e.g. mild dementia)

Dementia moderate-severe = DL revoked

Dementia early or mild = Reexamination

In this manner, the California DMV hopes to balance the need for

public safety and with the perseveration of personal independence .

Reporting…….Reporting…….

In California in 1988 , healthy and safety code section 410 added AD and related disorders to the list of conditions that physicians are required to report to their local health departments, which then forward this information to CA DMV.

Based on the results of these examinations as well as a physician completed written driver medical evaluation (DME) form the DMV could allow the driver to:

Continue driving unrestricted

Continue driving with restrictions

Revoke or suspend DL.

SUMMARYSUMMARY

Safety, mobility and cost are critically important

Physician role is difficult: caseloads, poor training

Limited alternatives to driving

Recognize rights and feelings of older people

Many obvious solutions may not work very well

We started addressing this problem too late

"Above all, we must work together to ensure that "Above all, we must work together to ensure that older adults can remain mobile and productive older adults can remain mobile and productive even when they have to give up driving.“even when they have to give up driving.“

Thomas Meuser, Ph.D.

Research associate professor of neurology at Washington University.

THANK YOUTHANK YOU