Alice Pomidor, MD, MPH
Department of Geriatrics
Florida State University College of
Medicine
Copyright 2007, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

1. Recognize 3 risk factors for
Older Drivers
2. Describe extra risks associated with dementia
3. Identify 3 potential risk reduction interventions
4. Briefly discuss
Legal & Ethical
Driving Issues

South Florida Sun-Sentinel -2007
 80-yr-old Boca Raton woman
 Driving a 1990 Mercury Grand Marquis
 Went over a concrete parking block, onto the sidewalk, through a metal parking sign and into the windows of the DMV office
 Was there for a license renewal retest

St. Petersburg Times - 2005
 93-year-old man
 Apparently suffering from dementia
 Fatally struck a pedestrian and drove for three miles with the man's body through his windshield
 Spotted by a tollbooth attendant who called

 “It’s getting very hard to drive at night. I don’t like to go out because I don’t think it’s safe. Is there something you can do to help?”
 “You have to talk to Dad about his driving when you go in. He almost hit someone the other day, and I don’t feel like he can take the children out.”
 “ My neck is so sore from that fender-bender.
The emergency room said to go see the doctor if the pain didn’t go away after a few days.”

Welcome to Florida
Age
65 + years
# of
Drivers
Over 2.2 million
85 and up 242,480
Fatalities in 2001
1. Florida = 268
2. Texas = 254
3. CA = 224
NHTSA:
By 2020, one in four drivers will be age 65 or older
Leading cause of accidental death for ages 65 – 74, secondleading cause over age 75

1 Federal Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey.
Washington, DC: U.S. Department of Transportation.

•More men than women :
About 25% of women in this age cohort never learned to drive.
•Drive fewer miles per year :
Average 5800 miles per year, compared with 9800 miles per year in younger drivers.
•MVAs slower
: Accidents usually involve lower speeds and are more likely to involve multiple vehicles.

•Often self-restrict :
Tend to avoid driving at night, during rush hour, through bad weather, or through unfamiliar areas.
•Moving violations:
Most frequently incurred by missing signs and signals, crossing lines while passing, or making left-hand turns.

Varies hugely between
States:

8 states require no testing at the time of renewal

16 states require extra testing for older drivers, or more frequent renewals Driving tests can be a real bear!

Only California requires reporting of dementia to their
Bureau of Motor Vehicles


License renewal every 4-6 years, depending on driving history

In-person every third cycle (can mail it in for up to 18 years)

Written, road tests at discretion of the
Department of Highway Safety & Motor
Vehicles (DHSMV )

Vision testing over age 80 at in-person renewal

 Vision/hearing changes
 Neurologic changes
 Musculoskeletal changes
 Comorbid chronic illness
 Functional changes
 Medications

Static visual acuity: 20/40 or worse in 13% over age 65

Field cuts: present in 13% over age 65; 70 degrees noticed

Glare/light sensitivity: light scatters, can change day to nighttime acuity from 20/50 to 20/200

Useful Field of View: 40% loss doubles crash rate

Increased prevalences of...
Diabetic retinopathy
Cataracts
Macular degeneration
Glaucoma

40 dB or less in good ear for unrestricted license
(AMA Recommendation)

Classical definition:
Slows with advancing age
Perceptionresponse time:
Similar in older & younger adults; within 2.5 seconds allowed

Grip strength of 35 pounds or more is recommended in order to control wheel, unless adaptive equipment used

Relative risk/odds ratio
Back pain in the past 12 months
Diabetes with neuropathy
Depression
Coronary artery disease
Stroke
Arthritis among females
0 1 2
Other chronic illnesses: Seizure disorders and dementia (30% still drive with moderate dementia)
3

Relative risk/odds ratio
Falls in the past 2 years
Walking < one block per day
Difficulty copying a pentagon
3 or more foot abnormalities
0 0.5
1 1.5
2 2.5
3
Nearly 50% likelihood of adverse driving event in the next year if bottom three conditions exist

Relative risk/odds ratio
ACE inhibitors
Beta-blockers
NSAIDs
Benzodiazepines
Alcohol abuse
Tricyclic antidepressants
Opioid analgesics
Anticoagulants
0 2 4 6

 Unable to locate familiar places (gets lost)
 Does not observe traffic signs (esp stop signs)
 Drives at inappropriate speeds (usually slow)
 Makes poor or slow decisions in traffic (at fault 5 times more often in left hand turn crashes)
 Becomes angry, frustrated or confused easily while driving
 3 years or more since diagnosis
Brown LB, Ott BR. Driving and dementia: a review of the literature. J
Geriatr Psychiatry Neurol 2004;17: 232-240.

 Driving History-who, what, when, where, why, how
 Accident or “near-miss” events
 Recent changes/self-restrictions
 Chronic Illnesses
 Alcohol use
 Medications

 Visual screening: Snellen chart, visual fields
 Auditory screening: Whisper test, audioscope.
 Cognitive screening: Clock-drawing test, MMSE
 Psychological screening: Depression scale
 Functional status: ADL’s, IADL’s, falls.
 Musculoskeletal/neurological screening: Gait observation, feet exam, hand grip, joint range of motion, proprioception, strength


Treat any reversible deficits identified above .

Eliminate potentially problem medications

Counsel on proper use of seat belts

Counsel avoidance of suboptimal driving conditions such as lack of sleep

Recommend avoidance of driving under influence of alcohol or medications


Encourage use of driving refresher courses
(such as “Drivers 55 Plus” )

Identify alternative transportation

Refer to occupational therapy or local driving school for formal evaluation

Association of Driving Rehabilitation
Specialists at http://www.aded.net/i4a/pages/index.cfm?pageid=1

 AAA -Senior Drivers program at www.seniordrivers.org/home/toppage.cfm
 AARP -Driver Safety info at www.aarp.org/life/drive
 National Highway Transportation & Safety
Administration ( NHTSA ) Older Road Users www.nhtsa.dot.gov/people/injury/olddrive

 Begin discussions early to ease transition
 Identify a “trusted person”
 Many adverse consequences of driving cessation, including:
 depression
 dependency
 caregiver strain
 social withdrawal
 increased risk of entry into long-term care facilities
 restricted mobility

 Discuss alternate strategies
 confiscate keys
 park at a distance
 discontinue insurance
 disable or sell car
 have safe copilot (controversial)
 provide picture ID
 grind keys down

Section 322.126 (2), (3), Florida Statutes , provides that " Any physician, person, or agency having knowledge of any licensed driver’s or applicant’s mental or physical disability to drive...is authorized to report such knowledge to the Department of Highway
Safety and Motor Vehicles... The reports authorized by this section shall be confidential... No civil or criminal action may be brought against any physician, person, or agency who provides the information required herein.“ www.hsmv.state.fl.us

 All citizen complaints are evaluated
 If validated, re-examination at the driver license office or a medical report is required
 Drivers have 30 days to submit a required report or their driving privilege is revoked until they do so
 If the evaluator does not find any substance or validity to the complaint, no further action is taken

 If report indicates further review is needed, case is referred to the Medical Advisory Board
 Board may:
 request additional testing

 recommend restrictions recommend revocation of the driver’s license
 Drivers may be required to complete an onroad test as a condition of licensure or reinstatement

 Florida At Risk Driver
Council (FADAC)
 Reviewed current status of older drivers in Florida
 Recommendations issued February 2004
 Ken Brummel-Smith,
MD, chairperson
 4 pilot programs going