Quickly assess driving safety in the elderly: only 10 states require physicians to report patients to the department of motor vehicles.
NEW ORLEANS--Informing an elderly patient that it's time to stop driving because of health-related safety concerns is one of the toughest, most tension-racked aspects of primary care practice, according to Dr. Hollis D. Day.
"The driving conversation with the elderly patient and family is probably the least favorite conversation that I have with anyone. And the fact that my colleagues send their patients to me to have that conversation tells me they don't like it either," Dr. Day, a general internist at the University of Pittsburgh, said at the meeting.
"The reason is we're actually afraid that it's going to impair our future relationship with our patient. We've been with these patients for years, and now we're telling them to stop doing something that is absolutely critical and vital to them. It makes us look like the bad guy. But it doesn't have to be that way," she stressed.
She shared experience-based tips on how to make that discussion go as well as possible. She also explained how to efficiently conduct a driving safety assessment within the confines of a 10-minute office visit.
The first thing to understand about driver safety assessment is that there are no validated criteria for determining risk, she noted.
Although a classic study of Alzheimer's disease outpatients showed that they were overall less likely than nondemented controls to successfully complete a driving simulator test, many of the patients with mild Alzheimer's disease did pass the test. And no cut point on the Mini-Mental Status Examination could be identified below which it was unsafe to drive (J. Am. Board Fam. Med. 1998;11:264-71).
"There were people who were apparently safely driving with MMSE scores of 21 and 20. So there is no hard and fast cut point at this time. This is important because there are legal considerations," Dr. Day said.
Public safety dictates that physicians have a duty to recommend limitation or cessation of driving if a patient's health impairs their driving ability. Only 10 states have a mandatory requirement for physician reporting to the department of motor vehicles, but another 22 encourage reporting if the physician thinks there is a problem. State requirements change frequently.
The best place for physicians to go to learn their current state laws is the website of the Insurance Institute for Highway Safety (www.iihs.org/lawslolderdrivers.aspx), which is updated every 6 months.
In Dr. Day's home state of Pennsylvania, any health care provider has a legal duty to report a patient to the Department of Motor Vehicles within 10 days of diagnosing a qualifying condition. Such conditions specifically include visual impairment that is uncorrectable, such as macular degeneration or diminished depth perception, as well as Parkinson's disease, Alzheimer's disease, and any other cardiovascular, cerebrovascular, convulsive, or other health conditions that could impair a person's driving ability.
She sends off a standardized reporting form to the DMV. What happens next varies widely and seemingly arbitrarily, she said. Some patients will get a letter from the DMV stating that they need to come in for testing--either a written test, a road test, or a driving simulator. Others get a cease-and-desist order.
"That's when I get the angry phone calls. I tell them in advance that I have to report them, but if they're cognitively impaired, they may not remember having this conversation," Dr. Day said.
She'll often use the annual wellness visit as an opportunity to talk about driving safety. But she also can carry out a driving evaluation during a 10-minute office visit. The key elements are to check the heart and lungs and perform a 10-second Get-Up-and-Go mobility test; a cognitive screening test; a musculoskeletal exam addressing the cervical spine, knees, and hips; and vision testing, which she has her medical assistant do.
The Get-Up-and-Go test entails having the patient rise out of a chair without the use of arms, walk three paces, turn around, and sit back down in the chair--all as fast as possible. It should take less than 10 seconds.
"That's less than 10 seconds in your office to determine whether someone has got problems--potentially an arthritis problem or something else that could affect their driving ability. I defy you to give me any other screening test that takes less than 10 seconds," she said.
The fastest cognitive screening test is the Mini-Cog, which consists of clock drawing plus a three-word recall. It provides an indication as to whether additional neuropsychological testing is necessary. Dr. Day said that she also uses the Trail Making B test "all the time" because there is some evidence that it's a fairly good indicator of driving ability It's best to get someone on the office staff to become comfortable administering it.
The test instructions allow grossly impaired patients up to 5 minutes to connect the letters to the numbers, which is too much of a physician's time during a 10-minute visit.
Red flags in the history include a myocardial infarction, a stroke, traumatic brain injury due to a fall, seizures, the use of medications known to impair driving, and delirium.
"Development of delirium during a hospitalization is a sign that there's actually some underlying cognitive impairment that hasn't been recognized yet," according to Dr. Day.
Her preliminary screen for driving safety routinely includes the "10 Questions to Ask the Patient," which, she said, is described in the American Medical Association's very useful "Physician's Guide to Assessing and Counseling Older Drivers."
Among the 10 questions are, for example, "'Have you received any traffic citations for speeding, going too slow, improper turns, failure to stop, etc.?'" and "'Have others criticized your driving or refused to drive with you?'" she said. Patients can fill out the answers on a clipboard while they are in the waiting room.
Many patients will quickly see where these questions are headed and won't answer honestly. That's why the AMA also has come up with "10 Questions to Ask the Family." Among them are " 'Does the patient need a copilot to alert them of potentially hazardous events or conditions?'" and "'Do you feel uncomfortable in any way driving with the patient?'" Dr. Day said at the meeting. "That's a great question to ask the children because if they're not letting the grandchildren drive with grandma or grandpa, there's a problem," she pointed out.
Driver rehabilitation options include occupational therapy to address mobility limitations, instruction by a member of the Association for Driver Rehabilitation Specialists (www.driver-ed.org), local driving schools, and training courses offered by the American Association of Retired Persons, the American Automobile Association, and the National Safety Council.
But when it really is time to stop driving altogether, Dr. Day said that she speaks to the patient of "driving retirement," akin to the familiar milestone experience of retirement from work.
She also plays the public safety card, asking, "'Would you want to hit someone's child?'" And since she is in Pennsylvania, which is one of the mandatory reporting states, she 5 also mentions her own responsibility.
"I work that," she admitted. "I say, 'Look, my license is on the line. I have to report you.'"
One audience member, noting that driving cessation conversations are "often very tense," likes to lighten things up a bit in the following way: "I tell patients there are three categories of recommendations for driving: One is you can drive. Two is you cannot drive. And the third is you can drive, but not in my neighborhood."
Dr. Day said that an important part of preparing for the aftermath of not being able to drive involves alerting patients to the local resources that will help them get around without using their cars. Eldercare Locator (www.el-dercare.gov) is a U.S. Administration on Aging clearinghouse for local van services for the elderly and numerous other resources.
The National Association of Area Agencies on Aging (www.n4a.org) is another helpful organization. ITN America is a growing nonprofit volunteer organization of screened drivers available around the clock to drive patients (www.itnamerica.org).
She stressed that it is crucial to monitor for depression at the next office visit after a patient stops driving. Giving up the car keys is often a big blow to self-esteem, and it can reduce opportunities to engage in social activities.
Dr. Day reported having no relevant financial conflicts.
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|Title Annotation:||GERIATRIC MEDICINE|
|Publication:||Internal Medicine News|
|Date:||Jun 15, 2012|
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