Get schooled on driver’s safety for older adults by expert, Alice Pomidor MD, Professor of Geriatrics at Florida State University. Whether or not older adults can continue to drive is a huge problem faced by for primary care clinicians, and will remain one until driverless cars become ubiquitous. Topics covered include: how to take a driving history, red flags, physical exam, cognitive exam, and vision assessment for driver’s safety, resources, when to refer, alternate means of transportation, and the legal repercussions of reporting…or not reporting.
Written and produced by: Matthew Watto MD and Elizabeth Garbitelli MD Candidate 2022
Editor: Matthew Watto MD
Cover Image by: Kate Grant MD
Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD
Guest: Alice Pomidor MD
In-depth Show Notes
Three Clinical Scenarios Where Driving Discussion Arises
The 5 Rs for clinicians older adult driver’s safety
Can Drivers Judge Their Own Ability? Older adult drivers are poor judges of their own driving ability. Caregivers tend to be a better judge of driving capability, but only if they have witnessed a patient’s driving ability first hand. (Bixby Am J Occup Ther. 2015)
Starting the Conversation: Ask how patient got to appointment today. Then, ask if they are driving at all, even if they take alternate transportation to the office. Ask how their driving is going and for more details about driving habits. (E.g. When do you drive? Have you had any near-misses or driving scares?). Don’t assume that patients with limited physical mobility have been instructed not to drive!
Red Flags in History: Family concerns about a patient’s driving i.e. the “hallway pounce”. Recent surgery, hospitalization, or any acute event that could induce syncope or cognitive changes. Common examples include: MI, stroke, brain injury, new onset of conditions like uncontrolled afib, uncontrolled arrhythmias, orthostatic hypotension, history of falls, seizures, hypoglycemic episodes, or uncontrolled sleep apnea. We need to be addressing with all older adult patients who someday may become impaired. What’s their alternate mobility plan?
The Clinical Exam
What can we do in clinic or at bedside to test a patient’s driving ability?
Musculoskeletal testing: Functional range of motion (ROM) of their arms: clasp hands behind head and hands behind back. ROM in neck: Try to turn head and put chin on each shoulder and see how well they do. “Get up and go”: Get up out of chair without using their hands, walk 10 feet and walk back and sit down. If longer than 10 seconds, then their stability/coordination should be investigated.
Vision testing: Visual acuity of 20/70 is the cutoff for most states. Also test visual field by confrontation. Alternatively, have patient abduct arms to 90 degrees and wiggle their fingers while staring straight ahead. This proves a 180 field of vision if they can see their fingers wiggle. Patients will not notice visual field loss until it gets to 70 degrees (according to Dr Pomidor), which is equivalent to putting hands behind head and keeping elbows at just outside shoulder width. Bilateral visual field deficit is unrecognized by nearly 60% of patients and is associated with double the risk for motor vehicle crash (Kilter J.L (eds) Fifth International Visual Field Symposium. Documenta Ophthalmologica Proceedings Series, vol 35.)
Cognition: The mini mental status exam is NOT correlated with driving ability. Use the clock drawing test instead, which examines visual spatial, abstract reasoning, planning, and reading sense. Dr Pomidor often performs the “Mini Cog”: clock drawing combined with 3 item delayed recall.
Instructions for mini-cog (Tsoi JAMA Int Med 2015): Give patient 3 words to recall. Write them down so you remember. Have patient draw a circle and ask them to put numbers on the face of a clock. Give them a minute. Then ask them to place the hands at either: 10 after 11 o’clock or 20 after 8 o’clock. Those times are specifically chosen because they utilize both sides of the clock and are not overly rehearsed times (e.g. 9 o’clock). Finally, ask them to recall the words. Scoring: Is there a circle? Numbers in right spot? Numbers all there? Is the time correct? Usually you can see easily “good clock” vs. “bad clock” and advanced scoring is not needed.
Snellgrove Mazes– Count dead-ends or hitting walls, if patient takes longer than 30 seconds or more than 7 dead-ends or wall hits, then they fail (Here’s an article on maze tests and crash risk https://www.ncbi.nlm.nih.gov/pubmed/22683280 ).
Having The Tough Discussion: If discussing a new medication or new condition, use it as an opening to discuss driving skills. Frame the discussion around safety, and accident prevention. Emphasize the costs of vehicle repair, medical bills and the need to recover from a serious injury. Ask the caregiver if they’ve noticed how a patient’s medical conditions have affected their physical functioning or driving ability. This helps to show patients that the disease is taking away their driving ability, not the physician or their family.
Put yourself on their side, EARLY: Discuss ways to prolong people’s time in driver’s seat to maintain independence, before it becomes an issue. This fits nicely into the “welcome to Medicare visit”, or during preventative care discussions about conditions that could limit driving down the road (e.g. uncontrolled diabetes). -Dr Pomidor
Taking Away The Keys
Reporting Unsafe Drivers
Know your states laws. Is there immunity for reporting? Can you be prosecuted for breach of confidentiality? Is reporting anonymous? Physicians can be held third-party liable if they do not try to stop unsafe driver adequately. Document that you have counseled patients and their caregivers of patient’s inability to drive. In general, it’s safer to err on side of reporting. Report patients to the agency in your state that provides drivers licenses (usually a DMV, though Texas has a Dept of Public Safety).
Dr. Pomidor’s Take-Home Points
1) Ask About Driving: It’s your responsibility as the clinician
2) Start Early with Driving Discussion: Link preventative healthcare to continuing to drive safely. This puts you on the patient’s “side”
3) Ask Yourself: Would you accept a ride from this person?
Goal: Listeners will learn a systematic and pragmatic approach to the evaluation and management of older adult driver’s safety.
After listening to this episode listeners will…
Disclosures: Dr. Pomidor reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Links from the show:
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.