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Older Drivers: Recognition and Reduction of Risk Alice Pomidor, MD, MPH Department of Geriatrics Florida State University College of Medicine Copyright.

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Presentation on theme: "Older Drivers: Recognition and Reduction of Risk Alice Pomidor, MD, MPH Department of Geriatrics Florida State University College of Medicine Copyright."— Presentation transcript:

1 Older Drivers: Recognition and Reduction of Risk 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.

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

3 South Florida Sun-Sentinel -2007 l 80-yr-old Boca Raton woman l Driving a 1990 Mercury Grand Marquis l 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 Was there for a license renewal retest Driver crashes into license bureau

4 Elderly man drives with body in windshield 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

5 A Familiar Story? “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.”

6 Age # of Drivers 65 + years Over 2.2 million 85 and up242,480 Leading cause of accidental death for ages 65 – 74, second- leading cause over age 75 Welcome to Florida NHTSA: By 2020, one in four drivers will be age 65 or older Fatalities in 2001 1. Florida = 268 2. Texas = 254 3. CA = 224

7 1 Federal Highway Administration. 1997. 1995 Nationwide Personal Transportation Survey. Washington, DC: U.S. Department of Transportation. Fatalities by mileage and age

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

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

10 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 Only California requires reporting of dementia to their Bureau of Motor Vehicles Driving tests can be a real bear! License Renewal

11 Florida Licensing 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

12 Risk Factors for Driving Vision/hearing changes Neurologic changes Musculoskeletal changes Comorbid chronic illness Functional changes Medications Yours?

13 20/40 or worse in 13% over age 65 Static visual acuity: 20/40 or worse in 13% over age 65 Visual Changes-Acuity

14 present in 13% over age 65; 70 degrees noticed Field cuts: present in 13% over age 65; 70 degrees noticed Visual Changes-Fields

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

16 40% loss doubles crash rate Useful Field of View: 40% loss doubles crash rate Visual Changes-Useful Field of View

17 Increased prevalences of... Cataracts Glaucoma Macular degeneration Diabetic retinopathy Visual Changes-Eye diseases

18 40 dB or less in good ear for unrestricted license (AMA Recommendation) Hearing Changes

19 Similar in older & younger adults; within 2.5 seconds allowed Perception- response time: Similar in older & younger adults; within 2.5 seconds allowed Classical definition: Slows with advancing age Reaction Time

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

21 Seizure disorders and dementia (30% still drive with moderate dementia) Other chronic illnesses: Seizure disorders and dementia (30% still drive with moderate dementia) 0123 Relative risk/odds ratio Back pain in the past 12 months Diabetes with neuropathy Depression Coronary artery disease Stroke Arthritis among females Chronic Illnesses

22 00.511.522.53 Relative risk/odds ratio Falls in the past 2 years Walking < one block per day Difficulty copying a pentagon 3 or more foot abnormalities Nearly 50% likelihood of adverse driving event in the next year if bottom three conditions exist Functional Decline

23 0246 Relative risk/odds ratio ACE inhibitors Beta-blockers NSAIDs Benzodiazepines Alcohol abuse Tricyclic antidepressants Opioid analgesics Anticoagulants Medications and Alcohol

24 Risk Recognition in Dementia 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.

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

26 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 Driving Risk Assessment- Exam

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

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

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

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33 Driving “Retirement” 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

34 When you have no other choices 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

35 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 www.hsmv.state.fl.us Reporting

36 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 DHSMV Actions

37 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 on- road test as a condition of licensure or reinstatement Further DHSMV Actions

38 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

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