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Medical Assessment of the Older Driver

Introduction

Driving is an essential skill for most of older drivers to maintain their autonomy and independency. Being able to drive is important for them to carry out their daily activities, for example, to attend medical appointments and social functions. However, some older persons may continue to drive as usual and deny their disability despite their underlying medical disorders or functional disability which might restrict their ability to drive safely. Therefore, it is important to evaluate an elderly driver and to recommend cessation of driving if he/she is found to be unfit medically.

Sign and Symptoms

Importance of medical assessment for older driver

In older persons, many disease and age-related changes of physical and cognitive function can lead to impaired driving ability. To ensure safe driving, the older drivers need to have intact motor, visual, cognitive functions. They must be medically fit to drive too. Many older drivers manage to compensate for deficits by driving more slowly or avoid busy road. However, some older drivers may continue to drive despite significant deficits due to denial, dementia, or desire to maintain independence. Therefore, it is important for health care professionals to carry out a thorough evaluation of the older driver and to make appropriate recommendation.

Role of health care professional

The role of health care professionals is to do functional and medical assessments related to driving safety and to communicate recommendations effectively to older drivers and their family members.

They may detect deficits during a routine medical examinationor when older drivers or their family members seek advice on their fitness to drive. They should counsel the elderly drivers and family members on any functional deficits or medical conditions which can limit the older driver’s ability to drive safely or to suggest appropriate modification to the vehicle to ensure the safety of the older drivers and society at large.

The health care professional should report the clinical findings and recommendations to the Department of Motor Vehicles if the older driver’s medical status and functional disability warrants the elderly to stop driving. If the elderly drivers’ abilities are questionable, the health care professional should formally request an on-road evaluation by the Department of Motor Vehicles.

For older persons who are not fit to drive, alternative transportation should be arranged and it often involves dependence on other family members, friends or the use of public transportation.

Medical assessment of the older drivers

The main step in assessing the older person’s ability to drive is to perform a thorough evaluation, including a comprehensive history and physical examination with special focus on underlying medical conditions and drugs intake which may impair their ability to drive. Driving history should also be reviewed, including details of driving habits, previous accidents or getting lost may point to the underlying causes of impairments.

Medical assessment involves review of medical conditions and drugs that could impair driving ability, for example:

  • Falls
    History of falls in older persons in the past year indicates increased risk of motor vehicle accidents (MVA). Falls and MVA have common underlying factors, e.g. impaired visual acuity, muscle strength and cognitive function. Therefore, older drivers with history of falls should have further evaluation on functional ability.

  • Heart problems
    Heart problems may increase risk of driving. In general, older driver should be refrained from driving for at least 1 month following a Heart Attack or Bypass surgery. Older drivers with severe heart failure, for example, breathlessness at rest or while driving should be refrained from driving until further cardiac assessment.

  • Neurologic disorders
    Neurologic disorders can increase the risk of accidents during driving, for example:

  1. Stroke or transient ischemic attack (TIA)
    Elderly drivers with first episode of TIA should wait for at least 1 month before starting to drive; those with repeated TIAs or stroke should wait for at least 3 month before resuming driving. Thorough physical examination should be conducted to assess if the residual disability secondary to underlying stroke may affect the ability to drive.

  2. Seizures or fit
    Older drivers with history of fit or on treatment for fit should not drive.

  3. Other neurologic disorders, for example, Parkinson’s disease can cause functional disability and should be evaluated thoroughly by functional assessmentpeople suffering from this condition should undergo a thorough functional assessment.

  • Diabetes mellitus
    Older drivers with Diabetes Mellitus may develop low blood sugar (or hypoglycemic) episode while driving and it can pose a risk to them. Older persons who have history of recent hypoglycemic episode affecting consciousness should not be allowed to drive until factors contributing to the episode have been identified e.g. improper or inadequate diet intake, excessive physical activity, wrong timing or dose of insulin. Older drivers with impaired sensory in the extremities secondary to underlying diabetes can impair the ability to drive and should be assessed.

  • Sleep disorders
    Elderly with sleep disorders, for example, obstructive sleep apnea syndrome, can lead to day-time sleepiness and drowsiness which can increase the risk of driving. They should be refrained from driving until adequately assessed and treated.

  • Drugs
    Older drivers should be refrained from driving for at least a few days when starting on a new drug that may affect the eye-sight, physical ability or cognitive function, to be sure that no adverse effects occur. Some medications can increase the risk of driving because they can cause drowsiness or low blood pressure. Elderly patients should be asked to bring all their medications to the clinic in order to identify which drugs that can increase the risk of driving.

  • Alcohol intake
    Older drivers are involved in fewer alcohol-related fatal MVA. However, concurrent use of alcohol and other medications for the underlying co-morbid conditions can further impair the cognitive function and increase the risk of MVA.

In general, any medical conditions or drugs that can affect the level of consciousness or impair the functional ability should raise concern about driving safety of the elderly and will need further assessment.

Complication

Impact of driving cessation

Many older drivers may be recommended to stop driving in view of their safety. Driving cessation can have negative impact on elderly e.g. social isolation or depression and can lead to impaired quality of life. Therefore, the elderly driver should be counseled and further transportation arrangement should be made to avoid further worsening of their functional status.

References:

  1. Mark HB, Thomas VJ et al. The Merck Manual of Health & Aging first edition. Merck and Co, 2004.

  2. Mark HB, Robert B et al. The Merck Manual of Geriatrics, 3rd edition. Merck and Co, 2000.

  3. Brian NF, Judith C, Nicola P et al. An Australasian Model License Reassessment Procedure for Identifying Potentially Unsafe Drivers. Traffic Injury Prevention 2008 vol. 9:350-359.

  4. David BH. Which older patients are competent to drive? Approaches to office-based assessment. Canadian Family Physician March 2005 vol. 51:3362-368.

  5. Helena L, Catarina L, Torbjörn F et al. A Swedish survey of occupational therapists’ involvement and performance in driving assessments. Scandinavian Journal of Occupational Therapy 2007 vol. 14;4:215-220.

  6. Langford J, Oxle J. Using the safe system approach to keep older drivers safely mobile. IATSS RESEARCH vol.30 no.2,2006:97-109.

Last Review : 20 June 2014
Writer : Dr. Ho Bee Kiau
Reviewed : Dr. Nor Hazlin bt Talib