# Presentation: 913635

## Assessing and Counseling Older Drivers		

- Identifying and Assessing the Medically Impaired Driver

## AMA House of Delegates

**1925 - Recommended that drivers receive a physician’s certificate of medical fitness to drive.**
**1930 - Recommended that prior to licensure, applicants undergo an exam to determine physical and mental capacity to drive.**
**1938 - Section on ophthalmology issued ”Visual Standards for Operating a Motor Vehicle.”**

## AMA Committee to Study Problems of Motor Vehicle Accidents 			(1930’s-1950’s)

**1939 report classified conditions influencing driving as:**
**Permanent deficiencies**
**Transitory deficiencies**
**Brief or self-inflicted deficiencies **
**This report stated that alcohol causes impairment at a blood level of 0.05%.             **

## Slide 4

## Report - 1963

**“****Age per se should not be a limitation once the individual reaches licensing age, rather the functional capacity and ability of each individual should be the determining factor.”**

## “Too Old” to drive?

**Numerical age is not the problem**
**Impaired function is the limiting factor**
**                                  ****AMA report, 1963**

## Physician’s Guide to Assessing and Counseling Older Drivers

**	****Provides physicians with the tools necessary for assessing older patients for medical fitness to drive. **

## What functional abilities are important to driving?

**Vision **
**Cognition **
**Motor function**

## Physician’s Plan for Older Driver Safety 

*Screen*** to determine if patient is potentially at risk**
*Assess**** *****driving related functional skills (ADReS)**
*Treat**** *****underlying causes of functional decline**
*Refer**** *****for further evaluation and/or adaptive training**
*Counsel**** *****on safe driving behavior and alternative options**
*Follow-Up**** *****for signs of depression, isolation and compliance**

## How can physicians screen patients for medically impaired driving?  

- Be alert to Red Flags:
*Any medical condition, medication or symptom that can impair driving skills*

## Red Flags

- Acute events
- Patient’s or family member’s concern
- Medical history
- Chronic medical conditions
- Unpredictable/Episodic events
- Medications
- Review of systems

## Prescription & OTC drugs

**alcohol**
**antihistamines**
**antidepressants**
**benzodiazepenes**
**opiod analgesics**
**muscle relaxants**
**antipsychotics**

## If Red Flags are present

**Ask health risk assessment/social history questions**
**How did you get here today? **
**Has another treating physician brought up driving issues?**
**Gather additional information**
**Do other drivers on the road cause you distress? **
**Have you had any recent problems when you drive?**
**Understand your patient’s mobility needs**

## How can physicians assess for deficits in function?

**Assessment of Driving Related Skills**
**ADReS is a brief, function-based, in-office assessment of driving-related skills**
**ADReS does not assess patient’s performance on driving task**
**ADReS does not predict crash risk**** ****	**

## Assessment of Driving Related Skills 

**Motor Function****	**Rapid pace walk
- 				Manual test of motor strength
- 				Manual test of range of motion**  **

**Vision ****	****	**Visual fields by confrontation testing
**	****	****	****	**Snellen E Chart

**Cognition** 		Trail-Making Test, Part B
- 			Clock Drawing Test

## Interpreting ADReS results

**Recommended scoring limits to evaluate patient’s performance**
**The goal is to identify and correct any functional deficits that may impair driving performance**
**Recommendations are subject to state reporting laws and DMV requirements**

## Three courses of action

- If patient performs well, continue driving without further work-up or treatment
- If patient performs poorly, pursue medical treatment and necessary evaluation
- If patient’s poor performance can not be medically corrected, refer patient to a Driver Rehabilitation Specialist**  **

## Targeted clinical assessment
Functional on-road assessment
Prescribing and training clients in the use of adaptive equipment
Counseling and advising on driving concerns and mobility alternatives

- Functional on-road assessment
- Prescribing and training clients in the use of adaptive equipment
- Counseling and advising on driving concerns and mobility alternatives

- Certified Driver Rehabilitation Specialists have expertise in:

## Physicians can help maximize older driver safety

- Continue medical treatment & preventive care
- Counsel patients on health and driving
- Identify at-risk patients & help manage deficits
- Discuss driving retirement
- Abide by state reporting laws

## Legal considerations 	

**Protecting the patient**
**Case law illustrates that failure to advise patients on medical conditions and medications is negligent behavior**
**Case law also illustrates the health care system can be liable for breaching confidentiality**
**Protecting the public**
**Legal precedents demonstrates that physicians may be held liable for third-party injuries**

## Legal protection for patient reporting

**Immunity- ****exempts physicians from liability for civil damages**
**Anonymity/Legal protection- ****protects physicians from civil actions for damages caused by reporting in good faith**

## Policy Issues	

**Impaired function determines driving safety not age.**
**On the road test essential to see how patient compensates for impairments**
**No immunity for physicians who report their concerns in many states.**
**National need for legislation to allow  good faith reporting by physicians and other health professionals.**

## www.ama-assn.org/go/ olderdrivers

- American Medical Association

- www.nhtsa.dot.gov

- National Highway Traffic Safety Administration