Physicians and advance planning for 'driving retirement'.

By 2020, there will be more than 40 million older drivers on U.S. roadways.1 Older drivers face elevated risks of injury and death from car crashes and some may pose risks to the surrounding community, as a variety of impairments (cognitive, mental, physical, or sensory) and medications common in older adults can affect driving ability.2 At the same time, premature driving restrictions may negatively impact older adults’ well-being because of the important link between mobility, independence and good health.2 Almost all older adults will someday face the decision about whether to retire from driving,3 which requires a careful analysis of these risks and benefits. And almost always, such decisions are difficult and emotional. Physicians have a unique and critical role in guiding older drivers because they are trusted by patients and their families, are in a position to have access to information about an individual’s physical and cognitive conditions that might affect driving ability, and have ethical and legal obligations related to patient and community safety.2, 4 This information includes disease diagnosis or prescribed medications that may induce sleepiness or impact cognitive processing speed.5, 6 However, physicians are often reluctant to discuss with a patient their medical fitness to drive.2, 7 Physicians have reported that they find it difficult tell a driver it’s time to “hand over the keys” because of limited training or experience with counseling older drivers, inadequate knowledge of relevant state policies, fears of damaging the physician-patient relationship, or concern about the potentially devastating impact of this transition on an older driver’s life.2 Because of these concerns, as well as competing demands during office visits, physicians may wait to bring up driving until a family member reports a concern or there is a crash other “red flag.”4 But consider this: most Americans will outlive their safe driving ability by approximately 7 to 10 years.3 Therefore, “driving retirement” is inevitable for most older adults.8 Older adults may stop or limit their driving for a variety of reasons, such as physical conditions (for example, declining vision), financial concerns (such as the expense of owning a car), or anxieties about driving.9 Whatever the catalyst, driving retirement can be a profound and distressing experience for an older adult. However, advance planning for driving retirement offers the potential to ease an older adult’s transition from driving to other forms of transportation and possibly to strengthen, rather than harm, the physician-patient relationship. Physicians may want to consider using “anticipatory guidance” with their older patients; this practice is used in pediatrics to prepare parents for coming physical and developmental phases10 but might also be useful in geriatrics. For example, advance planning for driving retirement might be incorporated into discussions about issues relevant to older adults, including home safety, financial security, and mobility. Advance planning for driving retirement is a multi-faceted process that should address a variety of issues.8, 11 First, efforts to help older drivers plan to retire from driving should consider their readiness for change and their ability and willingness to find and use alternative sources of transportation. Older drivers (and concerned family members) should anticipate the older adult’s transportation needs, especially the need to travel for work, shopping, participation in community activities, and visits to family and friends. Older adults should also consider transportation options besides driving. These options might include the availability and willingness of family or friends to provide rides (although older adults may be reluctant to become a “burden”). Senior ride services and public transit should also be explored; ideally, local databases would be available to guide discussions. Older drivers should also consider the relative costs of various forms of transportation, including driving, using available simple financial worksheets. Driving retirement discussions should also address the emotional factors associated with driving,8 especially those related to loss of mobility, independence and self-esteem. Thus these conversations should consider an individual’s motivation for driving, emotional stake in driving, social connectedness related to driving, and ability to learn new approaches to transportation.12 Advance planning for driving retirement should also include a discussion of what an older driver would want to do if, in the future, a new or worsening medical condition begins to affect driving safety. While some at-risk older drivers may trust the recommendation of a trusted physician or family member, others may demand a higher “standard of proof” (such as failure to pass a formal on-road driving examination). There are various options for screening and assessment of an older driver’s ability, although there is still debate about which on- or off-road tests work best to measure risk. The ideal screening test—one that is evidence-based, simple, accurate, predictive and easy-to-administer in a busy clinical setting—does not yet exist. Physicians should consider formalizing discussions about driving retirement by using an “Advance Driving Directive” to document a patient’s wishes. These are non-binding worksheets designed to facilitate conversations about future driving-related decisions, including formal testing and driving retirement.4 They encourage the older driver to identify a trusted individual to help inform future decisions about driving, especially in the case that significant cognitive impairments develop. Ideally, planning for driving retirement should be part of a larger, comprehensive process of planning for aging that covers health and health care, social supports, and environmental factors such as housing and community transportation.13 This process must involve older individuals as well as community planners, the business and medical care communities, and local governments, all working together to support the mobility, independence and social well-being of older adults.13 Within the healthcare setting, advance planning for driving retirement may be too long and complicated a process to complete during a single office visit, especially in the face of competing priorities and time demands. A decision aid may help with the process,14 but older adults will need support from multi-disciplinary teams that may involve general and specialist physicians, nurses, case managers, social workers, and physical and occupational therapists. But the need for a systems-based approach should not minimize the important role physicians play in discussing driving issues with patients and in advocating for more institutional and societal support. Driving is a key activity of daily living (ADL); just as physicians routinely consider other ADLs, such as the ability to obtain and prepare food or manage finances, they should help patients assess their driving ability and, when appropriate, facilitate discussions about driving retirement. Advance planning for driving retirement should become routine in our clinical practices—and in our homes—in order to support older adults and promote their health, safety and independence.