The older driver: who is responsible? The state, the doctor, or the older driver?

The physician has a Hobson's choice in deciding if an older driver with problems of normal aging, disease, and medications should continue to drive. Several cases are presented here to illustrate the problem, open dialogue, and present a partial solution. The ability to drive will prevent or delay the onset of maladaptive correlates of aging, namely the loss of independence. In the year 2000, 18.9 million older drivers were licensed, which is an increase of 36% since 1990 (US Department of Transportation 2001). Moreover, there was a 12% increase of the over-65 population within this same time period. It is unknown how many older people lose their licenses due to poor health or are turned in by their physicians for medical reasons, as stipulated by law due to Federal Privacy Laws. Furthermore, information about how many older persons voluntarily give up their licenses is also not known. In view of the increasing number of elderly drivers, one of the largest automobile insurance companies in the US has produced an attractive booklet for discussing “family conversations” with older drivers. This highlights the problem that individuals and families, in most cases, do not stop impaired older drivers from driving. The medical profession needs an outside agency to insulate them from a difficult decision and still fulfill their responsibility to society. Normal aging has a major influence on vision, hearing, reaction time, and mobility. Furthermore, there are a number of common diseases that impact the older driver such as atherosclerosis and all its consequences, hypertension, degenerative joint disease, and diabetes. The geriatric population also takes many drugs, both prescription and over-the-counter, and these have side effects that can influence the ability of the older driver to manage an automobile (Finestone 2003). The reality of aging is that many of the physical and mental skills needed to safely operate a motor vehicle deteriorate. Older drivers have diminished vision, particularly at nighttime, reduced depth perception, greater sensitivity to glaring lights, reduced muscle strength, decreased flexibility of neck and trunk, slower reaction time, and less ability to divide their attention among various tasks, therefore decreasing their ability to make quick judgments. In light of the July 2003 accident in Santa Monica, CA, USA, where an elderly male driver sped down the length of an outdoor market killing 10 out of 50 persons struck by his car, the topic of driving in the elderly has become front-page news. The fatality rate for drivers 85 years and older is nine times that of drivers in the aged 25–69 according to the National Highway Transportation Safety Administration (US Department of Transportation 2001). Motor vehicle crashes are the leading cause of injury-related deaths for people aged 65–70, again emphasizing the seriousness of this problem (Traffic Safety Facts 2002). The burden of deciding which older person should drive or not drive places a physician in a very difficult situation. Many older drivers almost totally depend on their cars for transportation for medical visits, shopping, religious services, and socialization. Driving affords them a certain amount of independence and is very important for maintaining quality of life. National Patient Privacy laws further add to the complexity of the problem. The following case reports originate from the author's geriatric practice and illustrate some of the problems practicing physicians face. One proposed solution is the use of driving schools, which exist in some states of the US. Such schools may involve a medical referral and allow third-party evaluation of an older person's driving ability and degree of safety (see Appendices 1 and 2). However, there is a cost involved, which could be subsidized by the state or federal government rather than putting the burden on the older driver.