Driving Cessation with the Older Adult

Driving Cessation with the Older Adult. By: Mikira Patel, Kandice Speight , Jeanette Ward.

Older Adult Driver Safety Tips.

Driving Cessation. Occurs in older adults when they develop functional disabilities that affect their ability to safely drive. Men will have an estimated 6 years without the functional ability to drive a car , while women will have an estimated 10 years. As an advanced practice provider, we can help older adults continue to drive by identifying and managing medical conditions, such as cataracts and arthritis, or by discontinuing driving-impairing medications.

Clinical Levels of Care for Prevention of Driving Disability.

Why does driving cessation matter?. Unintentional injuries are the seventh leading cause of death among older adults Motor vehicle crashes are the second most common cause of injury after falls. Older adult drivers have a higher fatality rate per mile driven than any other age group except drivers younger than 25.

When do you step in and take away someone's independence?.

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[Audio] Chihuri reference. Loss of driving autonomy leads to...

[Audio] Betz, aarp. Advanced planning matters. Older adults are twice as likely to discuss driving safety with family members as with providers more likely to stop driving if the PCP and family both agree they are no longer safe to drive more likely to experience better health outcomes if they develop a plan for driving cessation It is important to educate patients and family members about driving safety and to screen annually.

Here to help!. Caregiver -they may be the first individuals who identify an older adult is unsafe to drive Primary care provider - Screen/assess ability to drive annually. Make appropriate referrals. Nurse -monitor vital signs, evaluate functional abilities, disease risk factors, medication adherence and adverse effects, personal health behaviors and health literacy..

Here to help! (continued). Occupational therapist -assess the older adult’s functional abilities. OT often seek additional training to become driving rehabilitation specialists, who can perform expert special assessments and therapeutic interventions specifically regarding fitness to drive Social worker -help identify resources to overcome barriers to changing driving patterns or eventual driving cessation Pharmacist - assist in pharmacologic management of medical conditions that may impair driving State licensing authority - makes the final determination if an individual is allowed to continue to drive.

What is in the literature?. Fatal crashes considerably increase after the age of 70 (aarp, 2021). Providers and families for elderly patients have not been the best at assessing and communicating about driving and driving cessation (American geriatric society, 2019). Cessation of driving leads to a higher rate of depression in elderly (Chihuri et al., 2016)..

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[Audio] Access to safe transportation : Common public bias that older drivers are unsafe or that driving privileges need to be restricted based solely on age can negatively influence health care professionals. They may fail to assess older adults for medical fitness to drive or may encourage them to stop driving prematurely. This can negatively affect their emotional and social wellbeing and also create access problems (like not being able to get to their doctor's appointments) and real health implications for the older adults like depression, premature admission to assisted living facilities, and mortality ( O'Neil et al., 2019) - Rural vs. urban Drivers: Despite cognitive and physical limitation, older adults in rural areas compared to urban areas, are more motivated to continue driving because of fewer options for public and alternative sources of transportation and the longer distances between regular destinations such as grocery stores, pharmacies, health care providers ( Strogatz et al., 2020) - Socioeconomic status influences driving status because it has an impact on access to a reliable vehicle to drive while still able to drive safely, as well as an impact on access to transportation alternatives after age-related driving cessation. For older adults living on fixed incomes, the costs of owning, maintaining, and operating a motor vehicle can be prohibitive. Furthermore, low-income elderly have less means available to pay for alternative transportation" ( Adler & Rotunda, 2006). -Quality Health Care: Lack of regular and reliable access to quality health services can eventually lead to development of disease and disability. Declining health is known to be associated with driving cessation in older adults. This is due to age-related declines in health, physical, and cognitive functions. The relationship between health status and driving cessation is mutually causative; that is, declining health may lead to driving cessation, and driving cessation in turn may result in adverse health outcomes ( Chihuri et al., 2016) - Gender, Race and Age : Driving cessation is strongly associated with increasing age and gender. Older men are less likely than older women to stop driving. In a longitudinal investigation of gender and racial differences in driving cessation, women and racial minorities were more likely to stop driving compared with men or non-Hispanic Whites. Racial disparities in cessation exist, and in fact widen with increasing age. ( Choi et al., 2013) -Social support: Social health, measured by social engagement, social contacts and social support, refers to the capacity to interact in society. One study found that driving cessation increased risk of social isolation and was associated with a 51% reduction in the size of social networks of friends and relatives over a 13-year period ( Qin et al., 2020)..

[Audio] A survey of geriatric physicians in the United States, discovered 31.8% were ignorant of state guidelines regarding reporting at-risk drivers. Reporting at risk drivers can damage the clinician-patient relationship, violate patient confidentiality, and potentially loose patients..

[Audio] Advise / counsel patients about medical conditions and medication adverse effects that may impair their ability to drive safely. Failure to do so may make the provider liable for third party injuries in certain circumstances / jurisdictions. Some States ( CA, DE, NJ, NV, OR, PA) have mandatory reporting requirements that may give rise to liability for failure to report. Use the State licensing agency's official form to report the required medical conditions. Only the minimum information necessary to show that the patient may be an unsafe driver should be provided. Know that laws, regulations, and policies of your State are subject to change. Seek legal advice on specific issues/ questions..

[Audio] In adhering to State reporting laws, physicians may need to breach patient confidentiality. However, several measures can be taken to reduce the impact on the physician-patient relationship -Before reporting a patient to the State licensing agency, physicians should inform the patient of their intent and explain that it is the ethical, and in some cases, legal responsibility of the physician to make a referral to the State licensing agency. It may help to remind patients that physicians do not determine whether they are licensed to drive, that decision is ultimately made by the State. - patient permission should be obtained before contacting caregivers, and this should be documented in the patient's health record. If the patient maintains decisional capacity and denies permission, their wishes must be respected. - Document Diligently: good documentation may protect the physician from civil liability. Include: Red Flags that indicate at risk for driving Any counseling specific to driving (e.g., documenting that the patient is aware of the warning signs of hypoglycemia and its effects on driving performance). Formal assessment of the patient's driving-related functions (e.g., documenting that the patient has undergone the Clinical Assessment of Driving Related Skills ( CADReS) -Any medical interventions and referrals that have been made to improve the patient's function, as well as any repeat testing to measure improvement. A copy of the driver rehabilitation specialist ( DRS) report if the patient has undergone driver assessment and/or rehabilitation. The physician's recommendation including a summary of interventions (e.g., "sent letter to patient to reinforce recommendation," "discussed transportation options and gave copy of ' Patient Resource Sheet'," "contacted family members with patient's permission,").

[Audio] Although anyone may request that a driver be medically evaluated, the requests to the N.C. Division of Motor Vehicle's Medical Review Program typically come from: Physicians - about patients at risk to themselves/ others Law enforcement officers who have observed drivers with poor driving habits related to health problems ( vision, slow reaction time, reports of blackouts, falling asleep or seizures ) Wreck reports Involuntary commitment orders and adjudication incompetency orders submitted by the court system.

Special License Renewal Rules for Older Drivers (66+) in N.C.

[Audio] No single assessment can accurately predict the ability to drive safely- need to use several. The Clinical Assessment of Driving Related Skills ( CADReS) is a toolbox of evidence-based practical, office-based assessment tools to screen for impairment in the key areas of vision, cognition, and motor/ sensory function as they relate to driving. Clinical team members should choose from tools in each area that best address their patient's needs and document their encounters..

[Audio] A driver rehabilitation specialist ( DRS) with a professional medical degree is best qualified to make a fitness-to-drive decision when an at-risk older adult has functional impairments in physical, visual, or cognitive abilities. A comprehensive driving evaluation is completed by a DRS and occupational therapist and includes a medical and driving history, a clinical assessment of underlying component abilities, and an on-road evaluation that results in a range of client-centered recommendations. An occupational therapist will evaluate and plan interventions for patients with impairment of ADL and IADLs. Their recommendations may include referral for specialized services, a comprehensive driving evaluation, or recommendation to cease driving..

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References. Arms, T (2016). The NP's role of assessing and interveneing with older adults. Nursing Research and practice,2016, https://doi.org/10.1155/2016/3254857 Adler, G. and Rottunda , S. (2006). Older adults' perspectives on driving cessation. Journal of Aging Studies, 20(3), 227-235. https://doi.org/10.1016/j.jaging.2005.09.003 Betz, M. E., Villavicencio, L., Kandasamy, D., Kelley-Baker, T., Kim, W., DiGuiseppi , C., Mielenz , T. J., Eby , D. W., Molnar, L. J., Hill, L., Strogatz , D., Carr , D. B., Li, G., & LongROAD Research Team (2019). Physician and Family Discussions about Driving Safety: Findings from the LongROAD Study. Journal of the American Board of Family Medicine : JABFM, 32(4), 607–613. https://doi.org/10.3122/jabfm.2019.04.180326 ​ Clinician’s Guide to Assessing and Counseling Older Drivers, 4th Edition NHTSA Report No. DOT HS 812 228 (2019) American Geriatrics Society & A. Pomidor , Ed. Copyright American Geriatrics Society Chihuri, S., Mielenz , T. J., DiMaggio, C. J., Betz, M. E., DiGuiseppi , C., Jones, V. C., & Li, G. (2016). Driving Cessation and Health Outcomes in Older Adults. Journal of the American Geriatrics Society, 64(2), 332–341. https://doi.org/10.1111/jgs.13931 Choi, M., Mezuk , B., Lohman, M. C., Edwards, J. D., & Rebok , G. W. (2013). Gender and racial disparities in driving cessation among older adults. Journal of aging and health, 25(8 Suppl), 147S–62S. https://doi.org/10.1177/0898264313519886 Haas, S. (2011). Old People Driving . YouTube. https://youtu.be/BaHxeuTSl-M ​ Health in Aging. (2021). Driving safety for older adults. Retrieved on November 10th, 2021, from https://www.healthinaging.org/driving-safety North Carolina Department of Transportation (2021). Medical review program. Retrieved from https://www.ncdot.gov/dmv/license-id/license-suspension/medical-review-program . O'Neill, D., Walshe, E., Romer, D., & Winston, F. (2019). Transportation Equity, Health, and Aging: A Novel Approach to Healthy Longevity with Benefi ts Across the Life Span. NAM perspectives, 2019, 10.31478/201912a. https://doi.org/10.31478/201912a Stacey, C. (2021). Is it Time for your Loved One to Retire from Driving. AARP. https:// www.aarp.org /caregiving/basics/info-2019/is-it-time-to-stop- driving.html Strogatz , D., Mielenz , T. J., Johnson, A. K., Baker, I. R., Robinson, M., Mebust , S. P., Andrews, H. F., Betz, M. E., Eby , D. W., Johnson, R. M., Jones, V. C., Leu, C. S., Molnar, L. J., Rebok , G. W., & Li, G. (2020). Importance of Driving and Potential Impact of Driving Cessation for Rural and Urban Older Adults. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 36(1), 88–93. https://doi.org/10.1111/jrh.12369 Qin, W., Xiang, X., & Taylor, H. (2020). Driving Cessation and Social Isolation in Older Adults. Journal of aging and health, 32(9), 962–971. https://doi.org/10.1177/0898264319870400.