Older drivers

Introduction
Driving safety is a public health issue that is paramount in the context of an aging society. Motor vehicle injuries are the leading cause of injury-related deaths among 65 to 74 year olds, and the second leading cause, after falls, among 75 to 84 year olds. Additionally, drivers over 80 have higher crash rates per mile driven than any other age group except teenage drivers. Common effects of aging, such as vision deficits and changes in cognition and musculoskeletal abilities, can affect driving safety. Age-related health problems (e.g. stroke, diabetes) and medication side effects can also impact driving safety. There is a challenge of balancing safety and independence. Driving for many is perceived to be a right rather than a privilege. Especially in American culture, driving remains an important part of an elder’s identity. Possession of a driver’s license has been referred to as an “asphalt identikit”.

Guidelines
License renewal policies vary from state to state. The American Medical Association set guidelines in 1999 and 2003 encouraging physicians to notify the Department of Motor Vehicles (in their state) when they are concerned about medical conditions that could make driving unsafe for patients they treat. A survey revealed that across stakeholder groups of physicians, policemen, and community members, there is not agreement regarding the type of assessment needed to determine driving competence.

Risk Factors for Continued Driving
Risks for continuing driving when it is no longer safe to do so include being male, living alone, and having dementia.

Risks of Driving Cessation
There are risks associated with driving cessation given poor transportation alternatives. Elders tend not to increase their use of public transit as they age, and the majority of elders who cease driving rely on private cars for transport. Driving cessation is associated with a loss of mobility, decreased engagement in activities, reduced access to proper health care, and a greater likelihood of health problems like depression.

Driving Management Options
There are medical, functional, and psychosocial management options available for elder drivers with safety concerns.

Medical Options

 * Reducing or elimination alcohol use
 * Minimizing prescription drug use
 * Managing underlying medical problems such as diabetes

Functional Options

 * Self-limiting driving (based on the time of day, weather conditions, distance and familiarity of locations)
 * Wearing a seat-belt
 * Using a “co-pilot”

Psychosocial Options

 * Reframing giving up the keys to driving retirement
 * Avoiding using “good” and “bad” driving language, focusing instead on “safety”
 * Using medical (as opposed to age-related) explanations
 * Highlighting the risk to self and others, and the potential legal/insurance repercussions to crashes
 * Identifying transportation resources.

Other Options
Last resort authoritarian options include reporting the driver to the RMV, hiding or removing car keys or changing the lock, disabling or removing the car, and obtaining an official letter from the MD to stop driving. A more proactive approach involves making a transportation plan that includes alternative resources before it is necessary to use them, considering relocating to a more supportive environment, and making a formal driving contract.

DriveWise Program
Because driving is important to one’s independence and self-esteem, health care providers and family members are careful not to end driving privileges prematurely. On the other hand, delaying this decision may jeopardize safety. No one likes being “the bad guy” when it comes to making decisions about a person’s future driving. The DriveWise program at Beth Israel Deaconess Medical Center (BIDMC) was created in 1996 to help families and health care providers with this difficult decision making process. The program aims to confront the issue of driving safety in a manner that is both compassionate and evidence based. Recognized as a national model and the first of its kind, the DriveWise program offers an objective evaluation of driving safety for people of all ages who have experienced neurological, psychological, and/or physical impairments. Many DriveWise patients suffer from mild dementia; other patients have been evaluated with problems such as: head injury, brain tumors, seizures, Multiple Sclerosis and Parkinson’s Disease. The program, which was developed by the divisions of Behavioral Neurology and Occupational Therapy at BIDMC, is comprised of a multidisciplinary team, including social workers, occupational therapists, certified driving instructors, and neuropsychologists. This unique team approach results in a thorough examination of driving performance and provides support to patients and their families through the process. The DriveWise assessment reassures health professionals about those patients who, despite medical problems, are safe to continue driving. It also identifies those individuals whose compromised skills make driving no longer safe. By engaging in research and community education, the DriveWise team has opportunity to influence public policy affecting the older driver. The program has consulted countless physicians, family members, and community agencies to help resolve or to offer approaches to difficult driving dilemmas. To date, the program has assessed over 400 participants.

DriveWise Evaluation and Follow Up
The multidisciplinary team conducts a thorough evaluation that includes: Written recommendations summarize the finding of the evaluation. Some drivers benefit from remediation. Others are trained in the use of adaptations for the car or strategies for safer driving. When untreated medical issues, such as vision problems, compromise driving, referrals are made to hospital specialists. Alternative transportation resources in a community are identified as needed. If cessation of driving is recommended, the emotional impact of this loss is explored and support is provided to the driver and family. Consent forms allow contact with the RMV when appropriate.
 * A clinical social work assessment;
 * In-clinic occupational therapy assessment;
 * On-road driving assessment with an occupational therapist and driving instructor, an element not offered by other driving evaluation programs;
 * Patient/family feedback meetings with the clinical social worker.

Referral to DriveWise
Family members, primary care physicians, or specialists may make referrals by calling Beth Israel Deaconess Medical Center’s Division of Behavioral Neurology at (617) 667-4074. DriveWise follows a private pay model (not covered by Medicare).