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Evaluate older patients for ability to drive safely
Consult resources, involve the family, and refer to therapists and specialists.
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Optometrists can play a significant role in assessing driving ability in older patients, according to Swati C. Modi, OD, FAAO.
“Driving privileges for many represent a level of independence,” Modi said in an interview with Primary Care Optometry News. “In older patients, visual impairment and losing driving privileges have a significant psychosocial impact related to fear and anxiety that can lead to social isolation.”
A good resource for eye care professionals is the American Geriatrics Society’s Clinicians Guide to Older Drivers, a 2016 update to the American Medical Association’s physician’s guide, Modi said. It includes discussions on issues related to driving as well as a listing of vision requirements per state.
Most state guidelines in determining licensure rely on only visual acuity, Modi said. Some states also include visual field information, but contrast sensitivity function is a strong, if not better, predictor of crash risk, based on several driving studies, including those by Cynthia Owsley, PhD.
For an unrestricted license in the U.S., visual acuity requirements are 20/40 or better, with 20/200 as an absolute minimum, she said. For a restricted license, visual acuity is typically 20/60 to 20/100. Three common driving restrictions are: daytime driving only, a set speed limit and driving in familiar areas only.
Bioptic or spectacle-mounted telescopes are permitted for driving in the majority of states. Visual field criteria vary from state to state, with some states requiring 140 degrees, and others having no minimum field requirement. She noted that severe binocular visual field loss doubles crash risk.
Modi also spoke on this topic at the Envision Conference, an annual multidisciplinary low vision rehabilitation and research conference, held in Denver in September 2016.
Aging, vision and driving
Motor vehicle injuries are the leading cause of injury-related deaths among those 65 to 74 years old, she continued. After falls, driving is the second leading cause of injury-related deaths in those 75 years and older.
Further, older drivers are considerably more fragile, she explained. By age 80 male and female drivers are 4.0 and 3.1 times more likely, respectively, than 20-year-olds to die because of a motor vehicle crash.
The fatality rate for drivers 85 years and older is nine times higher than the rate for drivers 25 to 69 years, she added.
Many aging issues can impact driving ability: vision, slower response times, motor skills/coordination, hearing loss, cognitive function, multiple medical conditions and risk-taking behavior, Modi said.
Certain conditions and diseases can be red flags, she said. These include neurological diseases such as multiple sclerosis, dementia, Parkinson’s, peripheral neuropathy, residual deficits from stroke, psychiatric disease, metabolic disease, chronic renal failure and respiratory disease such as chronic obstructive pulmonary disease and sleep apnea.
Medications that may influence driving safety include: anticholinergics, anticonvulsants, antidepressants, antiemetics, antihistamines, antihypertensives, antipsychotics, benzodiazepines and sedatives/anxiolytics, muscle relaxants, narcotic analgesics and stimulants.
“Vision is just part of the equation in assessing a patient’s safety for driving,” she said. “Although older patients tend to self-regulate driving, it is important to discuss driving with patients and their family to determine qualifications and if rehabilitation and/or alternatives to driving need to be explored.”
Talking to patients
Modi suggests asking questions related to driving when taking the patient history, such as, “Are you a driver?”, “How much do you drive?” and “Are you having any difficulty seeing traffic signals or signs?”
Older patients may already modify their driving by including less highway and more local street driving, driving during non-rush hour, daytime only and making shorter and fewer trips.
When counseling a patient who can no longer drive safely, Modi recommends considering using the term “driving retirement.” She said to involve the patient and family in the decision-making process and acknowledge that safe mobility is a priority. Develop an alternative transportation plan to alleviate depression and loneliness
Modi suggests thinking of this conversation as four steps: Explain why it is important to retire from driving, discuss transportation options (find an area agency on aging to help identify these options), reinforce driving cessation (in some cases, you can send a “do not drive” follow-up letter), schedule a follow-up visit to answer questions and confirm that the patient has stopped driving
“If they have stopped driving, I will ask questions related to their well-being and/or if they have been able to connect with some of the alternative transportation options,” Modi told PCON. “If the patient voices frustration or if the patient admits to depression (which, in some cases, is apparent whether or not the patient voices it), I will make the referral to their primary care physician, psychiatrist, social worker or a support group.”
Modi recommended using the Geriatric Depression Scale routinely in the follow-up visit.
If a patient that you recommended to cease driving is still driving, she suggested knowing your state’s reporting laws.
“There is no consensus regarding reporting,” Modi said. “Texas, for example, does not require reporting; however, some states, including California and New Jersey, have mandatory reporting requirements. The requirements differ among states, just as visual acuity and visual field requirements also vary.
“Ultimately, if an older patient’s potential driving performance is still in question, assess performance by enlisting the help of occupational therapists and certified driving rehabilitation specialists, despite whether the patient’s visual acuity and/or visual field meet the state driving guideline,” Modi concluded. – by Abigail Sutton
- References:
- American Geriatrics Society and National Highway Traffic Safety Administration. www.nhtsa.gov/sites/nhtsa.dot.gov/files/812228-cliniciansguidetoolderdrivers.pdf. (Report No. DOT HS 812 228). Posted December 2017. Accessed Feb. 2, 2017.
- American Medical Association. one.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Contents.html. Posted June 6, 2003. Accessed Feb. 2, 2017.
- Ball K, et al. J Am Optom Assoc. 1992;63:71-79.
- Modi S. Driving and older adults. Presented at: Envision Conference; Sept. 7-10; Denver.
- Owsley C, et al. Arch Ophthalmol. 2001;119(6):881-887. doi:10.1001/archopht.119.6.881.
- Tanabe S, et al. Invest Ophthalmol Vis Sci. 2011;52(7):4177-4181. doi: 10.1167/iovs.10-6264.
- For more information:
- Swati C. Modi, OD, FAAO, is a clinical assistant professor at the University of Houston College of Optometry. She can be reached at scmodi@central.un.edu.
Disclosure: Modi reports no relevant financial disclosures.