The Older Driver
Am Fam Physician. 2020 May 15;101(10):625-629.
An 81-year-old man came for a routine visit with his wife, who mentioned that her husband has become more forgetful, confused, and requires more assistance with his activities of daily living. She was worried about his safety and would like you to talk to him about not driving anymore. My patient was upset by the suggestion that he may no longer be fit to drive safely. How should a family physician address this?
Advancing age on its own is not a reason to stop driving. The ability to drive may enable older adults to maintain family and social interactions and to promote independence by accessing community resources, services, and volunteer opportunities.
Nevertheless, crash fatalities in people older than 65 years have increased 22% from 2008 to 2017; older age increases fatality risk and is highest among driver older than 85 years.1 Several factors influence this trend, including greater numbers of older drivers and miles driven, and older age increases fatality risk and is highest among drivers older than 85 years.2 If an accident occurs, older drivers are also more likely to sustain more serious injury than younger occupants of vehicles.
Despite the age-related increase in potential for harm associated with driving, only 7% of older adults report discussing driving safety issues with a family member.3 It is often a family member or caregiver who forces the issue by bringing it to the attention of the family physician. Table 1 describes some age-related changes that family members, caregivers, or patients might notice that might affect a person's ability to drive safely.4–10
Aging-Related Physiologic Changes That Increase the Risk for Driving-Related Harms
|Domain||Significance||Age-related changes and relevance to driving ability|
Attention is critical to driving safety. Concerns with attention include the ability to use several sensory abilities to detect, process, and take appropriate action for potential threats.
Ability to divide attention between central information (e.g., speedometer, radio controls) and information from the periphery (the road) sharply declines with age Ability to switch attention rapidly between tasks declines sharply with age Older adults are most commonly involved in crashes in situations that require integrated complex perceptual and cognitive processes (e.g., turning across traffic at intersections, merging or changing lanes on the highway)
Chronic medical conditions, such as diabetes mellitus, heart disease, or stroke, are more prevalent as people age and may affect driving ability. Medications used to treat chronic and aging-related conditions may impair optimal functioning and exacerbate driving-related hazards.
Drivers who have diabetes are 1.5 times more likely to be involved in crashes where they are at fault Those with cognitive impairment are three times more likely to be involved in crashes where they are at fault Arthritis may make it difficult to perform certain actions that are essential for safe driving (e.g., head turning for parking, checking for blind spots) Dementia affects the ability to reason, remember, and perform complex actions Conditions such as stroke or Parkinson disease may contribute to slower reflexes, the ability to move certain body parts, or the ability to make complex and speedy decisions
Optimal hearing provides additional significant information (e.g., warning horns, sirens, auditory lane-changing signals, warnings of vehicles that are too close or in blind spots).
Age-related hearing loss (presbycusis) can result in reduced ability to appreciate and react to auditory signals Ability to distinguish and process important auditory signals in noisy environments decreases with age
Potentially inappropriate medication Nearly 20% of older adult drivers use medications that are known to affect or impair driving and increase the risk for crashes. Deprescribing interventions may help reduce harm and increase driving safety.
Most common potentially inappropriate medications are benzodiazepines (16.6% of the total identified), hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%)4 Urban, white, older drivers who are women had a higher risk of using one or more potentially inappropriate medications4
Reduction of processing speed is common with age. Safe and skilled driving requires anticipation of hazards and the ability to react appropriately.
Reduction in processing speed is associated with driving-related decisions such as taking exit turns and noticing warning or directional signs Older adults are twice as slow as younger adults in information processing operations (i.e., perceptual, cognitive, motor processing)5
Impaired vision is associated with driver discomfort, difficulty with tasks, and crash risk. Decreased visual field is ass
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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to email@example.com. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, associate deputy editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
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