As the number of older drivers in the United States increases, concern about the potential implications for safety and mobility is growing. The roles and responsibilities of the driver, the family, the licensing agency and the physician in the process of determining who should or should not be driving will be the subject of much discussion in the coming years.
Earlier surveys indicated that responding physicians did not agree on what their roles should be and were uncertain about the extent of their legal responsibilities.1,2 However, many physicians reported that they had discussed driving with patients and felt that it was their responsibility to assess relevant medical factors and possibly report patients who appeared to be at increased safety risk. These studies identified a number of issues to be addressed to improve the process of assessment, including a clearer definition of the physician's and state's roles in the process, better guidelines about what to assess and how, and better information about what happens after someone is reported.
In this issue of American Family Physician, Carr3 reviews the physician's role in the process of deciding whether patients are still capable of driving. Although the number of older drivers is increasing and the objective of family physicians is to help prevent injuries and deaths associated with motor vehicle accidents, it is important to remember that most older drivers are safe and make appropriate adjustments in their driving exposure to minimize risk.
Part of the difficulty in the assessment of patients is determining who is at increased safety risk and why, and whether intervention can lower that risk. Carr's article describes a number of factors to consider: the patient's driving patterns; a history of adverse events and concern on the part of the family; the use of centrally acting medications or alcohol; the presence of medical conditions or functional impairments that may be relevant to driving safety; and the appropriate use of safety devices, such as seat belts.
Carr also reviews potential referral sources to determine whether any conditions or impairments identified affect driving safety and the assessment of possible interventions to correct or adapt to these conditions. Finally, the role of the physician in synthesizing this information and counseling the patient and the family is described, along with the importance of viable alternative sources of transportation in effecting necessary changes in driving behavior. Several factors may improve physicians' ability to identify potential problems in older drivers and maximize the likelihood and effectiveness of physician involvement:
Clearly define and publicize the role of the physician (as well as the driver, the family and the state licensing agency) in the process.
Know what the current legal responsibilities are in the physician's jurisdiction: is reporting voluntary or mandatory, and for what conditions or impairments? Also, who does one report to and what happens when someone is reported? A contact person in the state agency with a well-publicized telephone number or e-mail address may facilitate the process.
Know what to look for to raise suspicion about whether someone is at increased risk for driving safety problems. This does not mean that physicians must determine whether someone should or should not drive or be licensed. However, physicians can detect and intervene if medical conditions, medications and functional impairments relevant to driving safety are present. Considerable research is under way to improve the tools physicians may use in making such a determination.
Know where to refer patients to determine whether conditions or impairments are likely to affect driving safety. Identify the resources for driving assessment and retraining in the area, as described by Carr, or investigate whether such an assessment can be performed by the licensing agency. In this process, it is helpful to know the cost of the assessment and who is responsible for payment. Also, it is often helpful to have a responsible family member ride with the patient to get a sense of their interaction with traffic and safety behaviors. Because families are often entrusted with ensuring compliance with driving recommendations or licensing decisions, particularly for patients with cognitive impairment, such an experience can help the family understand the need for change or for ongoing monitoring. Once all of the information is obtained, it may be up to the physician to synthesize the information and make a recommendation to the patient and the family regarding driving or alternative transportation. Having a contact person available, possibly a case manager or a social worker associated with a local hospital or a geriatric assessment center, can be a valuable resource in helping patients and families adjust to driving limitations or cessation or in identifying viable alternative sources of transportation. Ultimately, society needs to do a better job of identifying or developing such transportation resources and coordinating services among different agencies.
Regardless of individual opinions about what the physician's roles and responsibilities in this process should be, patients, families and licensing agencies often turn to us for educated opinions and advice regarding their ability to continue driving or the need for driving limitations or cessation. It is important to remember that the physician is not alone in this process, but is part of a larger system. While that system could be improved in a number of areas, its ultimate objectives will not change much.
Physicians must try to balance independence and autonomy with personal and public safety, while maintaining the mobility, activity level and quality of life in the elderly. Gathering as much relevant information as possible is the key to helping convince ourselves, the patient, the family or the licensing agency about the need for change. Doing so, while emphasizing and maintaining the positive aspects of the physician-patient relationship, is the key to helping our patients and their families make a difficult decision.