The older adult driver

More adults aged 65 and older will be driving in the next few decades. Many older drivers are safe behind the wheel and do not need intensive testing for license renewal. Others, however, have physiologic or cognitive impairments that can affect their mobility and driving safety. When an older patient's driving competency is questioned, a comprehensive, step-by-step assessment is recommended. Many diseases that impair driving ability can be detected and treated effectively by family physicians. Physicians should take an active role in assessing and reducing the risk for injury in a motor vehicle and, when possible, prevent or delay driving cessation in their patients. Referral to other health care professionals, such as an occupational or physical therapist, may be helpful for evaluation and treatment. When an older patient is no longer permitted or able to drive, the physician should counsel the patient about using alternative methods of transportation.     

Supporting Safety in the Older Adult Driver: A Public Health Nursing Opportunity

The effective operation of a motor vehicle encompasses a wide range of cognitive processes that can decline due to age‐related changes in neuroanatomical structures and cognitive functionality. The increasing number of older adult drivers in our rapidly aging population heightens the public safety concern of unsafe driving associated with these changes. Nurses caring for older adults in public health settings are well positioned to make a difference in the management of older patients who may be at risk of endangering themselves or others on the roadways. In this article, information is provided for increasing nurses’ awareness of the cognitive factors inhibiting effective driving, recognizing older adults who may be at risk for unsafe driving, and facilitating a patient/family to seek a driving evaluation.     

Driving and dementia: a review of the literature.

In North American society driving is closely linked with independence. Unfortunately, the freedom to operate a motor vehicle may be lost when an individual develops a specific medical diagnosis. The complex issue of dementia and driving safety is frequently encountered by health care professionals. Physicians are required, by law, to report any medical diagnosis such as dementia, that may affect driving safety. Physicians often refer to occupational therapists to assist them in determining if an individual's impairment significantly impacts driving safety. Unfortunately many health care professionals are not using reliable, valid and sensitive tests to determine the point at which an individual with dementia will become an unsafe driver. Through a review of the literature, the authors explore the effects of normal aging and cognitive impairment on driving safety. Specific assessment tools used to assess driving ability are examined and the role of health professionals in driver assessment is discussed. Some suggestions to improve the overall approach to evaluating driving safety are offered in the conclusion.     

Promoting smoking cessation

Cigarette smoking causes significant morbidity and mortality in the United States. Physicians can use the five A's framework (ask, advise, assess, assist, arrange) to promote smoking cessation. All patients should be asked about tobacco use and assessed for motivation to quit at every clinical encounter. Physicians should strongly advise patients to quit smoking, and use motivational interviewing techniques for patients who are not yet willing to stop smoking. Clinical contacts with unmotivated patients should emphasize the rewards and relevance of quitting, as well as the risks of smoking and anticipated barriers to abstinence. These messages should be repeated at every opportunity. Appropriate patients should be offered pharmacologic assistance in quitting, such as nicotine replacement therapies, bupropion, and varenicline. Use of pharmacologic support during smoking cessation can double the rate of successful abstinence. Using more than one type of nicotine replacement therapy ("patch plus" method) and combining these therapies with bupropion provide additional benefit. However, special populations pose unique challenges in pharmacotherapy for smoking cessation. Nicotine replacement therapies increase the risk of birth defects and should not be used during pregnancy. They are usually safe in patients with cardiovascular conditions, except for those with unstable angina or within two weeks of a coronary event. Varenicline may increase the risk of coronary events. Nicotine replacement therapies are safe for use in adolescents; however, they are less effective than in adults. Physicians also should arrange to have repeated contact with smokers around their quit date to reinforce cessation messages.     

Smoking Cessation Counseling by Emergency Physicians: Opinions, Knowledge, and Training Needs

Objectives: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice.
Methods: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians.
Results: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling.
Conclusions: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.     

Imposed versus involved: different strategies to effect driving cessation in cognitively impaired older adults

In the lives of persons with cognitive impairments, a time comes when it is necessary to give up driving. This may be a particularly difficult issue for the driver, his or her family members, and their health care professionals. In this study, the phenomenon of unsafe driving by cognitively impaired older adults and the process of affecting driving cessation, was explored through guided interviews with 216 persons throughout the state of Florida. Participants included professionals working in the aging network, mobility counselors, safety officers, individuals with a mild degree of cognitive impairment and their family members. The strategies employed to influence or effect cessation could be categorized as those that involved the individual affected and those that were imposed on the individual. Conditions that appeared to influence whether driving cessation would occur were observed. There were distinct pros and cons to each strategy. In this article, specific information is provided to guide nurses working with cognitively impaired people who have become unsafe drivers. It is expected that driving cessation can be voluntarily effected in many cases but may have to be imposed in others. The skilled nurse will know when and which type of recommendation is appropriate.     

Dementia and driving: autonomy versus safety

PURPOSE: This article reviews the effects of various types of dementia on driving skills, the available assessment measures, legal considerations, and the important role played by the nurse practitioner (NP) in the process of recommending driving cessation. It provides strategies and resources that may offer guidance to NPs who are attempting to balance the continued independence of patients with dementia, as represented by driving, with the safety not only of such patients but also of the public at large. DATA SOURCES: A review of the biomedical literature, resources available on the World Wide Web, and illustrative case studies were used. CONCLUSIONS: The diagnosis of dementia alone is often insufficient to determine driver competence because the topographic losses of dementia are complex. Recognizing when cessation should occur is made more difficult because objective assessment tools do not exist to predict impaired driving skills. Recommending driving cessation at the appropriate time can be a challenge for NPs, who must balance such a significant impact on the driver's autonomy with concerns about public safety if the patient continues to drive despite progressive impairment. IMPLICATIONS FOR PRACTICE: The progressive loss of cognitive abilities in dementia presents a series of ongoing challenges for the patient throughout the disease continuum. Unfortunately, the recommendation to stop driving can present one of the more immediate issues confronting the patient, the family, and the healthcare provider. Failure to assess diminished driving skill can lead either to premature or to delayed driving cessation. Either outcome can have adverse effects on the patient, the patient's family, and public safety.     

The clinician's role in promoting smoking cessation among clinic patients.

Like other chronic conditions, nicotine dependence offers both challenges and rewards to clinicians. The treatment of this condition frequently requires experience in pharmacology, behavioral science, and social aspects of medicine. Physicians are uniquely qualified to assist patients in their efforts to overcome the multifaceted condition of tobacco addiction. In providing this treatment, the clinical challenges are far outweighed by the benefit to patients who stop smoking. For many patients, smoking cessation is, by far, the most important step they can take to improve their health and increase their life span. Physicians who help patients accomplish this difficult goal provide a life-saving service. There is sufficient scientific evidence to guide physicians in their approach to smoking patients. Brief, systematic interventions have been shown to increase patient smoking cessation rates. The intervention can be described in four steps: ask about smoking, advise smokers to stop, assist those who want to stop, and arrange adequate follow-up. These interventions are used consistently when a smoking cessation program is adopted by an entire office practice. The components of this office-based program include defining staff roles, maintaining a smoke-free office, stocking appropriate materials, making use of the medical record to identify smokers and to remind staff to intervene, and monitoring patient progress. The potential public health impact of physician intervention with smoking patients is enormous. Even with very modest expectations of cessation rates, 100,000 physicians using effective intervention can produce over 3 million new ex-smokers in the United States each year. In conjunction with other community-based tobacco control efforts, this physician-lead effort will result in a marked reduction in the morbidity and mortality caused by smoking and, thus, control of "the most important public health issue of our time."     

The clinician's role in preventing smoking initiation.

Initiation of tobacco use begins primarily during childhood and adolescence, and physicians can play a major role in preventing the onset of tobacco use. The National Cancer Institute recommends that physicians incorporate the four A's in their practices--four activities that promote smoking cessation and prevention: ask, advise, assist, and arrange follow-up. Physicians who care for children should include a fifth A, anticipatory guidance. Anticipatory guidance is the practice of providing counsel regarding potential problems. By providing messages that are appropriate to the patient's age and developmental stage, physicians can intervene in early stages of tobacco use. As role models and leaders, physicians can also influence attitudes in the schools and community.     

Medicinal drugs and automobile driving ability

When prescribing drugs, the physician is responsible to warn his patient about potential impairment of driving capability. To do this, he needs to be aware of the duration and profile of actions, notably sedative and other effects affecting vigilance, cognitive and psychomotor functions. It is advisable to keep written records about such information. Impairment of driving capability may be more pronounced when ethanol is used during the action of drugs affecting central nervous function. The majority of published studies, particularly from epidemiological work with drivers, indicate an increased risk of accidents associated with the therapeutic use of benzodiazepines or cyclic antidepressants. Epidemiological data for other drugs available so far do not allow definite conclusions. Among antihistamines for drivers, loratadine or fexofenadine are probably preferable to ceritizine or older antihistamines. Patients with diabetes who drive should be informed about the risks and self-management of hypoglycaemia.     

Office counseling for the adolescent

Physicians can and do influence adolescents' health-related behaviors. A recent study of low-income adolescents found that most adolescents report they are not receiving sufficient counseling about risk and risky behaviors from their physicians [8]. The results of this study and the author's personal experience (teaching physicians how to counsel and interview adolescents) support the need for physicians to learn more about office-based counseling with adolescents. Physicians who care for teens should learn how to meet the unique needs of individuals at varying stages of development and be prepared to offer counseling services tailored to the special needs of this population. Awareness of counseling techniques and knowledge of how to use those techniques effectively should help family medicine physicians to provide effective comprehensive health care to adolescent patients.     

Are opioid-dependent/tolerant patients impaired in driving-related skills? A structured evidence-based review

Previous reviewers have concluded that opioids cause dose-related impairment in opioid-naive volunteers on psychomotor skills related to driving. Data relating to opioid-dependent/tolerant patients have not yet been reviewed. To determine what evidence, if any, exists for or against opioid-related driving skill impairment in opioid-dependent/tolerant patients, we performed a structured evidence-based review of all available studies addressing the issue of whether opioid-dependent/tolerant patients are impaired in driving-related skills. A computer and manual literature search for studies relating to opioid-dependent/tolerant patients and driving-related skills produced 48 relevant reports. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: (1) psychomotor abilities studies; (2) cognitive function studies; (3) effect of opioid dosing on psychomotor abilities studies; (4) motor vehicle driving violations and motor vehicle accident studies; and (5) driving impairment as measured in driving simulators and off/on road driving studies. For each topic area, each study was categorized for the type of study it represented according to guidelines developed by the Agency for Health Care Policy Research (AHCPR). The strength and consistency of the evidence in each subject area also then was categorized according to AHCPR guidelines and a quantitative method. This evidence-based review indicated the following: (1) There was moderate, generally consistent evidence for no impairment of psychomotor abilities of opioid-maintained patients; (2) There was inconclusive evidence on multiple studies for no impairment on cognitive function of opioid- maintained patients; (3) There was strong consistent evidence on multiple studies for no impairment of psychomotor abilities immediately after being given doses of opioids; (4) There was strong, consistent evidence for no greater incidence in motor vehicle violations/motor vehicle accidents versus comparable controls of opioid-maintained patients; and (5) There was consistent evidence for no impairment as measured in driving simulators off/on road driving of opioid-maintained patients. Based on the above results, it can be concluded that the majority of the reviewed studies appeared to indicate that opioids do not impair driving-related skills in opioid-dependent/tolerant patients. This evidence was consistent in four out of five research areas investigated, but inconclusive in one. As such, additional controlled studies are required. Until more data are available, however, physicians may wish to consider the approach to this problem recommended in this review.     

Smoking cessation

Cigarette smoking is the primary cause of chronic obstructive pulmonary disease, and smoking cessation is the most effective means of stopping the progression of chronic obstructive pulmonary disease. Worldwide, approximately a billion people smoke cigarettes and 80% reside in low-income and middle-income countries. Though in the United States there has been a substantial decline in cigarette smoking since 1964, when the Surgeon General's report first reviewed smoking, smoking remains widespread in the United States today (about 23% of the population in 2001). Nicotine is addictive, but there are now effective drugs and behavioral interventions to assist people to overcome the addiction. Available evidence shows that smoking cessation can be helped with counseling, nicotine replacement, and bupropion. Less-studied interventions, including hypnosis, acupuncture, aversive therapy, exercise, lobeline, anxiolytics, mecamylamine, opioid agonists, and silver acetate, have assisted some people in smoking cessation, but none of those interventions has strong research evidence of efficacy. To promote smoking cessation, physicians should discuss with their smoking patients "relevance, risk, rewards, roadblocks, and repetition," and with patients who are willing to attempt to quit, physicians should use the 5-step system of "ask, advise, assess, assist, and arrange." An ideal smoking cessation program is individualized, accounting for the reasons the person smokes, the environment in which smoking occurs, available resources to quit, and individual preferences about how to quit. The clinician should bear in mind that quitting smoking can be very difficult, so it is important to be patient and persistent in developing, implementing, and adjusting each patient's smoking-cessation program. One of the most effective behavioral interventions is advice from a health care professional; it seems not to matter whether the advice is from a doctor, respiratory therapist, nurse, or other clinician, so smoking cessation should be encouraged by multiple clinicians. However, since respiratory therapists interact with smokers frequently, we believe it is particularly important for respiratory therapists to show leadership in implementing smoking cessation.     

HIV infection in athletes. What are the risks? Who can compete?

The activities of athletes and personnel who provide their medical care may place them at slightly greater risk for infection with human immunodeficiency virus (HIV) than their nonathletic peers. At this point, there is no reason to disallow participation of athletes who are HIV-infected. Thus, sports physicians need to assume that they are at risk for accidental exposure to HIV and use appropriate precautions. Most important, physicians can educate athletes, coaches, and trainers to practice "safe" athletics and medical care to minimize the risks of exposure to and transmission of HIV. Testing for HIV can be encouraged for athletes who may be at risk and should be done for any athlete who specifically requests it. Physicians should encourage further study to clarify the specific issues and risks of HIV infection created by athletic competition and prepare to deal with the changing knowledge about HIV and AIDS.     

Unrecognized chronic dehydration in older adults: examining prevalence rate and risk factors

Dehydration has serious consequences for older adults, including increased risk of illness or death. This retrospective review of medical records describes the prevalence, assessment, and risk factors for chronic dehydration in 185 older adults who visited an emergency department in June 2000. Results showed chronic dehydration was present in 89 (48%) patients. Physicians documented assessment for signs of dehydration in 23 (26%) of the dehydrated older adults, but no independent assessments for dehydration were recorded by nurses. These findings indicate many older adults may suffer from unrecognized dehydration, and nurses should be alert to the possibility that dehydration may be present in community-dwelling older adults as well as those who live in residential facilities.     

Interventions to facilitate smoking cessation

Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in the United States, and nearly one third of those who try a cigarette become addicted to nicotine. Family physicians, who see most of these patients in their offices every year, have an important opportunity to decrease smoking rates with office-based interventions. The U.S. Public Health Service recommends that primary care physicians use the five A's (Ask, Advise, Assess, Assist, and Arrange) model when treating patients with nicotine addiction. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. Behavior modification can improve long-term smoking cessation success; even brief (five minutes or less) advice on smoking cessation during an office visit can increase cessation rates. The effectiveness of nonpharmacologic treatments generally is lower; therefore, pharmacotherapy is recommended for smokers who are willing to attempt cessation, unless medical contraindications exist. The pharmacologic agents approved by the U.S. Food and Drug Administration for treatment of tobacco dependence include bupropion (a non-nicotine therapy) and nicotine replacement therapies in the form of a gum, patch, nasal spray, inhaler, and lozenge. These agents have similar long-term success rates.     

Herbal medications and other dietary supplements. A clinical review for physicians caring for older people

Evidence for the safety and effectiveness of dietary supplements is mixed. The extent to which older people use dietary supplements concomitantly with conventional medications is often under-appreciated by physicians. We conducted a literature review on clinical considerations associated with dietary supplement use, focusing on benefits and harms, motivations for use and contribution to polypharmacy among older people. Vitamin D?≥?800?IU has demonstrated benefits in fracture prevention. Vitamins A, E, and β-carotene have been associated with an increase in total mortality in several meta-analyses. A range of non-vitamin dietary supplements have been studied in randomized controlled trials but their efficacy remains largely unclear. Supplement use has been associated with a range of adverse events and drug interactions yet physicians rarely initiate discussions about their use with older patients. Older people may take dietary supplements to exercise control over their health. Given the contribution of supplements to polypharmacy, supplements may be targeted for “deprescribing” if the risk of harm is judged to outweigh benefits. This is best done as part of a comprehensive, patient-centered approach. A respectful and non-judgmental discussion may result in a shared decision to reduce polypharmacy through cessation of dietary supplements.

• KEY MESSAGES

• Herbal medications and other dietary supplements are highly prevalent among older people. Physicians are often unaware that their patients use herbal medications and other dietary supplements concomitantly with conventional medications.

• Herbal medications and other dietary supplements contribute to high rates of polypharmacy, particularly among older people with multimorbidity. Herbal medications and other dietary supplements can interact with conventional medications and be associated with a range of adverse events.

• Physicians need to be patient-centered and non-judgmental when initiating discussions about herbal medications and other dietary supplements. This is important to maintain and develop patient empowerment and self-management skills.