Assessing older drivers: a primary care protocol to evaluate driving safety risk

Most articles on elder drivers offer either general advice, or review testing protocols that divide drivers into two distinct groups: safe or unsafe. We believe it is unreasonable to expect any testing to fully separate drivers into just these two mutually exclusive groups, so we offer a protocol for a more practical approach. This protocol can be applied by primary care physicians. We review the justification for the many steps of this protocol, which have branches that lead to identifying drivers as low risk, high risk (for accidents) or needing further evaluation. Options for further evaluation are provided.     

Self-reported health and driving cessation in community-dwelling older drivers

BACKGROUND: Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults. METHODS: Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later. RESULTS: Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73). CONCLUSIONS: Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.     

Visual attention and older drivers: the contribution of inhibition of return to safe driving

Increasing data suggest that visual attention may be impaired in some older drivers, and that such impairment may be related to poorer driving abilities and a higher crash risk. Because effective scanning of the environment is important for safe driving, the authors sought to examine the relationship between a reflexive visual attention mechanism and driving. To examine this issue the authors conducted a preliminary study using the inhibition of return (IOR) paradigm, which has been labeled as a fundamental search mechanism. Forty-one drivers aged 55 and over completed two on-road driving evaluations and IOR testing. After accounting for the contribution of age, IOR statistically predicted overall driving evaluation scores (p = .045), and the number of errors in scanning the environment (p = .031). To the authors' knowledge these findings represent the first documentation of a relationship between IOR and driving. The results are informative regarding the importance of reflexive visual attention mechanisms towards safe driving.     

Sleep disturbances and adverse driving events in a predominantly male cohort of active older drivers

OBJECTIVES: To evaluate the association between sleep disturbances and adverse driving events in active older drivers. DESIGN: Longitudinal. SETTING: Clinic and community sites in greater New Haven, Connecticut. PARTICIPANTS: Four hundred thirty older persons (mean age 78.5, 84.9% male) who drove at least once a week. MEASUREMENTS: Baseline measures included self‐reported driving patterns and sleep questionnaires (Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Sleep Apnea Clinical Score (SACS)). The primary outcome was an adverse driving event based on self‐report and driving records and categorized as a crash or traffic infraction (composite I) or as a crash, traffic infraction, near crash, or getting lost (composite II). RESULTS: Participants reported driving a median of 17.0 miles per day, with 96.7% (416/430) driving daily or every other day. Although 26.0% (112/430) had insomnia (ISI≥8), 19.3% (83/430) had daytime drowsiness (ESS≥10), and 19.9% (84/422) had high sleep apnea risk (SACS>15), the median scores for the ISI, ESS, and SACS were normal at 3.0, 6.0, and 8.0, respectively, and only 5.1% reported drowsy driving. Over a period of up to 2 years, 24.9% (104/418) and 51.4% (215/418) of participants had a composite I and II driving event, respectively. In unadjusted and adjusted multivariable models, insomnia, daytime drowsiness, and high sleep apnea risk were not associated with a composite I or II driving event. CONCLUSION: In a predominantly male cohort of active older drivers, sleep disturbances were mild and not associated with adverse driving events. Accordingly, and because older persons are known to self‐regulate driving practices, future studies should evaluate whether sleep disturbances are more important as a mechanism that underlies driving cessation rather than compromising driving safety.     

Older drivers and cataract: driving habits and crash risk

BACKGROUND: Cataract is a leading cause of vision impairment in older adults, affecting almost half of those over age 75 years. Driving is a highly visual task and, as with other age groups, older adults rely on the personal automobile for travel. The purpose of this study was to examine the role of cataract in driving. METHODS: Older adults (aged 55-85 years) with cataract (n = 279) and those without cataract (n = 105) who were legally licensed to drive were recruited from eye clinics to participate in a driving habits interview to assess driving status, exposure, difficulty, and "space" (the distance of driving excursions from home base). Crash data over the prior 5 years were procured from state records. Visual functional tests documented the severity of vision impairment. RESULTS: Compared to those without cataract, older drivers with cataract were approximately two times more likely to report reductions in days driven and number of destinations per week, driving slower than the general traffic flow, and preferring someone else to drive. Those with cataract were five times more likely to have received advice about limiting their driving. Those with cataract were four times more likely to report difficulty with challenging driving situations, and those reporting driving difficulty were two times more likely to reduce their driving exposure. Drivers with cataract were 2.5 times more likely to have a history of at-fault crash involvement in the prior 5 years (adjusted for miles driven/week and days driven/week). These associations remained even after adjustments for the confounding effects of advanced age, impaired general health, mental status deficit, or depression. CONCLUSIONS: Older drivers with cataract experience a restriction in their driving mobility and a decrease in their safety on the road. These findings serve as a baseline for our ongoing study evaluating whether improvements in vision following cataract surgery expand driving mobility and improve driver safety.     

Deciding on driving cessation and transport planning in older drivers with dementia

As a result of a significant amount of research in the last two decades, geriatricians have now a much clearer view of the assessment of driving and transport for those with dementia. The most radical underlying conceptual shifts have been: (a) a better balance between the important goals of mobility and safety, and (b) an awareness of the limitation of cognitive approaches to driving ability, and of the need to develop better approaches based on function and behaviour. Building on Comprehensive Geriatric Assessment, useful information can be determined by the multidisciplinary team, but the availability of on-road testing is critical to appropriate assessment of driving in those with dementia. The development of both present and future planning of driving and transport should be viewed as a collaborative process with patients and their families.     

Validation of the triage risk stratification tool to identify older persons at risk for hospital admission and returning to the emergency department

OBJECTIVES: To assess the predictive validity of the Triage Risk Stratification Tool (TRST) to identify return to the emergency department (ED) or hospitalization in a multicenter patient sample. DESIGN: Prospective, observational study with 1‐year follow‐up. SETTING: EDs of three hospitals in Toronto, Canada. PARTICIPANTS: Seven hundred eighty‐eight subjects aged 65 to 101 (mean age 76.6, 58.5% female) who presented to the ED and were discharged home from the ED. MEASUREMENTS: Trained clinical assessors completed the TRST on patients aged 65 and older during a 4‐week study period. Patients who subsequently returned to the ED or were admitted to the hospital were identified using hospital information systems and classified as experiencing the composite endpoint at 30, 120, and 365 days. RESULTS: The mean TRST score was 1.55 (range 0–5), and 147 (18.7%) patients experienced the composite endpoint of return to the ED or hospital admission by 30 days. The sensitivity of a TRST score of 2 or greater was 62%, (95% confidence interval (CI)=54–70%), specificity was 57% (95% CI=53–61%), and likelihood ratio was 1.44 (95% CI=1.23–1.66). The area under the curve was 0.61 using a cutoff score of 2. CONCLUSION: The TRST demonstrated only moderate predictive ability, and ideally, a better prediction rule should be sought. Future studies to develop better prediction rules should compare their performance with that of existing prediction rules, including the TRST and Identifying Seniors at Risk tool, and assess the effect of any new prediction rule on patient outcomes.     

Vision, aging, and driving: the problems of older drivers.

Although there are well-recognized declines in visual functioning with age, their contribution to the problems of older persons on tasks in the natural environment, including driving, are largely unknown. Adults ranging in age from 22-92 years were surveyed in regard to their visual difficulties when driving and performing everyday tasks. The visual problems of drivers increased with age along five different visual dimensions: unexpected vehicles, vehicle speed, dim displays, windshield problems, and sign reading. Several of the age-related visual problems that were reported appear to be related to the types of automobile accidents more common among older drivers. The study also replicated the findings from an earlier investigation of non-driving tasks that showed visual declines with age on five dimensions: visual processing speed, light sensitivity, dynamic vision, near vision and visual search. These findings indicate promising areas of research regarding the effects of visual aging on tasks in the natural environment.     

Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.

BACKGROUND: Although sleep apnea is common, it often goes undiagnosed in primary care encounters. OBJECTIVE: To test the Berlin Questionnaire as a means of identifying patients with sleep apnea. DESIGN: Survey followed by portable, unattended sleep studies in a subset of patients. SETTING: Five primary care sites in Cleveland, Ohio. PATIENTS: 744 adults (of 1008 surveyed [74%]), of whom 100 underwent sleep studies. MEASUREMENTS: Survey items addressed the presence and frequency of snoring behavior, waketime sleepiness or fatigue, and history of obesity or hypertension. Patients with persistent and frequent symptoms in any two of these three domains were considered to be at high risk for sleep apnea. Portable sleep monitoring was conducted to measure the number of respiratory events per hour in bed (respiratory disturbance index [RDI]). RESULTS: Questions about symptoms demonstrated internal consistency (Cronbach correlations, 0.86 to 0.92). Of the 744 respondents, 279 (37.5%) were in a high-risk group that was defined a priori. For the 100 patients who underwent sleep studies, risk grouping was useful in prediction of the RDI. For example, being in the high-risk group predicted an RDI greater than 5 with a sensitivity of 0.86, a specificity of 0.77, a positive predictive value of 0.89, and a likelihood ratio of 3.79. CONCLUSION: The Berlin Questionnaire provides a means of identifying patients who are likely to have sleep apnea.     

Young driver risk taking: a description of dangerous driving situations among 16- to 19-year-old drivers

Dangerous drinking and driving situations contribute heavily to morbidity and mortality among older adolescents. One hundred ninety-two high school drivers related 662 dangerous driving incidents (430 by males, 232 by females) in which they were involved in the preceding 6 months. Dangerous driving incidents were characterized by reckless intent, driving late at night, riding with other peers involving alcohol and drugs, reporting impaired driving, and distractions in the car. Adolescent drivers are commonly involved in dangerous drinking-driving situations with peers and without significant consequences. There are points along the continuum leading up to, during, and after such events that offer opportunities for significant prevention and intervention. Such strategies are reviewed.     

Effective strategies to identify postmenopausal women at risk for osteoporosis

The early identification of postmenopausal women at risk of fracture, followed by effective therapeutic intervention, can substantially improve patient outcomes. Bone mineral density measurements and comprehensive risk assessment are essential components in deciding when to intervene with osteoporosis pharmacologic treatment. Simple, easy-to-administer risk assessment tools are available to assist the physician in identifying patients in need of further evaluation or treatment and aid in patient counseling. Furthermore, effective pharmacologic treatments are available that have demonstrated reductions in the risk of vertebral and nonvertebral fractures. Some therapies, such as selective estrogen receptor modulators and bisphosphonates, are able to act early in the course of treatment to reduce this risk of vertebral and nonvertebral fractures. The tools to reduce the underrecognition and undertreatment of osteoporosis are readily available. Primary care physicians are in a unique position to use these tools as part of a more proactive approach to fracture prevention in postmenopausal patients.     

The utility of a single test to identify women at risk for gestational diabetes

A number of single tests have been proposed as both screening and definitive tests of glucose intolerance during pregnancy. Despite limitations imposed by a lack of uniformity in methodology and definitions of gestational diabetes mellitus, there appears to be an independent relationship between some single-test results and clinically meaningful outcomes. Further study is needed to identify those glucose values above which women and their babies who are at risk for glycemia-related adverse outcomes may be identified.     

Capturing side-effect of medication to identify persons at risk of delirium

Delirium, an acute confusional state characterized by decline in attention and cognition, is a common, life-threatening, but potentially preventable clinical syndrome among older persons. Deficits in cholinergic function have been postulated to cause delirium and cognitive decline. In particular, an imbalance between levels of acetylcholine and monoamine (such as dopamine) may cause delirium. We describe two cases of delirium in hospitalized older patients, supporting the "cholinergic deficiency hypothesis". In the first patient, hypo-reactive delirium developed a few hours after a dose of the long-acting opiate tramadol (a drug with anticholinergic effect) as analgesic for pain related to advanced peripheral artery disease. In the second patient, with vascular parkinsonism plus pre-frontal cortex vascular lesions, hyper-reactive delirium developed a few hours after a prescribed administration of L-dopa. These symptoms disappeared completely on the following day. These two "natural" experiments support the hypothesis that both hypo-reactive and hyper-active delirium may be caused by a reduction in cholinergic signaling.