The Older Adult Driver

American Family Physician,  Jan 1, 2000  by David B. Carr

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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. (Am Fam Physician 2000;61:141-6,148.)

Demographic changes in the United States have resulted in a growing number of drivers over age 65. It is estimated that by the year 2020, more than 15 percent of drivers will be older than 65.1 Older adults who drive are able to maintain important links to their communities. Those who stop driving are at risk for isolation and depression,2 and often have associated functional impairment.3 Moreover, the societal cost of providing transportation services for older people who cannot drive is considerable.

Because of lack of training in injury prevention or rehabilitation, the fear of losing a patient or, perhaps, legal concerns, family physicians may be reluctant to address the issue of an older person's driving capabilities. Injury prevention and health maintenance are important objectives in family practice. The physician's goal is to identify treatable causes while preserving patients' mobility and independence. Driving should be viewed as an aspect of this independence. Family physicians can play a pivotal role in maintaining or even improving driving skills in their older patients. For patients who can no longer drive, physicians can recommend other transportation resources.

Public safety concerns about the driving performance of older adults have been raised by evidence showing an increased crash rate per mile driven for drivers aged 70 or older compared with other adult age groups.4 This increased crash rate has been attributed to age-related changes in driving skills in addition to various medical illnesses.5 Older drivers, however, tend to drive less at night, during adverse weather conditions, during rush hours or in congested thoroughfares. These factors, along with a reduction in overall miles driven per year, make public policy decisions on screening older drivers questionable, considering that the number and severity of crashes by younger drivers outweigh those by older people. Nevertheless, these concerns may be important when dealing with individual patients.

Driving Assessment

Driving issues in an older patient may come to the attention of the family physician for various reasons. The patient may question his or her own ability to drive safely. A concerned family member or friend may have observed unsafe driving behavior. The department of motor vehicles may have requested the physician's opinion of a person's driving abilities. Many older adults have jobs, such as driving school buses or company vehicles, and they may be required to have an annual health examination. Finally, the physician may consider driving an important safety or mobility issue when a patient has symptoms such as lightheadedness or diseases such as diabetes mellitus.

driving history

The comprehensive assessment should begin with the driving history. Important human, environmental and vehicular information can be elicited from the patient, the family members, or both (Table 1). Obtaining additional information from someone who has driven as a passenger with the patient or observed the patient's driving behavior may be useful. Any mention of close calls, mishaps, disorientation or becoming lost in familiar areas should alert the physician to possible problems. If the informant answers no to the question "Do you feel safe riding with the patient?" the interviewer should ask whether this is a change. If the risky behavior has been noted for years, it is unlikely to be due to a new medical illness.

medication review

Medications can affect driving skills; for example, an association between the use of long-acting benzodiazepines and crash rates in older adults has recently been reported.6 Several other classes of drugs, when assessed by road tests or simulators, are associated with either an increased risk of crashing or impaired driving skills (Table 2). Some cases of physician liability that involve driving are related to medication prescription.7 Physicians should warn a patient if a prescription drug may affect tasks such as driving or operating heavy machinery and should document this conversation in the medical record.