When should I discuss driving with my older patients?
EPISODIC INCAPACITATION
Approximately 1% to 3% of all motor vehicle accidents are due to sudden incapacitation of an otherwise safe driver.
Syncope. Neurally mediated (vasovagal) syncope accounts for 30% to 35% of syncopal episodes while driving.6 Cardiac arrhythmias are the next most common cause and include bradyarrhythmias (7%), supraventricular tachyarrhythmias (2%–15%), and ventricular tachyarrhythmias (5%–17%). Because neurocardiogenic syncope often recurs, consider restricting driving for those with recurrent or severe neurocardiogenic syncopal episodes until symptoms are controlled.
Arrhythmias. Driving recommendations for various arrhythmias7,8 are listed in Table 2.
Many patients who have an implantable cardioverter-defibrillator (ICD) device experience an unexpected shock. For individuals with a history of ventricular tachycardia or fibrillation, the 5-year actuarial incidence of appropriate ICD shocks ranges between 55% and 70%. However, data indicate that 90% to 100% of drivers who received ICD discharges while driving continued to drive without causing motor vehicle accidents.9,10
Seizures. States differ in their rules for reporting drivers who have epilepsy or breakthrough seizures. Physicians should refer to their state regulations when counseling these patients.
POLYPHARMACY
Polypharmacy is common in older adults. Many take psychoactive drugs that can impair tracking, alertness, coordination, and reaction time. With the “Roadwise Rx” tool (www.roadwiserx.com), health care providers and patients can enter the names of medicines to check if they affect driving ability. Nonproprietary on-line tools such as “START” (Screening Tool to Alert doctors to Right Treatment) and “STOPP” (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) can be used to prune medication lists.
DRIVING EVALUATION
America is a nation of highways overflowing with cars. Cars provide transportation but also reflect wealth and personality, particularly for men. Practically, the ability to drive a car allows older men and women to socialize in the community, shop for essentials, and take care of themselves without being a burden. Driving cessation can cause social isolation and depressive symptoms and can strain caregiver resources.
It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician for further risk assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.
The evaluation typically involves an assessment of the driver’s knowledge of traffic signs and laws, a cognitive assessment, possibly a simulation, and finally an on-road driving evaluation if deemed appropriate. Medicare coverage depends on diagnosis and the state carrier.
