A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father’s decline following her mother’s death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.
THE CASE: A 78-year-old widower with hypertension, type 2 diabetes, and hyperlipidemiais referred for a comprehensive geriatric assessment.His daughter is concerned about her father's decline following her mother's death a year ago.His memory seems to be deteriorating. His desk is cluttered with bills, but he refuses to lethis daughter help him or even look at his checkbook.Several months ago he had driven to her house and arrived an hour late. She suspectshe might have gotten lost, but her father attributed the delay to construction in the area. Sixmonths ago she noticed a dent in the fender, but her father denied being in an accident.The patient reports that he drives almost daily. He claims that he has never had an accidentor near miss or received a citation. He denies getting lost. The daughter notes that herfather is cautious and always drives under the speed limit.The patient visits an ophthalmologist once a year and has no history of eye changes. Hehas some numbness and burning of the feet but no history of dizziness or falls. He complainsof "neck arthritis" but does not take medication for this. The patient thinks his memory is"pretty good"; however, his daughter notes that he repeats himself frequently. He does notthink he is sad or depressed, but he has taken an over-the-counter (OTC) sleeping pill nightlysince his wife died. He does not smoke or drink alcohol. His medications include enteric-coatedaspirin, an ACE inhibitor, and a statin. His daughter found a bottle of acetaminophen/diphenhydramine in his medicine cabinet. At his daughter's suggestion, he started takingginkgo biloba several months ago, and she thinks it has helped his memory.The patient's orthostatic vital signs are normal. His vision is 20/40 in each eye. The patienthas a high school education; the Mini-Mental Status Examination (MMSE) score is20/30. The Geriatric Depression Scale score is 1/15, which indicates that he is not depressed.The clock drawing is abnormal (Figure 1), however. Physical examination confirms limitedrange of motion of the neck, peripheral neuropathy, and a Rapid Pace Walk of 9 seconds.Given the warning signs that it may no longer be safe for thispatient to drive--what is the best way to intervene?Motor vehicle accidents arethe leading cause of injury-relateddeaths among persons aged 65 to74 years and the second leadingcause (after falls) among those75 years and older.1 Elderly drivershave a higher fatality rate per miledriven than any other age groupexcept those 25 years and younger.The fatality rate for drivers 85 yearsand older is 9 times higher than thefatality rate for drivers aged 25 to 69years (Figure 2).2Unlike accidents that involveyounger drivers, most accidents thatinvolve elderly drivers occur duringdaylight hours, on good roads, andwithout the influence of alcohol.Elderly persons are more likely tohave disease- and medication-relatedimpairments. Many elderly patientsreport some self-regulation of drivinghabits because of age-relatedchanges, health concerns, and possible side effects of medications. Theytend to drive fewer miles and theyreduce nighttime driving and drivingin poor weather conditions, onfreeways, and during rush hour.They may even try to reduce thenumber of left-hand turns. Familiesmay be falsely reassured by the patient'sslow driving. The most commontraffic violations among elderlydrivers involve failure to yield,improper turning, incorrect lanechanging, and difficulty in enteringor leaving expressways. Red flagsfor driving problems are listed inthe Table.Many patients with poor visionare unaware of it; some, because ofdementia, lack insight into their drivingdeficits. However, there are alsopatients who may stop driving toosoon and who suffer from isolationand lack of socialization because oflimited or nonexistent alternativetransportation. Depressive symptomsincrease with driving cessation,and it is important to be alert for thispossibility. In American society, particularly,driving is a source of independenceand self-esteem. This isanother reason for tact and sensitivitywhen addressing the issue withthe patient.Note that physician reportinglaws vary widely. The Physicians'Guide to Assessing and CounselingOlder Drivers, published by theAMA, includes information fromevery state.3 It also addresses issuessuch as immunity, anonymity,legal protection for reporting, whatconstitutes a breach of physician-patientconfidentiality, and legal versusethical responsibilities. If the patientlacks insight into his or her condition,it is imperative to involve thefamily and/or another person whohas decision-making responsibilityfor the patient.EVALUATION
Although there is no way to directlyassess crash risk, you canprovide a comprehensive evaluationthat includes a vision examinationand cognitive and functional screening,as well as an assessment ofmotor function, age-related risk factors,and relevant disease conditions,medications, and functionaldeficits. This information sheds lighton overall risk and provides objectiveevidence of the need for a formaldriving evaluation.Vision. In addition to changesin visual acuity, older age is associatedwith an increased incidence ofglaucoma, macular degeneration,cataracts, and diabetic retinopathy.Most states require 20/40 vision forunrestricted licensing.Visual fields may decline. Stroke,lid ptosis, and glaucoma are contributoryproblems. More than half of patientswith field cuts are unaware ofthe deficit.Contrast sensitivity declines.Increasing contrast is needed to pickout a target from the background,which makes it more difficult todrive at night or in snow or rain.Glare intolerance increases withage and is exacerbated by eye disorderssuch as cataracts, which makehalos around lights during nighttimedriving a hazard.Decreased adaptation to abruptchanges in light also affects the abilityto drive safely at night.The AMA monograph includesa chapter on formal assessment ofvisual acuity using the Snellen Echartand instructions for testingvisual fields by confrontation.3 Abnormalitiesmay prompt a referral for a formal eye examination.Cognition. The MMSE is oftenused for screening, but the correlationwith driving risk is not as reliableas that provided by the ClockDrawing Test. A recent study demonstratesthe association betweenspecific elements of the test andpoor driving performance. Any incorrectelement warrants formaldriving evaluation.4 Studies havealso shown an association betweenperformance on the Trail-MakingTest, Part B (Figure 3), anddriving.3 The patient is asked to connectthe circles, alternating lettersand numbers in order. An abnormalresult is taking more than 180 secondsto complete the task. This resultcalls for a formal driving evaluation.Motor function. The AMAguide includes a number of tests toassess driving-related skills. Ascore sheet can be photocopied toprovide documentation and addedto the patient's chart. For the RapidPace Walk, the patient is asked towalk 10 feet, then turn and walkback to the starting point as quicklyas possible. Researchers found thatpersons who took longer than 7seconds to complete the task weretwice as likely to have a trafficmishap in the year following thetest as those who completed it inless than 7 seconds.5Medication. Most patientsolder than 65 years take at least 1prescription medication daily, andmany take 2 or more.6 Age-relatedchanges that affect pharmacokineticsand pharmacodynamics contributeto the risk of side effects anddrug-drug interactions. Be sure toask about alcohol intake, OTC remedies,and herbs or other supplements.Benzodiazepines, as well asmuscle relaxants, antihistamines,and opioids, may increase risk of amotor vehicle accident. The AMAguide provides extensive informationon medical conditions and medicationsthat may impair driving.OUTCOME OF THE CASE
The 78-year-old patient describedin the opening case had a normalmetabolic panel, complete blood cellcount, and levels of vitamin B12 andthyroid-stimulating hormone. A CTscan of the head showed microvascularchanges and an old lacunarinfarct.The patient and his family weretold that he appeared to have milddementia, based on his memoryloss, decline from a previous levelof functioning, and cognitive difficulties.The risks and benefits of cholinesteraseinhibitor therapy werediscussed. The patient was advisedto stop taking acetaminophen/diphenhydramine because diphenhydraminecan exacerbate confusion.7 He was also advised to discontinuegingko because reports ofits effectiveness are inconsistent andit is not recommended with concomitantaspirin use. Treatment ofthe patient's vascular risk factorswas continued.It was recommended that thepatient limit his driving to familiartrips in the neighborhood duringdaylight hours. The family was providedwith information about communityresources for alternativetransportation.The patient was unwilling to restricthis driving. A formal evaluationby a driving rehabilitation specialistwas recommended. The patient wasadvised that if he con-tinued to drivewithout an evaluation, the departmentof motor vehicles would be notifiedand would schedule an evaluation.This agency has the authorityto revoke a driver's license.On the morning of the drivingevaluation, the patient knocked off aside mirror while pulling out of thegarage and decided to forgo thetest. He was upset but agreed tostop driving. A series of follow-upvisits was arranged to monitor fordepressive symptoms and social isolation,and to encourage activitiesoutside the home.Several months later, the patientis satisfied with the arrangements foralternative transportation. His granddaughtertakes him grocery shoppingevery week, and friends andother family members have alsoagreed to drive him. The church vanpicks him up on Sunday. He hasarranged for transportation to physicianappointments through the AreaAgency on Aging.
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