Interventions with the Older Driver
If older drivers with significant functional deficits decide to limit or stop driving, the role of health care practitioners is largely supportive. If the medical evaluation identifies potentially correctable deficits and older drivers acknowledge these deficits but still wish to continue driving, practitioners can offer treatment to help correct the deficits or impairments. However, aside from treating medical conditions that impair driving ability, most practitioners are ill-equipped to formulate or execute a driving rehabilitation plan; referral to specialists is often helpful.
Although some older drivers can benefit from driving refresher courses (eg, American Association of Retired Persons Driver Safety Program available at www.aarp.org), most should be referred to occupational therapists that specialize in driving rehabilitation (called driving rehabilitation specialists—to find one of these specialists, contact local rehabilitation facilities or access the driving rehabilitation specialist finder or the driver rehabilitation specialist member directory). Driving rehabilitation specialists usually do comprehensive driving assessments that include clinical tests of vision, motor, and cognitive skills as well as on-road evaluations. During on-road evaluations, the specialist goes in a vehicle with the older driver to evaluate actual driving skills in varied traffic conditions. The vehicle used during the evaluation should be equipped with features that allow the specialist to maintain safe control (eg, passenger-side brake). These specialists can also assist by
Instituting a tailored rehabilitation plan to increase motor skills or cognition and perception in the driver’s daily life
Providing adaptive equipment, such as a spinner knob, to help with one-handed steering or more complicated devices such as hand controls
Evaluating the response to the rehabilitation plan and providing feedback to the driver, involved relatives, and the physician as to whether the driver's driving abilities are adequate to continue driving or whether driving restrictions are indicated
Providing mobility counseling or advice on alternate modes of transportation
In most states, the cost of a rehabilitation driving assessment is not covered by insurance (Medicare or private) and may be an out-of-pocket cost.
If older drivers deny or are unaware of their limitations or if deficits do not respond to treatment, practitioners may need to be more proactive. In these situations, practitioners should discuss issues relevant to driving safety, potential driving cessation, patient transportation needs, and alternative transportation resources with the patient and family members.
The practitioner should balance the benefits of safety to the patient, pedestrians, and other drivers against the costs of social isolation, worsening functional status, impaired quality of life, and clinical depression. For some patients (eg, those with severe dementia), the benefits of driving cessation clearly outweigh the costs.
Alternative transportation options should be discussed; they vary from community to community, and contact with local resources such as the Alzheimer’s Association (www.alz.org) or American Automobile Association Foundation for Traffic Safety (seniordriving.aaa.com) may provide updated information on options. Family members can find publications and online information about having conversations with older drivers. See, for example, the Hartford publications "Understanding Dementia and Driving" and "We Need to Talk: Family Conversations with Older Drivers".
The loss of driving privileges can be relatively devastating in terms of maintaining independence. If alternative transportation cannot be arranged and the ability to maintain activities of daily living is adversely affected, loss of driving privileges sometimes prompts the need to move in with a family member or transition to an assisted-living facility or retirement community.
If the driver’s functional limitations or medical status seems to warrant driving cessation, practitioners should follow the reporting requirements of their state Department of Motor Vehicles. States vary in their reporting laws. All states have voluntary reporting laws, but some states have mandatory reporting laws. (See the National Highway Traffic Safety Administration's [NHTSA] Physician’s Guide to Assessing and Counseling Older Drivers for state licensing requirements and reporting regulations.) In most states, statutes protect the practitioner’s anonymity or provide immunity to the practitioner. Legal consultation may be beneficial when an office or institution is developing a reporting policy and procedure.
Before making a report, practitioners should discuss recommendations for driving cessation directly with the patient and family rather than simply filing a report. Practitioners should make every attempt to persuade the patient to cooperate with driving restrictions. Such discussion should include why the patient’s limitations make driving unsafe and why the practitioner is obligated to report.
In some situations, practitioners must report functional limitations or medical status to state agencies against the wishes of their patients; this action often has a negative impact on the practitioner-patient relationship. Regardless, medical information can be legally disclosed if a patient’s driving impairment might jeopardize public safety; practitioners who do not notify appropriate authorities may be legally liable for subsequent injuries.