Clinicians should consult national guidelines and resources related to assessment and management of older drivers (see More Information More Information Medical assessment of the older driver includes a thorough review of medical conditions and/or drugs that can impair driving ability. Such medical conditions can be chronic disorders that impair... read more and also Overview of the Older Driver Overview of the Older Driver For many older adults, driving an automobile is their preferred option for community transportation. Medical disorders that impair driving in older adults may have two serious adverse outcomes... read more .)
Older adults are likely to have multiple comorbidities and may be taking several drugs. A significant number of drugs, typically those affecting the central nervous system (eg, causing confusion, sedation) can potentially impair driving. Many have been shown to impair driving performance during road tests or in driving simulators and have been associated with an increase in motor vehicle crash (MVC) risk. Despite these risks, many of these drugs should not be stopped abruptly and may need to be tapered. Obtaining input from the prescribing physician or pharmacist is important before stopping them.
Some drugs that have been shown to increase driving risk include
Antihistamines, benzodiazepines, opioids, anticholinergics, hypnotics, antihypertensives, and tricyclic antidepressants, which can cause drowsiness, hypotension, or arrhythmias
Antiparkinsonian dopamine agonists (eg, pramipexole, ropinirole), which can occasionally cause acute sleep attacks
Antiemetics (eg, prochlorperazine) and muscle relaxants (eg, cyclobenzaprine), which can alter sensory perception
Antiseizure drugs, which can cause sedation (alternatives may need to be considered)
When starting a new drug that could affect visual, physical, or cognitive function, patients should refrain from driving for several days (depending on the time required to reach a steady state) to be sure no adverse effects occur.
Falls Falls in Older People A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders... read more and MVCs share common causative factors (eg, impaired vision, muscle strength, and cognition). A history of falls in the past indicates increased risk of MVCs in older adults and should prompt further evaluation for intrinsic factors that can impair mobility and driving Motor function Adequate visual, motor, and cognitive abilities are needed to drive safely and require functional assessment to identify deficits. Some of these assessments can be done by primary health care... read more (eg, visual, cognitive, and motor skills). (See Functional Assessment of the Older Driver Functional Assessment of the Older Driver Adequate visual, motor, and cognitive abilities are needed to drive safely and require functional assessment to identify deficits. Some of these assessments can be done by primary health care... read more .)
The presence of a cardiac disorder may increase driving risk, particularly disorders that may impair consciousness or cause syncope (eg, arrhythmias Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more ). Patients who have had cardiac procedures (eg, coronary artery stents or bypass grafts, placement of internal defibrillator/pacemakers) or certain acute events (eg, unstable angina Unstable Angina Unstable angina results from acute obstruction of a coronary artery without myocardial infarction. Symptoms include chest discomfort with or without dyspnea, nausea, and diaphoresis. Diagnosis... read more , myocardial infarction Acute Myocardial Infarction (MI) Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and/or diaphoresis... read more ) need to refrain from driving for a brief time during recovery; the length of time depends on the procedure and the patient's clinical condition. Cardiac disorders can cause chronic cognitive impairment (eg, sedation, drowsy driving) or acute impairment in consciousness (eg, dizziness, syncope).
Patients with severe heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more (eg, class IV heart failure, dyspnea at rest or while driving) should refrain from driving until they can be evaluated with on-road testing and have the approval of their clinicians.
Neurologic disorders also increase driving risk. Specific disorders include
Stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more or transient ischemic attack (TIA) Transient Ischemic Attack (TIA) A transient ischemic attack (TIA) is focal brain ischemia that causes sudden, transient neurologic deficits and is not accompanied by permanent brain infarction (eg, negative results on diffusion-weighted... read more : Drivers with a single TIA should wait 1 month before resuming driving; those with recurrent TIAs or a stroke should be event-free for at least 3 to 6 months before resuming driving and be cleared by their neurologist or primary care physician. Physical examination should be done to assess how residual disability due to stroke may affect driving ability. Consider referring those with persistent visual, motor, or cognitive deficits to an occupational therapist-based driving assessment clinic.
Seizures Seizure Disorders A seizure is an abnormal, unregulated electrical discharge that occurs within the brain’s cortical gray matter and transiently interrupts normal brain function. A seizure typically causes altered... read more : Regulations for drivers who have seizures are state-specific, but most states require a seizure-free interval (often 6 months) before they reinstate driving privileges. Antiseizure drugs can adequately control seizures in about 70% of patients, although relapses may occur when these drugs are withdrawn. State-specific information regarding driver's license eligibility for people who have seizures should be sought (see the Epilepsy Foundation's State Driving Laws Database) along with advice from a neurologist.
Alzheimer disease Alzheimer Disease Alzheimer disease causes progressive cognitive deterioration and is characterized by beta-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter. Diagnosis... read more or progressive dementing disorders will eventually impair key functional abilities, including those required for driving. Monitoring patients for new driving errors that can be attributed to changes in cognition or identifying significant impairments in psychometric tests Cognitive function Adequate visual, motor, and cognitive abilities are needed to drive safely and require functional assessment to identify deficits. Some of these assessments can be done by primary health care... read more may be useful in determining referrals for on-road evaluation and/or possibly driving cessation. The American Academy of Neurology has practice parameters on driving and dementia ( 1 Neurologic disorders reference Medical assessment of the older driver includes a thorough review of medical conditions and/or drugs that can impair driving ability. Such medical conditions can be chronic disorders that impair... read more ). Several states presently require physicians to report significant cognitive impairment to the state's Department of Motor Vehicles.
Many other neurologic disorders (eg, Parkinson disease, multiple sclerosis) cause disability and should be monitored by functional assessment and, when appropriate, an on-road evaluation.
Diabetes mellitus Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more poses a risk because patients may become hypoglycemic while driving. Patients who have had a recent hypoglycemic episode with unawareness should not drive for 3 months or until factors contributing to the episode (eg, diet, activity, timing and dose of insulin or antihyperglycemic drug) have been assessed and managed. Sensory changes in the extremities due to neuropathy, retinopathy, or both caused by diabetes can also impair driving ability.
Severe hyperglycemia is associated with cognitive impairment, and patients should not drive until their blood glucose and symptoms are under better control.
Sleep disorders, most notably obstructive sleep apnea syndrome Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more , can cause drowsiness leading to MVCs, and patients should refrain from driving until they are adequately treated. Use of a continuous positive airway pressure (CPAP) device has been shown to improve performance in a driving simulator and reduce MVCs.
Neurologic disorders reference
1. Iverson DJ, Gronseth GS, Reger MA, et al: Practice parameter: Evaluation and management of driving and dementia: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74(16):1316–1324, 2010. doi: 10.1212/WNL.0b013e3181da3b0f
The following are some English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
National Highway Traffic Safety Administration: Clinician's Guide to Assessing and Counseling Older Drivers, 4th edition
Austroads: Assessing Fitness to Drive: An Australian resource providing medical standards for driver licensing
Epilepsy Foundation: State Driving Laws Database: A US resource providing information for drivers with epilepsy
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