This session will address counseling the at-risk driver, healthcare provider responsibility and liability, clinician resources to provide older drivers, and procedures for reporting. This session will also include information on recognizing the sense of loss and grief experienced by someone who must relinquish a driver’s license

Dave, Jatin

Ellicks, Michele

Ellison, James

Kerrigan, Debra

Weinberger, Marjorie

English

University of Massachusetts Boston: ScholarWorks at UMass

Steve Evans Director of Medical Affairs Phone:  (857) 368- 8020 Fax: (857) 368-0802 http://www.massrmv.com/rmv/medical/index.htm Retirement from Driving: Having The Difficult Conversations James M. Ellison MD MPH Director, Geriatric Psychiatry Program McLean Hospital Successful Retirement from Driving Makes Everyone Feel Good • Story of Mr. and Mrs. A’s decision Contentious Retirement From Driving Is A Nightmare! • Dr. and Mrs. B Paradox: Older Drivers Are Safer AND More Vulnerable • In 2008, 33 million older licensed drivers in US • Older drivers pay attention to safety:1 – Tend to drive when conditions are safest – Higher rate of seatbelt use – Lower rate of alcohol-related impaired driving • But older drivers are more vulnerable to injury/death – 500 injuries per day in US – 15 deaths per day in US – Unintentional injury is 8th cause of death among ≥65 years old – Fragility estimated to account for 60-95% of -excess death rates per VMT in older drivers2   1. http://www.cdc.gov/motorvehiclesafety/Older_Adult_Drivers/adult-drivers_factsheet.html; 2. Li et al. Accid Anal Prev 2003;35:227-35  Absolute Rates of Drivers in Fatal Crashes Suggest Low Risk for Elderly Drivers 024681016 17 18 19 20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485+FemalesAll DriversMalesDriver Fatality Rates per Miles Traveled Clarifies Nature of Risk Driver Age (Years) 1996 NHTSA Data, Fatality Rates per 100 million vehicle miles traveled  Characteristics of Elderly Drivers’ Traffic Fatalities • Daytime (79%) • Weekdays (73%) • Other vehicles involved (73%) • Male>Female • Making a left turn (OR 5) • Less often associated with high BAC • Less often without use of restraints (75% vs 62%)   The Vital Factors • Frailty • Vision • Motor Strength • Cognition – Memory – Speed – Executive Function  Cognitively Impaired Drivers Fail to Voluntarily Retire from Driving • Relationship of dementia diagnosis or MMSE to unfitness for driving is not completely clear. • Retirement from driving may be delayed by: – Limited awareness of deficit – Difficulties with transportation alternatives  – Caregiver denial or needs – Delay in cessation of up to 48 months after caregiver’s perception of need to stop1 • In one study, only 42% of DAT patients stopped driving before a crash occurred, and mean MMSE was 19.9 at time of first crash.2 1. Cotrell and Wild. Alz Dis Assoc Disord 1999;13:151-6; 2. Friedland et al. Ann Neurol 1988;24:782-6. 11 Barriers to Assessment (1) • Clinician barriers – Time, Skill, Reluctance to distress patient – Lack of mandate, fear of retribution • System barriers – Formal assessment is expensive – License renewal is relatively easy – Transportation alternatives may be limited • Caregiver barriers – Empathy – Conflict avoidance – Convenience Date of download:  4/15/2015 Copyright © 2015 American Medical Association. All rights reserved. From: Discussing Driving Concerns With Older Patients:  I. Vision Care Providers' Attitudes and Behaviors JAMA Ophthalmol. 2013;131(2):205-212. doi:10.1001/2013.jamaophthalmol.124 Figure. Referral patterns of optometrists (OD) and ophthalmologists (MD) when they identify concerns about driving safety among their older adult patients. T indicates total; VCPs, vision care providers. Figure Legend:  13 Barriers to Assessment (2) • Driver Barriers – Enjoyment of driving – Denial or limited awareness – Desire for continued autonomy – Self-esteem – Avoidance of dependence When Do You Discuss It? • Early! Before there is a crisis • Or Later, when risk becomes apparent • Not on the fly • Not without preparation • Really understand the meaning of driving! – One of the most significant age-associated losses  Do you have difficulty seeing clearly in the dusk and dark?   Do headlights from other vehicles obstruct your sight?   Are you easily intimidated by passing vehicles including   trucks and motorcycles? Do you have difficulty reading road signs?   Do you have difficulty following construction detours or   seeing the police officer on detail near construction zones?   Do you have difficulty seeing train crossing signals or   hearing train whistles?   Do you have difficulty keeping up with the posted speed limit?   Do you get drowsy behind the wheel or have difficulty concentrating? http://www.massrmv.com/rmv/medical/safeDriver.pdf   Safe Driver Checklist  (1)  Do you have difficulty hearing other vehicles?   Do you often get lost on once familiar roads?   Do you forget the basics - putting on your headlights and wearing a seat belt?   Are you unsure of your parking skills?   Can you parallel park and park in a straight line?   Are you unsure of your reflexes and reaction time?   Is it difficult to react quickly, e.g. braking to avoid a collision?   Have family, friends, or police officers told you that you aren’t a safe driver?   http://www.massrmv.com/rmv/medical/safeDriver.pdf   Safe Driver Checklist  (2) Danger Signals • CDR score of 0.5 or 1.0 • Caregiver rating of driving as unsafe • History of crashes/citations • Self-imposed limits on driving • MMSE of 24 or less • Aggressive or impulsive personality traits But NOT self-rating, lack of self-imposed limits Neurology 2010;74:1316-1324 How Do You Prepare? • Plan your approach • Know the reasons for concern • Know the alternatives • Be prepared for resistance • Learn about motivational interviewing How Do You Discuss It? (1) • Motivational Interviewing provides a way: 1. Assess readiness for change:  A. Precontemplation  B. Preparation  C. Action  D. Maintenance  How Do You Discuss It? (2) Avoid confrontation Weigh the Pros and Cons of driving/ not Know the alternatives Express empathy Support self-efficacy Roll with the resistance Develop discrepancy Listen reflectively Dugan, E. The Driving Dilemma. New York, HarperCollins, 2006. Next Steps • Repeated discussions (especially with cognitively impaired person) • Evaluate whether “phasing out” is safe vs. complete cessation • Enlist clinicians in process as needed    Debra A. Kerrigan, MS, OTR/L Newton-Wellesley Hospital Department of Rehabilitation Services Drive Safe Program  Drive Safe Program LEGAL ISSUES:  • Reporting  •  Liability  ETHICAL ISSUES:  • Patient Confidentiality • HIPPA  • Conflicting Obligations • To the patient •  Public Health Occupational Therapy Code of Ethics  Division of Professional Licensure – Board of Allied Health Encouraging voluntary surrender vs. provider reporting?  • Transportation options   • Family/caregiver support  • Community support • Mr. G. – 91 y.o.  • Not driving s/p TIA  • Mrs. B – 94 y.o.  • Driving; no clear reason for referral  • Mr. S – 71 y.o. • Dementia; multiple evaluations in 2.5 yrs  Driving is a Privilege but Community Mobility is a Right.  

Plenary Session III – Medical Track: Reporting At-Risk Drivers to MassDOT Medical Advisory Board

https://scholarworks.umb.edu/cgi/viewcontent.cgi?article=1017&amp;context=olderdriversafetysummit

Plenary Session III – Medical Track: Reporting At-Risk Drivers to MassDOT Medical Advisory Board

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