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Clinical Crossroads | Clinician's Corner

Impaired Driving From Medical Conditions:  A 70-Year-Old Man Trying to Decide if He Should Continue Driving

Matthew Rizzo, MD, Discussant
JAMA. 2011;305(10):1018-1026. doi:10.1001/jama.2011.252.
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Some medical disorders can impair performance, increasing the risk of driving safety errors that can lead to vehicle crashes. The causal pathway often involves a concatenation of factors or events, some of which can be prevented or controlled. Effective interventions can operate before, during, or after a crash occurs at the levels of driver capacity, vehicle and road design, and public policy. A variety of systemic, neurological, psychiatric, and developmental disorders put drivers at potential increased risk of a car crash in the short or long term. Medical diagnosis and age alone are usually insufficient criteria for determining fitness to drive. Strategies are needed for determining what types and levels of reduced function provide a threshold for disqualification in drivers with medical disorders. Evidence of decreased mileage, self-restriction to driving in certain situations, collisions, moving violations, aggressive driving, sleepiness, alcohol abuse, metabolic disorders, and multiple medications may trigger considerations of driver safety. A general framework for evaluating driver fitness relies on a functional evaluation of multiple domains (cognitive, motor, perceptual, and psychiatric) that are important for safe driving and can be applied across many disorders, including conditions that have rarely been studied with respect to driving, and in patients with multiple conditions and medications. Neurocognitive tests, driving simulation, and road tests provide complementary sources of evidence to evaluate driver safety. No single test is sufficient to determine who should drive and who should not.

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Figure. Information Processing Model for Understanding Errors That May Lead to Vehicle Crashes in Drivers With Medical Disorders
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The driver (1) perceives and attends to stimulus evidence (eg, through vision, audition, somatosensory, and vestibular inputs) and interprets the situation on the road; (2) formulates a plan based on the driving situation and previous experience or memory (eg, of routes, locations of nearby vehicles, how to operate the controls or respond to particular emergencies); (3) executes an action (eg, by applying the accelerator, brake, or steering); and (4) monitors the outcome as a source of potential feedback for subsequent corrective actions (the return pathway from behavior to stimulus). The driver's behavior is deemed safe or unsafe due to errors at 1 or more stages in the driving task.2

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Tiered Assessments for Older Drivers
Posted on March 3, 2011
Marian E. Betz, MD, MPH
University of Colorado School of Medicine, Department of Emergency Medicine
Conflict of Interest: None Declared
As the elderly population in the US grows, there is increasing awareness concerning the need to identify and retrain or restrict unsafe older drivers without unnecessarily limiting the mobility of those who are safe.[1] Numerous demographic, clinical and driving-related variables have been examined in relation to driving ability, but no single characteristic accurately predicts future crashes,[2] as driving risk arises from a variety of medical conditions, aging-related impairments (cognitive, mental, physical, sensory) and medications.[2, 3] Driver evaluation programs like the one Mr. P used, with specially-trained occupational therapists and other providers, are considered the most comprehensive method of driver assessment.[4, 5] Unfortunately, these programs are not typically covered by health or automobile insurance and many patients cannot afford the fees, which are often hundreds of dollars. In addition, given the large number of drivers and small number of programs, it is not realistic to expect every older driver to participate in testing. Therefore, a multi-tiered process of screening followed by comprehensive assessment likely represents the most efficient, cost-effective and fair approach.[1, 2, 6] Self-screening instruments for use at home include the AAA Roadwise Review, the AAA Drivers 65 Plus, and the Driving Decisions Workbook.[2, 6, 7] Most use a battery of questions and paper- or computer-based tests to assess a driver and offer tailored recommendations. While self-screening offers some advantages (including being nonintrusive[6] and increasing self-awareness) these tools are not practical for use in busy medical settings. Also, many are a compilation of tests based on expert opinion rather than crash outcomes, so the predictive validity of individual components is unknown.[6] Existing screening tools for physicians include the Physician Guide to Assessing and Counseling Older Drivers[2] and the Canadian Medical Association Driver Guide.[8] While such guides may help clinicians understand and remember the various physical, cognitive, and psychomotor areas to assess, they are too broad for practical use in busy settings and have not been validated with crash outcomes.[6] Mr. P. needs to weigh the risks and benefits of continued driving. Older drivers as a group have higher rates of fatal and at-fault crashes per vehicle miles travelled,[9] and older adults have less physiologic reserve to recover from injuries. However, driving shorter distances and less frequently,[10] as many older drivers do, might limit his crash risk (and the risk he poses to others).[9] There are benefits to continued driving, as it strengthens ties to and involvement in the community, enhances independence, and possibly delays the onset of mental and physical health problems.[3, 10] The risk-benefit analysis will differ for each patient, based on issues such as transportation alternatives. Information to help with these decisions is available from organizations like the American Medical Association (http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety.shtml), the AAA Foundation for Traffic Safety (http://www.seniordrivers.org/home/), and the American Occupational Therapy Association (http://www.aota.org/Older-Driver/Consumer.aspx). Our role as physicians is to assist individual patients with these complex decisions and to support systems that provide comprehensive driving assessments for those most at risk without relying on unpopular and ineffective strategies based on advanced age alone.[5] References: 1. Proceedings of the North American License Policies Workshop. AAA Foundation for Traffic Safety. June, 2008; Washington, DC. http://www.aaafoundation.org/pdf/LPWorkshopRecommendations.pdf 2. Carr DB, Schwartzberg JG, Manning L, Sempek J. Physician’s Guide to Assessing and Counseling Older Drivers, 2nd Edition. 2010; http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.shtml. 3. Safe Mobility for Older People. National Highway Traffic Safety Administration, DOT HS 808 853. 1999. http://www.nhtsa.dot.gov/people/injury/olddrive/safe/. 4. van Roosmalen L, Paquin GJ, Steinfeld AM. Quality of life technology: the state of personal transportation. Phys Med Rehabil Clin N Am. Feb 2010;21(1):111-125. 5. Langford J, Braitman K, Charlton J, et al. TRB Workshop 2007: Licensing authorities’ options for managing older driver safety--practical advice from the researchers. Traffic Inj Prev. Aug 2008;9(4):278-281. 6. Eby D, Molnar LJ, Kartje PS. Screening. Maintaining Safe Mobility in an Aging Society. Boca Raton, FL: Taylor & Francis Group, LLC; 2009:65-82. 7. Carr DB, Ott BR. The older adult driver with cognitive impairment: "It’s a very frustrating life". JAMA. Apr 28 2010;303(16):1632-1641. 8. CMA Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles. 2006; http://www.cma.ca/index.php/ci_id/18223/la_id/1.htm. 9. Tefft BC. Risks older drivers pose to themselves and to other road users. J Safety Res. 2008;39(6):577-582. 10. Oxley J, Whelan M. It cannot be all about safety: the benefits of prolonged mobility. Traffic Inj Prev. Aug 2008;9(4):367-378. Conflict of Interest: None declared
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