NEW ORLEANS – Informing an elderly patient that it’s time to stop driving because of health-related safety concerns is one of the toughest, most tension-racked aspects of primary care practice, according to Dr. Hollis D. Day.
"The driving conversation with the elderly patient and family is probably the least favorite conversation that I have with anyone. And the fact that my colleagues send their patients to me to have that conversation tells me they don’t like it either," Dr. Day, a general internist at the University of Pittsburgh, said at the meeting.
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A quick conversation with an elderly patient can determine if it’s time for he or she to stop driving.
"The reason is we’re actually afraid that it’s going to impair our future relationship with our patient. We’ve been with these patients for years, and now we’re telling them to stop doing something that is absolutely critical and vital to them. It makes us look like the bad guy. But it doesn’t have to be that way," she stressed.
She shared experience-based tips on how to make that discussion go as well as possible. She also explained how to efficiently conduct a driving safety assessment within the confines of a 10-minute office visit.
The first thing to understand about driver safety assessment is that there are no validated criteria for determining risk. While a classic study of Alzheimer’s disease outpatients showed they were overall less likely than nondemented controls to successfully complete a driving simulator test, many of the patients with mild Alzheimer’s disease did pass the test. And no cut point on the Mini-Mental Status Examination could be identified below which it was unsafe to drive (J. Am. Board Fam. Med. 1998;11:264-71).
"There were people who were apparently safely driving with MMSE scores of 21 and 20. So there is no hard and fast cut point at this time. This is important because there are legal considerations," Dr. Day said.
Public safety dictates that physicians have a duty to recommend limitation or cessation of driving if a patient’s health impairs driving ability. Only 10 states have a mandatory requirement for physician reporting to the department of motor vehicles, but another 22 encourage reporting if the physician thinks there’s a problem. State requirements change frequently. The best place to go to learn your current state laws is the Insurance Institute for Highway Safety website, which is updated every 6 months.
In Dr. Day’s home state of Pennsylvania, any health care provider has a legal duty to report a patient to the Department of Motor Vehicles within 10 days of diagnosing a qualifying condition. Such conditions specifically include visual impairment that’s uncorrectable, such as macular degeneration or diminished depth perception, as well as Parkinson’s disease, Alzheimer’s disease, and any other cardiovascular, cerebrovascular, convulsive, or other health conditions that may impair driving ability.
She sends off a standardized reporting form to the DMV. What happens next varies widely and seemingly arbitrarily. Some patients will get a letter from the DMV stating they need to come in for testing – either a written test, a road test, or a driving simulator. Others get a cease-and-desist order.
"That’s when I get the angry phone calls. I tell them in advance that I have to report them, but if they’re cognitively impaired, they may not remember having this conversation," Dr. Day said.
She’ll often use the annual wellness visit as an opportunity to talk about driving safety. But she also can carry out a driving evaluation during a 10-minute office visit. The key elements are to check the heart and lungs and perform a 10-second Get-Up-and-Go mobility test; a cognitive screening test; a musculoskeletal exam addressing the cervical spine, knees, and hips; and vision testing, which she has her medical assistant do.
The Get-Up-and-Go test entails having the patient rise out of a chair without the use of arms, walk three paces, turn around, and sit back down in the chair – all as fast as possible. It should take less than 10 seconds.
"That’s less than 10 seconds in your office to determine whether someone has got problems – potentially an arthritis problem or something else that could affect their driving ability. I defy you to give me any other screening test that takes less than 10 seconds," she said.
The fastest cognitive screening test is the Mini-Cog, which consists of clock drawing plus a three-word recall. It provides an indication as to whether additional neuropsychological testing is necessary. Dr. Day said she also uses the Trail Making B test "all the time" because there is some evidence that it’s a fairly good indicator of driving ability. It’s best to get someone on the office staff to become comfortable administering it. The test instructions allow grossly impaired patients up to 5 minutes to connect the letters to the numbers, which is too much of a physician’s time during a 10-minute visit.