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GM10 Geriatric Medicine
Simplified Functional Approach to Driving Assessment
1. Unimpaired vision
2. Adequate cognition
3. Ability to maintain consciousness
4. Physical mobility (e.g. mobility of arms/
legs/neck)
Key Factors to Consider in Older Drivers SAFEDRIVE
Safety record
Attention (e.g. concentration lapses, episodes of disorientation)
Family observations
Ethanol abuse
Drugs
Reaction time
Intellectual impairment
Vision/Visuospatial function
Executive functions (e.g. planning, decision- making, self-monitoring behaviours) Geriatrics 1996;51:36-45
Cognitive Tests and Determining Fitness to Drive in Dementia: A Systematic Review.
J Am Geriatr Soc 2016;64(9):1904-17.
Objectives: To examine the relationship between cognitive tests and driving to determine whether a cognitive assessment can be implemented as a tool to examine driver safety.
Methods: Systematic review of 28 studies investigating the relationship between cognitive functioning and driving in individuals with dementia. Results: Composite batteries comprising multiple individual tests from different cognitive domains consistency predicted driving performance for individuals with dementia. Scores on individual tests or tests of a single cognitive domain did not predict driver safety.
Conclusions: While studies consistently found composite batteries predicted driving performance, these tests were not clinically usable as they lacked the ability to discriminate between safe and unsafe drivers. Need development of a reliable, valid composite battery that can correctly determine driver safety in patients with dementia.
Driving Competency Toronto Notes 2019 Driving Competency
Reporting Requirements
• physician-reportingtotheMinistryofTransportationismandatoryinallprovincesandterritories except in Quebec, Nova Scotia, and Alberta, where it is discretionary
• British Columbia, Ontario: must refer for re-test at ≥ 80 yr
• not an issue unique to geriatrics – any patient may suffer from a medical condition that impairs their
ability to drive should be reported • intheU.S.,variesbystate
Conditions that may Impair Driving
Table 7. Conditions that Impair Driving
Alcohol
Blood Pressure Abnormalities Cardiovascular Disease
Cerebrovascular Conditions
COPD
Cognitive Impairment/ Dementia
Diabetes
Drugs
Hearing Loss
Musculoskeletal Disorders Post-Operative
Seizures
Sleep Disorders
Visual Impairment
Patients with history of impaired driving and those with high probability of future impaired driving should not drive until further assessed
Alcohol dependence or abuse: if suspected, should be advised not to drive
Alcohol withdrawal seizure: must complete a rehabilitation program and remain abstinent and seizure-free for 6 mo before driving
Hypertension: sustained BP >170/110 should be evaluated carefully
Hypotension: sustained BP <90/60; if syncopal, discontinue until attacks are treated and preventable
Suspected asymptomatic CAD or stable angina: no restrictions
STEMI, NSTEMI with significant LV damage, coronary artery bypass surgery: no driving for one mo following hospital discharge
NSTEMI with minor LV damage, unstable angina: no driving for 48 h if PCI or 7 d if no PCI performed
TIA: should not be allowed to drive until a medical assessment is completed
Stroke: should not drive for at least one mo; may resume driving if functionally able; no clinically significant motor, cognitive, perceptual or vision deficits; no obvious risk of sudden recurrence; underlying cause appropriately treated; no post-stroke seizure
Mild/moderate impairment: no restrictions
Moderate or severe impairment requiring supplemental oxygen: road test with supplemental oxygen
Moderate to severe dementia is a contraindication to driving; defined as the “inability to independently perform 2 or more IADLs or any basic ADL”
Patients with mild dementia should be assessed; if indicated, refer to specialized driving testing centre; if deemed fit to drive, re-evaluate patient every 6-12 mo
Poor performance on MMSE, clock drawing or Trails B suggests a need to investigate driving ability further
MMSE score alone (whether normal or low) is insufficient to determine fitness to drive
Diet controlled or oral hypoglycemic agents: no restrictions in absence of diabetes complications that may impair ability to drive (e.g. retinopathy, nephropathy, neuropathy, cardiovascular or cerebrovascular disease)
Insulin use: may drive if no complications (as above) and no severe hypoglycemic episode in the last 6mo
Be aware of: analgesics, anticholinergics, anticonvulsants, antidepressants, antipsychotics, opiates, sedatives, stimulants
Degree of impairment varies: patients should be warned of the medication/withdrawal effect on driving
Effect of impaired hearing on ability to drive safely is controversial
Acute labyrinthitis, positional vertigo with horizontal head movement, recurrent vertigo: advise not to drive until condition resolves
Physician’s role is to report etiology, prognosis and extent of disability (pain, range of motion, coordination, muscle strength)
Outpatient, conscious sedation: no driving for 24 h Outpatient, general anesthesia: no driving for ≥24 h
First, single, unprovoked: no driving for 3 mo until complete neurologic assessment, EEG, CT head Epilepsy: can drive if seizure-free on medication and physician has insight into patient compliance
If patient is believed to be at risk due to a symptomatic sleep disorder but refuses investigation with a sleep study or refuses appropriate treatment, the patient should not drive
Visual acuity: contraindicated to drive if <20/50 with both eyes examined simultaneously
Visual field: contraindicated to drive if <120° along horizontal meridian and 15° continuous above and below fixation with both eyes examined simultaneously
N.B. guidelines included refer specifically to private driving; please see CMA guidelines for commercial driving