Motor vehicle accidents are the leading cause of injury-related deaths among persons aged 65 to 74 years and the second leading cause (after falls) among those 75 years and older) Elderly drivers have a higher fatality rate per mile driven than any other age group except those 25 years and younger. The fatality rate for drivers 85 years and older is 9 times higher than the fatality rate for drivers aged 25 to 69 years (Figure 2). (2)
Unlike accidents that involve younger drivers, most accidents that involve elderly drivers occur during daylight hours, on good roads, and without the influence of alcohol. Elderly persons are more likely to have disease- and medication-related impairments. Many elderly patients report some self-regulation of driving habits because of age-related changes, health concerns, and possible side effects of medications. They tend to drive fewer miles and they reduce nighttime driving and driving in poor weather conditions, on freeways, and during rush hour. They may even try to reduce the number of left-hand turns. Families may be falsely reassured by the patient's slow driving. The most common traffic violations among elderly drivers involve failure to yield, improper turning, incorrect lane changing, and difficulty in entering or leaving expressways. Red flags for driving problems are listed in the Table.
Many patients with poor vision are unaware of it; some, because of dementia, lack insight into their driving deficits. However, there are also patients who may stop driving too soon and who suffer from isolation and lack of socialization because of limited or nonexistent alternative transportation. Depressive symptoms increase with driving cessation, and it is important to be alert for this possibility. In American society, particularly, driving is a source of independence and self-esteem. This is another reason for tact and sensitivity when addressing the issue with the patient.
Note that physician reporting laws vary widely. The Physicians' Guide to Assessing and Counseling Older Drivers, published by the AMA, includes information from every state. (3) It also addresses issues such as immunity, anonymity, legal protection for reporting, what constitutes a breach of physician-patient confidentiality, and legal versus ethical responsibilities. If the patient lacks insight into his or her condition, it is imperative to involve the family and/or another person who has decision-making responsibility for the patient.
Although there is no way to directly assess crash risk, you can provide a comprehensive evaluation that includes a vision examination and cognitive and functional screening, as well as an assessment of motor function, age-related risk factors, and relevant disease conditions, medications, and functional deficits. This information sheds light on overall risk and provides objective evidence of the need for a formal driving evaluation.
Vision. In addition to changes in visual acuity, older age is associated with an increased incidence of glaucoma, macular degeneration, cataracts, and diabetic retinopathy. Most states require 20/40 vision for unrestricted licensing.
Visual fields may decline. Stroke, lid ptosis, and glaucoma are contributory problems. More than half of patients with field cuts are unaware of the...