1. Carolina Osorio, MD
Geriatric Psychiatry Fellow
UCLA Semel Institute of Neuroscience and Human Behavior
March 26 2012

2. OBJECTIVES
 Understand the safety risks of older drivers
 Indentify conditions that may put older drivers at
risk
 Indentify the role of the physician
 Demonstrate familiarity with the law as well as
California DMV reporting methods and
requirements

3. DEMOGRAPHICS AND SAFETY
RISKS

4. Taxonomy of Older Driver
Behaviors and Crash Risk from
NHTSA Feb 2012
 Identify risky behaviors, driving habits
and exposure patterns that have been
showed to increase the likelihood of
crash involvement
 Crash types where older drivers were
most strongly overrepresented
2002-2006 using database from FARS
and NASS

5. Taxonomy of Older Driver Behaviors and Crash
Risk from NHTSA Feb 2012
 Older people were increasingly less likely to be driving the striking
vehicle in a two vehicle crash
 High – speed two lane roadways and multilane roads with speed limits
of 40-45 mph were associated with heightened older driver crash
involvement
 In two vehicle crashes, failure to yield was the most frequently cited
factor
 Starting at age 70, old drivers were specially likely to crash at
intersections
 With respect to single vehicles crashes , older drivers were somewhat
more likely to be identified as ill or blacking out, drowsy or asleep, using
medications or drugs ( other than alcohol), and having some other
physical impairments ( hearing loss)

6. Annual Crashes per 1,000
Licensed Vehicle Drivers by Age
of Driver (Source: Cerrelli, 1998)
Crashes per Million Miles
Traveled by Age of Driver
(Source: Cerrelli, 1998)

7. Percent of Persons with Dementia
by Age Group
50
45
40
% of Aged 35
Population 30
with 25
Dementia 20
15
10
5
0
65 - 70 70 - 75 75 - 80 80 - 85 85 - 90 90 - 95
Age

8. Problems related to age can include
 Reduced vision
 Decreased strength
 Medications
 Cognitive impairment Impaired
California 3.1 M
license drivers
Over 65 years

9. Older drivers have an increased likelihood of being injured or
killed in a crash.
L. Evans Traffic Safety (2004), Bloomfield Hills, MI: “Science Serving Society”

10. WHY IS DRIVING AN ISSUE

11.  Automobile crashes are the third leading cause of
death and injury in the United States with 40,000 to 50,
000 people killed in about 2 million accidents per year
 Drivers over age 75 had a higher rate of fatal accidents
nationwide in 2001- 2002. This problem is expected to
grow because by 2024, one in four U.S. drivers will be
over age 65
National Older Driver Research and Training Center
Physicians are in a unique position to anticipate the impact
of physical and mental conditions on driving
impairment.

12.  The privilege of driving is a source of freedom and
empowerment for many individuals. Removing this
privilege has its risks.
 The loss of ability to be independently mobile can be a
devastating psychological blow for an elderly patient. It
also may restrict a patient access to meet medical and
social services or to employment venues.

13. THE PHYSICIAN’S ROLE

14. CEJA of the AMA report on impaired drivers and
their physicians: I-99
 Physicians have an ethical responsibility to assess patients’
physical or mental impairments that might adversely affect
driving abilities
 Each case must be evaluated separately since not all
impairments may give rise to an obligation on the part of the
physician
 The physician must be able to identify and document
physical or mental impairments that clearly relate to the
ability to drive
 The driver must pose a clear risk to the public safety

15. Recommendations
1. Physicians should assess patients’ physical or mental
impairments
3. Before reporting, there are a number of initial steps
physicians should take
5. Physicians should use their best judgment when determining
when to report impairments that could limit a patient’s ability
to drive safely.
7. The physicians role is to report medical conditions that would
impair safe driving. The determination of the inability to drive
safely should be made by the states DMV.

16. Recommendations
1. Physicians should disclose and explain to their patients this
responsibility to report
3. Physician should protect patient confidentiality by ensuring
that only the minimal amount of information is reported
5. Physicians should work with their state medical societies to
create statues that uphold the best interests of patients and
community, and that safeguards physicians from liability
when reporting in good faith.

17. AMA PHYSICIAN’S GUIDE
American Medical Association &
National Highway Traffic Safety
Administration (NHTSA)
“Physician’s Guide to Assessing
and Counseling Older Drivers”
Quick screening and referral tool
Available at:
www.ama-assn.org/go/olderdrivers

18.  Office visit
 Medical History: OSA are 2-6 time more likely
to be involved in a MVA (Berger et al. 2000).
 ROS
 Family concerns
AGE ALONE IS NOT A RED FLAG
Remember to address driving safety as needed.

19. Assessment of driving related
skills (ADReS)
Working
Memory
Executive
Functioning
Spatial
Skills
Elaboration of rapid decision making

20. Assessment of driving related skills
(ADReS)
COGNITION
 Trail B: Lafont confirmed a high correlation between increasing
age and poor attentional and executive performance, as
measured by Trail-Making B, to be correlated with both crashes
and driving cessation (Lafont, 2008).
N = 81 sec
MCI = 136 sec
Dementia = 190
sec
Ashendorf, 2008

21.  Clock drawing test using Freund Scoring Criteria
YES NO
Only the numbers 1-12 are included
Number inside the clock
Numbers are spaced equally from each other
Numbers are spaced equally from the edge
One clock hand correctly points to 2
There are only 2 clock hands
There are no intrusive marks, writing or hands
indicating incorrect time
The scoring is based on seven “principal components” which
were derived by analyzing the clock drawing of 88 drivers 65
and older against their performance on a driving simulator
(Freund 2005).

22. Counseling the patient / family
Physicians are influential in a patient’s decision to
stop driving; in fact advice from a doctor is the most
frequently cited reason that a patient stops driving.
Persson, D. (1993)
3 Transportation options:
http://beverlyfoundation.org/
u Reinforce driving cessation:”Driving retirement”
g Follow up letter
g Follow up in a month

23. Driving Rehabilitation Specialist
 One who plans develops coordinates
and implements driving services for
individuals with disabilities
 Work with people who have strokes,
low vision, limb amputation
 www.ADED.net

24. What do with a difficult patient?
i Encourage patient to complete the self screening
tool
t Counsel your pt on Successful aging tips and tips
for safe driving
o Roadwise review
http://www.seniordrivers.org/driving/driving.cfm?button=roadw
r DOCUMENT your concerns and support this with
relevant information. Document patient reactions
along with any counseling you have provided.

27. REPORTING REQUIREMENTS
AND THE LAW

28. California Code of regulations (CCR) title 17 sub-chapter 2.5
“Disorders characterized by lapses of consciousness” sections
2800-2812.
“Reporting the local health authority” the non-communicable disease or
conditions – AD- and related conditions and disorders characterized by
lapses of consciousness .
2802 AD and related disorders. Means those illnesses that damage the brain
causing irreversible, progressive, confusion, disorientation, loss of memory
and judgment
2806 Disorders characterized by lapses of consciousness.
Loss of consciousness or a marked reduction of alertness or responsiveness to
external stimuli
inability to perform one or more ADLs
the impairment of the sensory motor functions used to operate a motor vehicle
EX: OSA, abnormal metabolic states (DM)

29. Important issues about the regulations:
 They are specific to physicians and surgeons per section
103900 of the Health and Safety Code
 The physicians who reports a patient diagnosed with a
disorder characterized by lapses of consciousness,
according to the Health and Safety code 103900, shall not
be civilly or criminally liable to any patient for making the
report.

30. Liability
Physicians are considered negligent if they do not inform
patients of medications and medical conditions that can
impair driving
○ Physicians may be held liable for civil
damages if they clearly failed to report an
impaired driver who causes a MVC
○ Immunity is granted to the physician if the
patient is reported prior to a MVC
○ Document all referrals, recommendations,
conversations, and reports (e.g. copy of a
driver retirement letter and “do not drive”
prescription)

31. California
Individuals 70 years of age and older
 Must renew license in-person
 License is renewed for five years if vision and written tests are
passed and there are no signs of cognitive impairment
 A “limited term” license may be issued for one to two years if a
medical problem exists but is not severe enough to stop driving
(e.g. mild dementia)
Dementia moderate-severe = DL revoked
Dementia early or mild = Reexamination
In this manner, the California DMV hopes to balance the need for
public safety and with the perseveration of personal independence .

32. Reporting…….
 In California in 1988 , healthy and safety code section 410
added AD and related disorders to the list of conditions that
physicians are required to report to their local health
departments, which then forward this information to CA
DMV.
 Based on the results of these examinations as well as a
physician completed written driver medical evaluation (DME)
form the DMV could allow the driver to:
Continue driving unrestricted
Continue driving with restrictions
Revoke or suspend DL.

33. SUMMARY

34. Safety, mobility and cost are critically important
Physician role is difficult: caseloads, poor training
Limited alternatives to driving
Recognize rights and feelings of older people
Many obvious solutions may not work very well
We started addressing this problem too late

35. "Above all, we must work together to ensure that
older adults can remain mobile and productive
even when they have to give up driving.“
Thomas Meuser, Ph.D.
Research associate professor of neurology at Washington University.
THANK YOU