Is It Safe For Your Patient To Drive?

In physician assistant school, many times we learn things that are cut and dry. The most common cause of this disease, or the most appropriate treatment for this pathogen. We memorize, learn pathways, and are relieved on exams when we find a question we absolutely know the answer to.

In the practice of medicine, however, there are many situations and patient cases that are nothing close to cut and dry. Ethics, legality, family, and many other factors can play a role in our decision making as a clinician. In addition, due to the quickness and pace of PA school, many times these situations are some that we have not encountered previously.

One of these particular cases that I face commonly in family practice is that of the driver evaluation in the elderly patient and for patients in general.

 

I was never taught this in school

The health care professional, particularly the primary care clinician, plays an important role in evaluating patients to be assured that they are safe to be out on the road operating a motor vehicle. As I began practice, this entire process was significantly overwhelming to me.

It was not something I learned in school, not something I felt comfortable with, and made for some very difficult patient encounters.

Perhaps the biggest challenge facing me was the lack of preparation and a lack of time. At visits, I felt overwhelmed by the “oh by the way, we’re concerned about Dad’s driving”, or the surprise form from the Department of Transportation given to me toward the end of a visit.

In the depths of a 15 minute office visit in a complicated patient with multiple comorbidities, it can be extremely challenging to sift through a neurological and cognitive exam as well as a history and physical, and determine whether someone is safe to drive a vehicle.

 

Understanding the statistics 

With this in mind, today we will review the process and methods for evaluating a patient for fitness to operate a motor vehicle. I have found this topic to be very enlightening and satisfying to review as a way of improving my patient care and make sure that I am keeping not only my patients safe, but the general public as well.

We will be discussing the broad recommendations for evaluation and will not focus on any specific disease process today. As a disclaimer, other specific diseases that may influence driving ability or lack of ability would include epilepsy, CHF, stroke, diabetes, and others. In my experience, having a specialist to help weigh in on this decision is paramount. Also, the evaluation of CDL physicals is beyond the focus of today’s article.

Driving is one of the tasks that we, as healthy people take for granted.

In the recent years, there have been numerous articles in regards to elderly persons who have accidentally drove into buildings or caused accidents, inciting debate as to when licenses should be re-evaluated. As the population grows, this may continue to be an important issue.

According to a 2019 article by Ladden, 79% of patients greater than age 70 continue to drive.

 

A family member will often bring in a parent

In my practice, a common occurrence is that a family member will bring in an aging parent for their chronic disease management and discuss the process of driving. Many times, concerns may be raised in regards to overall safety.

Family members can be an important resource for information regarding driving history, accidents, moving/speeding violations, and overall comfortability of being in a car with the driver. Additionally, patients may bring in forms that I must fill out in regards to the medical appropriateness of driving, which upon meeting someone for the first time or having limited time, can be very difficult.

Although we may not recognize it due to being second nature, driving is a significant privilege and provides a good sense of self-esteem and a sense of independence for patients (Ladden, 2019).

Many patients who are being evaluated for their ability to operate motor vehicle have been driving for years and many of the reflexes associated with driving are deeply engrained into us.

Many clinicians struggle with the evaluation of a driver because of little time with the patient and little physical interaction. If a patient is in for an office visit, the clinician may only see them walk in the door and sit down. This does not allow us to assess a great deal of their physical ability, which is necessary for a good evaluation.

In addition, many clinicians sight a lack of comfortability with the process in general. Upon broaching the topic, patients may get upset and irritated that someone would question their driving.

Some clinicians may feel embarrassed to bring up driving, or may be apprehensive because they feel that the clinician to patient relationship might change depending on the outcome (Ladden 2019).

In a Canadian study, up to 50% of clinicians interviewed indicated that they felt uncomfortable performing a formal driving evaluation. In a subsequent study, 30% of clinicians indicated that they did not know how to report their concerns to the state.

 

Risk factors for unsafe driving

There are numerous risk factors that should alert the clinician that there may be issues with driving. Some of the most commonly associated conditions include weakness, particularly in the proximal muscles, decreased grip and leg strength, difficulty with moving the neck (For looking over the shoulder while backing out). Other conditions include a history of frequent motor vehicle accidents, prior traffic violations, visual and cognitive impairment or deficit, presence of multiple medical conditions, and history of falling.

Medications that can impact the operation of a motor vehicle are numerous. It goes without saying that alcohol and other recreational drugs should never be combined with operating a motor vehicle.

Other prescription medications that may contribute to unsafe driving include

  • Benzodiazepines
  • Tricyclic anti-depressants
  • Anti-histamines.

Benzodiazepines represent a very specific risk factor and one study suggested that the risk of having a motor vehicle accident doubled in the first week after an initial prescription (Ladden, 2019).

 

Asking the right questions

As part of meeting with patients who may have concern related to driving, it is important to ask some questions in regards to driving. It may be useful to ask directly of the patient or family “Do you have any concerns about your driving ability?”

For obvious reasons, patients may dodge the question, but I am surprised by how many relatives may express concerns. It is important to ask the patient how they arrived to the appointment and what their resources would be for transportation if they were no longer able to drive. (Ladden, 2019).

Gauging both the frequency and length of driving is also important. Many patients may admit to driving just to the store for groceries or only a few miles to church on Sunday. Inquiring about previously documented traffic accidents, moving violations, speeding violations, and “close calls” are helpful as well.

This is where I find that relatives can be helpful, as the patient themselves may not always realize a close call.  Also inquiring about night driving, how much the patient plans on driving and asking the patient their level of comfortability and whether they would like to continue driving is helpful.

Additionally, asking the patient about difficulty with their activities of daily living is helpful.

Falls have been found to be an independent risk factor for having difficulty with driving or being at risk for having a traffic accident. Clinicians should be careful to document the number of falls in the last 6 to 12 months and consider this heavily when determining if the driver is safe to proceed. (Ladden, 2019).

In addition, a general rule of thumb that also helps is to determine how “With it” the patient is. Can they speak freely about their health? Do they know what medications they are on? Are they aware of their recent hospitalization?

 

Performing the physical exam

Once a history and discussion in regards to driving habits is undertaken, the clinician should perform a careful exam to help determine the next step. My first exam usually starts as the patient walks down the hallway to my exam room.

I gauge their balance, speed, steadiness, and screen for any gait abnormality. In the room, watching the patient get up from the chair using a Timed Up and Go Test can be helpful to screen for falls.

  • Does the patient use their arms?
  • How long does it take to stand up?
  • Are they unbalanced?
  • Vision, hearing, and cognitive processing are also very important to measure during the visit, but may not always be allowed due to time (Ladden, 2019).

Neurologic testing and cognitive evaluation may be indicated depending on the clinician’s concerns or family concerns for cognitive decline.  The Mini-Mental status examination (MMSE) and Montréal Cognitive Assessment (MoCA) are two tools that can help the clinician determine if cognitive impairment is present, and also gauge the severity. Although it is difficult to fully correlate a lower cognitive exam with poor driving ability, a MMSE score less than 24 is concerning. A Clinical Dementia Rating (CDR) is also another tool available. (Ladden, 2019).

 

In conclusion: is it safe for your patient to drive?

A good thorough history as well as a comprehensive physical exam can help guide the clinician forward with a decision as to whether the patient is safe to continue driving. An option if the clinician is concerned about driving is an occupational therapy evaluation.

Thankfully in my location, I have the ability to send patients for a driver evaluation through our OT service. In this case, the patient is brought in and are put through a series of road obstacles, road signs in a simulated car. Patients are given scores based on reaction time, braking speed, and much more. This greatly helps me determine whether a patient is safe to drive.

The decision to take a patient off of the road is a particularly challenging one and can create some difficult emotional conversations. Patients who lose their licenses due to physical or cognitive concerns do show incidences of depression and clinicians should also involve care coordinators, nurses, and family to assure that coordination of care is continued and sometimes even having a follow up visit to see how the patient is doing a month or so after the event can be helpful.

I hope that today’s article has shed some light on what can definitely be a difficult topic in clinical practice and contribute to difficult discussions with patients.

Arming yourself with the tools necessary to keep not only your patient, but the general public safe is very important. In addition, laws and regulations do vary significantly by state, so it is wisely recommended to review your state’s policies.

 

References

Ladden, M.D. (2019). Approach to the Evaluation of Older Drivers. UpToDate. Date of access

     6-8 August 2019.