Ed has been living alone for the five years since his wife died. First he moved to a smaller house and increased the days that his cleaning lady/housekeeper came. Initially all seemed to go smoothly, but on his 85th birthday his children noticed that Dad was more forgetful. Then one night he gave a ride to one of his daughters on his way home and all of the alarm bells went off. It was a shock. How was he getting around safely or better yet, avoiding traffic tickets? He frequently moved across the center line and didn't seem to notice cars turning in front of him.
But, there was a bigger problem. Who was going to talk to Dad and suggest that he no longer drive? What would they do if he said no -- in fact "hell no?" Driving was Dad's life line. He was the last of his friends who still drove. How would he eat out with his friends, go to the store, see an occasional movie? And, for the children, who was going to drive dad to all of his appointments, the grocery store and become the appointed chauffeur? Maybe it would be easier to just let him drive?
Driving and Aging
It's a big number. The National Highway Traffic Safety Administration reported that the number of drivers over the age of 65 is rapidly increasing and today it represents over 15 percent of all licensed drivers. The Baby Boomers have arrived and in the next 20 years that number is expected to triple. As a newly minted 65-year-old, it is hard to type this next fact, but around age 65 our driving skills deteriorate and our risk of accidents increases. At age 75 it dramatically increases secondary to:
- Dementia and loss of cognitive abilities
- Poor judgment- particularly in making left hand turns
- Decreased reaction time in responding to rapidly changing situations
- Visual and hearing loses that decrease awareness of their environment
As a result senior citizens account for a disproportionate number of fatal crashes, particularly when you factor in the reduced number of miles they drive. A sophomore school project created a chilling Public Service Announcement asking, "Do you have what it takes to drive safe?" The risks of letting Dad drive are very real and must be addressed. How does his family approach this common problem and where can his family turn for help?
We all wish that there was an easy, clear cut test to determine who is safe to continue to drive. It would remove a tremendous burden from physicians and families. The American Academy of Neurology recently published a Practice Parameter on evaluating the driving risk in people with dementia, with particular emphasis on our major problem -- people with early dementia who are still driving.
We have always considered the On-Road Driving Test (ORDT) as the gold standard for driving ability, but the Guideline notes that in some studies as many as 76 percent of patients with mild dementia could pass an ORDT, while other studies revealed that many elderly people who considered themselves safe drivers failed the ORDT. The point I find most useful was that a caregiver's or family members' rating of marginal or unsafe driving was highly useful in making the determination. This upsets advocates for elderly driving who fear family members may unnecessarily restrict their freedom.
There is a good deal of data in this Practice Guideline, but the bottom line is that "there is no test result or historical feature that accurately quantifies driving risk; clinicians are only capable of making qualitative estimates of driving risk." Some key features are evaluating:
- Increased problems on the Clinical Dementia Scale; a rating of memory, judgment, orientation, community affairs, home activities and personal care.
- Caregiver rating of the driver's abilities
- History of citations or traffic accidents
- Reduced driving mileage secondary to decreased abilities.
- Self reporting of avoiding certain driving situations, such as rain, nighttime, rush hour.
No one said this would be easy. Older drivers think of themselves as safe drivers. I am always amazed at my friends and colleagues who claim their reaction times are still as good as they were 20 years ago. I offer to test them at our Rehabilitation Hospital, but they all decline. In fact, I know of two acquaintances that, at the age of 65 and 70, went to 18 wheel truck driving school and started driving big rigs. Guys, let me know when you are on the road!
Parents will give the least credibility to family members, for parents are still parents and reluctant to accept any role reversal. Children are faced with going against their parents' wishes and being the bad guy. For the parent it may feel like the last link to independence and the ability to make decisions for themselves is being wrenched away. As a neurologist who specializes in neurorehabilitation, I see the same issues in people with disabilities who have had a stroke or brain injury. Practicing in Texas I always say that the two most difficult things to take away from someone are their car and their gun.
Having a Plan-Start Early
Depending on the family, convincing a parent to stop driving can be easy or very difficult. Either way it helps to have a plan. We freely discuss retirement planning, financial planning, funeral and burial wishes, medical directives, but not driving. The earlier you sit down and discuss the consequences of aging on driving the better. Sit down with your parents or loved one and have a plan of action. Will you start with self imposed limits? At what point will they agree to stop driving? We have these discussions on whether to place a person on a respirator or perform medical heroics, but we almost never discuss driving.
- Have frank and open discussions early when the person can still make rational decisions. Frame the discussion as you would discuss other medical and health issues.
- Plan early for how you will meet the needs of the person when they cannot drive.
- Develop a network to help and make regular appointments to take your loved one out. Recruit friends, neighbors, family and offer to reimburse them.
- Check out community transportation resources and taxi cabs. Paying for transportation can be far cheaper than insurance and car ownership.
When Reason Fails
This is the moment we dread. Reason has failed and Dad won't relinquish the keys. It's time to recruit help. At times, fellow seniors who have stopped driving can reason with Dad. Call his doctor and tell her the problem and that you need her help when you come in for a visit. It helps to gather some objective data. Take Dad for an eye and hearing exam and tell the doctor ahead of time that you are concerned about his driving abilities. Some states have mandatory reporting responsibilities for health care professionals while others leave it to their discretion. Be sure to check out the laws in your state.
When everything fails, you may have to take away the keys. Sometimes you just have to take responsibility and live with the consequences. You can contact your local law enforcement agencies and report your family member. If you are concerned about anonymity you can choose a friend, relative or doctor to file the report.
It may help to let the person keep their driver's license. It has been a form of identity since age 16 and it can be a major blow to have it taken away. Some people recommend leaving the car in the driveway for awhile so your loved one has a sense that the car is there for an emergency.
These are tough choices that save lives. The earlier you start to plan the easier it will be.
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