The surge of baby boomers now entering their 60s means more drivers on the road who may be impaired by dementia or other cognitive impairments linked to aging. Researchers at the Alzheimer's Disease Research Center (ADRC) of Washington University School of Medicine in St. Louis and elsewhere have developed a three-hour workshop that trains health care providers to identify potentially unsafe drivers with dementia and to encourage appropriate retirement from driving.
"We don't want to give the message that older drivers are always unsafe, because that's just not the case," says Thomas Meuser, Ph.D., research associate professor of neurology at Washington University. "But there are health-related changes associated with aging, including Alzheimer's disease and other forms of dementia, that impair medical fitness to drive."
In a recent issue of the Gerontologist, Meuser and colleagues reported on the effects of their workshop after presentations to health professionals in seven Missouri locations, including a number of rural cities with large elderly populations. The presentations were organized with assistance from local chapters of the Alzheimer's Association and other groups.
"We found a significant change in the willingness of participants to ask their patients questions about driving and to document findings and concerns in the medical record," Meuser says. "There was a real sense among participants that yes, there is something that I can do."
Debate is ongoing about when in the progression of dementia a patient becomes ineligible to drive. Most states, including Missouri, do not have specific prohibitions in this regard, but all states allow health professionals and others to report persons perceived as medically unfit to drive due to dementia or other conditions. In 2001, the American Academy of Neurology recommended that persons diagnosed with mild dementia stop driving for reasons of personal and public safety.
Physicians at Washington University use the Clinical Dementia Rating (CDR) interview to determine the level of dementia-related impairment. According to Meuser, a CDR rating of 1, representing mild to moderate deficits in memory and other cognitive and functional areas, is a reasonable stage at which retirement from driving may be initiated.
"Primary care physicians and other health professionals often have limited experience in diagnosing dementia and assessing driving safety, but a small amount of additional training can make a big difference," Meuser notes.
At the workshop, Meuser introduces Alzheimer's disease and its various stages. In another section, workshop developer David B. Carr, M.D., associate professor of medicine and of neurology, explains an American Medical Association (AMA) recommendation that physicians risk-stratify their patients, grouping them on the basis of their clinical observations into safe, unsafe and unsure. This offers physicians unfamiliar with the specialized process of CDR testing a framework to help identify patients who may need to be prohibited from driving.
A 1999 Missouri law allows physicians, family members and others to notify the state's Department of Revenue when concerned about an older motorist's ability to drive safely. At the workshop, participants are shown sample reporting forms and procedures for filling them out.
"The reporting process is anonymous," Meuser says. "And the federal Health Insurance Portability and Accountability Act (HIPAA), which places strict regulations on patient privacy, should not apply to this, because HIPAA allows for state reporting to protect public safety and health."
When a report has been filed, drivers are notified by the Department of Revenue that they have several options for proving they can still drive safely, starting with a statement from their physicians. Drivers may also have to retake the standard on-road driving safety test administered by the State Highway Patrol.
"Officials with the Department of Revenue, with the State Highway Patrol, and with the Missouri Department of Transportation have been an absolute joy to work with," Meuser notes. "They are very concerned about older driver safety and have welcomed us as researchers with open arms."
Pat Niewoehner, workshop coauthor and a driver rehabilitation specialist with the St. Louis Veteran's Administration Medical Center, demonstrates the role of the occupational therapist - driver rehabilitation specialist in evaluating medical fitness to drive. Another coauthor, Marla Berg-Weger, Ph.D., professor of social work at Saint Louis University, shows physicians how they can cooperate with family members to eliminate patient access to driving and seek alternate forms of transportation that allow patients to continue to lead fulfilling lives. Included is a videotaped dramatization of a physician working with a demented patient and a family member.
"It's important for healthcare providers to realize there are others who can help," Meuser says.
The workshop was created with funding provided by the National Highway Traffic Safety Administration and the National Institute of Aging through the ADRC and John C. Morris, M.D., the Friedman Distinguished Professor of Neurology and ADRC director.
Additional educational efforts and research studies are or will soon be underway with support from NHTSA, the AAA Foundation for Traffic Safety, the AMA and the American Society of Aging.
"This is an exciting time for research and education in support of older driver safety, and there's a role for just about everyone in these efforts," says Meuser. "Above all, we must work together to ensure that older adults can remain mobile and productive even when they have to give up driving."
Meuser TM, Carr DB, Berg-Weger M, Niewhoehner P, Morris JC. Driving and dementia in older adults: implementation and evaluation of a continuing education project. Gerontologist 2006 Oct;46(5):680-687.
Funding from the National Highway Traffic and Safety Administration and the National Institute of Aging supported this research.
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