Recently, a close family friend’s relative was a pedestrian in a crosswalk and was struck by a vehicle operated by a 94 year old. The pedestrian was in her early 60s, very fit and healthy, and had many good years ahead. However, she sustained a traumatic head injury and was taken off of life support 3 days later. A few years ago, an elderly driver ran over an officer directing traffic, resulting in his fatality and devastating his family. Just last week, an elderly driver backed out of her parking spot at a church and ran over 7 churchgoers, resulting in 3 fatalities. There are other similar situations that raise the question: at what point does it become unsafe to drive?
With the expanding population of elderly comes an increase in health risks both to the elderly and possibly to others as well. The road has always been a dangerous place. Vehicles have become safer over the years with installation of seat belts, safety glass, better tires and suspensions, and airbags. Some vehicles have sensors that will vibrate the seat to alert the driver if the car veers off course. Rear-facing cameras for reverse, as well as sensors that warn the driver of objects behind the vehicle, will hopefully add to greater safety while driving. Whereas technological improvements may increase the chance of survival on the road, additional risk factors persist that contribute to motor vehicle accidents and fatalities. In the last decade, distracted driving has worsened with the increase in cell phone calls and texting while driving. Driving under the influence of substances has also long contributed to driving fatalities.
When is the right time to have a discussion with elderly patients about relinquishing their driver’s licenses? There is no clear answer, and no well-established guidelines are available to assist physicians in making this determination. Discussions regarding elderly driving often involve a great deal of emotion. With advancing age, there can be a significant loss of independence. One of the most difficult losses for the elderly is self-transportation. Indeed, for some, this loss is so devastating that it can lead to sadness, anger, and suicidality. A review of some of the statistics regarding elderly driving proves to be enlightening. Seniors, when compared to other age groups, are generally safer drivers. As a group, they are more likely to wear seat belts and obey the speed limit, and are less likely to drink and drive. However, they are more likely to be injured or killed in motor vehicle accidents, which appears secondary to age-related fragility, making them more vulnerable to sustaining injury and less likely to recover from injury. It is this fragility that results in people aged 75 and over having the second-highest death rate per mile traveled.
The highest rate of death per mile traveled continues to belong to adolescents. The increase in crash fatality rate begins at age 75 and rises sharply after the age of 80. Aging is associated with physical and mental changes that may affect the ability to drive safely. These include physical conditions such as arthritis, reduced hearing, decreased visual acuity, slowed reaction times, and changes in cognition. By the age of 80, one-third of people have dementia, and by age 85, it is closer to 50%. Whereas the crash fatality rate for elders is currently high, it is still only about 60% of what it was back in the early 1970s. Overall, however, the total amount of fatalities is higher because the total number of elderly who continue to be licensed and driving is also higher. It is predicted that by 2050, the number of drivers over age 65 will be twice what it is today.
So when should our elderly stop driving? Many elderly recognize on their own that their skills are waning and make the decision gradually or completely. They may initially avoid driving at night or in adverse weather conditions. Often elderly drivers will plan their routes ahead of time in order to travel along roads where they feel the most safe and confident. The majority of elderly drivers voluntarily give up driving when they recognize that they are beginning to experience impairment. In my own family, as my father’s health deteriorated, he was more than happy to have my mom take over the majority of the driving duties. However, there continue to be situations in which people are unable to be objective or use good judgment and continue to drive beyond the point of driving impairment. They may not recognize the need or may refuse to relinquish their licenses at the request of loved ones. This is when difficult, emotional conversations must take place between physician and patient or among family members.
Reduction of preventable motor vehicle fatalities remains a global public health focus. As the elderly population grows at a significant pace, the issue of elderly driving will continue to be a challenge for patients and their families. It should be addressed in such a manner as to preserve the dignity of and as much independence as possible for the elderly patient. One factor I use as an indicator of when to begin the discussion of discontinuation of driving with my elderly patients and their families is when family members inquire at a visit if their loved one should still be driving. I feel this inquiry offers insight, as usually this suggests that they feel the elderly driver is unsafe. This also is a way for the family to diffuse some of the tension between the driver and his or her family members from a conversation that has likely already taken place. At that point, I will consult the patients themselves and gauge their insight into the situation. In my experience, these conversations often take place over several visits, and it is important to recognize that sometimes you are just planting the seed for the conversation to continue at future visits. Having the elderly driver participate in the decision can be quite beneficial. Above all, I aim to preserve the dignity and respect that my patients deserve as elder members of our society while also focusing on prevention of injury to them or others.