How should doctors decide when a senior driver’s license should be reviewed?
Doctors are expected to report people who have a medical condition that prevents them from being able to drive safely. But the line between fit and unfit to drive is difficult to define, especially for seniors with multiple cognitive, sensory and/or physical issues. And as baby boomers age, doctors will increasingly have to weigh the safety of their patient and others, with their patient’s desire for independence and mobility.
Joe Saltarski, an 89-year-old who lost his license earlier this year, thinks the current way doctors test senior drivers is unfair. A former bus driver, he’d only had one minor accident in his life. At age 87, he drove across the country to move closer to his son in Chilliwack, British Columbia.
The first doctor he saw in the province administered a test, called SIMARD MD, aimed at detecting cognitive impairments that can interfere with driving. For one part of the test, he was asked to name some vegetables he would see in a grocery store.
“I pretty near laughed,” says Saltarski.
Based on the results from that doctor’s office test, Saltarski was referred to the Ministry of Transportation and was required to do a road test. He failed that test because the examiner said he exceeded the speed limit in a school zone (which Saltarski disputes). And when he took a second test, the examiner failed him for driving too slow. “You can’t win for losing,” says Saltarski.
Due to the failed tests, Saltarski no longer has a license. He misses being able to go shopping or to the barber on his own, but the psychological blow of losing his license has hit him the hardest. “I feel like I’m going downhill,” he says.
When doctors recommend a patient not drive, it can seriously damage a doctor-patient relationship. “Some patients don’t go back to a doctor who has recommended they don’t drive,” says Chris Frank, a geriatrician and palliative care doctor in Kingston, Ontario.
It can also have negative repercussions for patients. “They feel they’re a bother to everyone if they ask for rides,” says Carol Libman, a consultant with CARP Canada, a seniors advocacy organization. “Isolation is one of the worst things. People get depressed,” she explains.
In other cases, however, family members have been pleading with their loved one not to get behind the wheel, to no avail, and appreciate a decision from an objective authority. When Frank recommended a male patient not drive last week, for example, “his wife was very relieved,” he says.
The decision to remove someone’s license can also prevent deaths. Although senior drivers don’t have more accidents than younger drivers, they are more likely to die in a crash due to increased susceptibility to injury and medical complications, according to the Centers for Disease Control and Prevention. In 2013, drivers 65+ made up almost 20% of driver fatalities caused by collisions, compared to 13% in the 20-24 age group, even though the age groups had the same rate of driver injury. Importantly, however, when it comes to the risk they pose to others, teenagers and drivers in their 20s are much more likely to kill other people on the road than seniors are.
Currently, there’s wide variability in how doctors evaluate a senior person’s driving fitness, and whether they assess it at all.
How doctors decide when to refer a senior who may be unfit to drive
In most provinces, when doctors think someone shouldn’t drive or are unsure, they are required to send a report on that person’s medical condition to their provincial Ministry of Transportation. In Alberta, Nova Scotia and Quebec, doctors aren’t legally mandated to report unsafe or potentially unsafe drivers. But even in those provinces, doctors’ professional bodies recommend reporting. “If a doctor believes that a patient may harm him/herself and/or others by continuing to drive, they are ethically obligated to report,” writes Kelly Eby, director of communications at the College of Physicians and Surgeons of Alberta. Depending on the information in the doctor’s report, transportation authorities may suspend the license immediately (if a person has advanced Alzheimer’s, for example), or they might request further medical or road testing.
How doctors decide whether a person’s medical condition should be reported to the Ministry of Transportation varies by province and by individual doctor. The Ministries of Transportation of BC and Alberta recommend that doctors administer the SIMARD-MD test for seniors they suspect may have cognitive issues that prevent them from driving safely. In Ontario, meanwhile, doctors rarely use the SIMARD-MD test, says Shawn Marshall, a doctor who is researching driving habits of seniors for the CanDrive research project.
Libman argues the SIMARD-MD test casts too wide a net and her opinion isn’t without backing. Research published in 2013 in Accident Analysis and Prevention found that drivers who passed many other cognitive tests failed the SIMARD-MD test and concluded the test “lacks sufficient precision to provide clear recommendations about fitness-to-drive.”
Physicians across Canada also rely on the Canadian Medical Association’s guide, which provides advice on what to think about when it comes to the driving ability of more than 100 medical conditions.
It’s ultimately up to physicians to decide how or whether to assess patients on their driving potential, however. One study from 2007 found that Ontario doctors only assessed driving capabilities among their patients who were diagnosed or suspected of having dementia a third of the time.
Chris Simpson, a cardiologist and the president of the Canadian Medical Association, thinks geriatric doctors are “pretty good” at assessing driving, but many family doctors don’t feel comfortable with “making a binary decision” when it comes to seniors who don’t have an obvious impairment. People who have seizures tend to be reported to the Ministry, but “the person with mild dementia, heart failure, renal failure, eyesight that’s not so great” are less likely to be reported, even though all these conditions could be just as dangerous.
Frank agrees. Doctors are much more likely to screen a senior for driving impairments “in cases where somebody says I don’t think my mother or father should be driving,” he says.
Improving the way doctors assess senior drivers
Part of the reason doctors are reluctant to assess senior drivers may be that the current in-office assessments available “have some validity” but can result in some safe drivers failing the assessment and some unsafe drivers passing the assessment. Marshall hopes his research will lead to more evidence-based decisions regarding when doctor’s refer senior patients to the Ministry of Transportation for review. Currently, he and his team are exhaustively examining various indicators of health status and driving habits for around 1,200 senior drivers over a six-year period.
Marshall says data collection will wrap up sometime next year, and based on the information, the CanDrive team hopes to identify the predictors of poor driving and create a tool to guide doctors in assessing patients. The tool likely won’t have simple pass or fail outcomes, says Marshall, but would indicate whether a senior patient is in a safe zone, unsafe zone or middle zone. “If the person is in the middle zone, then you would probably say, what can we do to keep them driving longer? And how do we prepare for when they are no longer able to drive?” he says.
Donald Redelmeier, a doctor and scientist at Sunnybrook Hospital, has conducted several research studies aimed at reducing vehicle collisions, the single biggest killer from birth to middle age. He thinks “how the individual driver is compensating” for changes in physical or cognitive function should be taken into account. Senior drivers tend to avoid driving at night or long distances, for example, which explains that even though seniors have far more collisions per kilometer driven than people in their thirties, they don’t get into more accidents overall than that age group.
Both Redelmeier and Marshall think that providing restricted licenses to senior drivers who may be borderline but not necessarily unsafe could help to improve drivers’ independence while still limiting their risk. Ontario is the only jurisdiction in North America that doesn’t allow restricted licenses for certain seniors. In Alberta, transportation authorities can restrict people to driving during the day time or within a certain distance from their homes, for example. While there is not sufficient evidence to show that putting conditions on a senior’s license decreases the risk of collisions, “graduated licensing for young drivers has been shown to be very effective,” notes Marshall.
As cognitive and physical impairments that come with age will increasingly prompt doctors to investigate driving capabilities, doctors should also think about whether reversible factors like medications or undiagnosed conditions could be interfering with a person’s cognition, says Marshall. “We always have to look at the individual level,” he explains. “Young drivers actually have the highest crash rates and we don’t say young people can’t drive.”