Dr. Diane Villanyi (biography, no disclosures)
What frequently asked question I have noticed
On many occasions, a patient’s relative has quietly whispered to me, “I know my mom/dad shouldn’t be driving anymore, but how do I get her/him off the road?” No one wants to be labelled as the snitch who took granny’s licence away. As a person ages, particularly if cognitive impairment develops, it can become increasingly difficult to reason with an individual regarding the most appropriate time to retire from driving. Each older adult presenting to your office comes with a unique list of comorbidities and psychosocial profile, all of which influence fitness to drive. Due to the variability from patient to patient and a lack of a validated screening test, there is no simple algorithm to use.
Data that answers this question
According to RoadSafetyBC, BC drivers aged 80 and older are responsible for almost 70% of the crashes in which they are involved. They have more crashes per kilometre driven than most age groups and are more likely to die in those crashes. Given the increasing number of comorbidities that tend to accumulate with advancing age, beginning at age 80 and every two years thereafter, drivers must have a Driver’s Medical Examination Report (DMER – view) filled out by a physician or nurse practitioner. The filled out Driver’s Medical Examination Report (DMER) must be returned to RoadSafetyBC within 45 days of the DMER’s issuance, otherwise the driver’s licence will be cancelled. The RoadSafetyBC website is flush with information about all aspects of driver medical fitness. Of greatest relevance is the Driver Medical Fitness Information for Medical Professionals which outlines the many medical conditions that impact fitness to drive, the impact on functional ability (cognitive, motor, sensory) to drive, and the guidelines for assessment: view.
Despite all these screening requirements, the reality remains that the risk presented by a driver with a particular medical condition cannot be calculated. Traditionally, determinations were made based on the medical condition and the presumed group characteristics of people with that condition rather than on how the medical condition impacted the functions necessary for driving on an individual basis. The Grismer case in 1999 resulted in a Supreme Court of Canada decision that mandated a driver be assessed individually according to his/her own personal abilities rather than according to group characteristics. Now, a functional approach is used to assess fitness to drive. The impact of each medical condition is assessed based on how it affects the cognitive, motor and sensory functions necessary for driving, thus a determination of fitness to drive is not solely based on a particular diagnosis.
RoadSafetyBC is the driving licencing authority that determines fitness to drive in BC. The Superintendent of Motor Vehicles delegates driver medical fitness program staff to conduct driver medical fitness assessments using all the information submitted to them. This includes the Driver’s Medical Examination Report (DMER) (view), the Enhanced Road Assessment (ERA) (view), and results of cognitive screening tests or other related tests, as requested by RoadSafetyBC.
DriveABLE, a private, contracted company testing in-office and in-car cognition, and the ICBC on-road driving test, are no longer part of the algorithm for assessing fitness to drive in a patient with cognitive impairment. On March 5, 2018 RoadSafetyBC replaced prior assessments with the Enhanced Road Assessment (ERA) in order to streamline the process. Once RoadSafetyBC refers a patient for an ERA, it is the individual’s responsibility to contact ICBC to book the assessment. Booking times vary throughout the province, but the ERA is to be completed within 60 days from receipt of the request. It is different from a traditional road test in that it tries to simulate the cognitive workload of real-world driving. The ERA comprises a pre-trip vehicle orientation, a 45-minute on-road drive (in the individual’s own vehicle) with a feedback session halfway through the drive, and a post-trip review. The feedback session provides an opportunity for the driver to take suggestions from the examiner and demonstrate whether they can incorporate the changes into their driving. Understandably, cognitive impairment would hinder performance on this test. This is not a pass-fail test; it provides more information for the Superintendent to make the driving determination on a particular individual. ERA FAQ page for patients: view.
Under Section 230 of the Motor Vehicle Act, in addition to physicians, registered psychologists, optometrists and nurse practitioners are obliged to report a patient who may be unfit to drive. A patient must be reported only if “a patient has a medical condition that makes it dangerous to the patient, or to the public, for the patient to drive a motor vehicle, AND continues to drive after the psychologist, optometrist, medical practitioner or nurse practitioner warns the patient of the danger.” The practitioner must fill out the “Report of a Condition Affecting Fitness and Ability to Drive form” (view) and submit it to RoadSafetyBC, the driving licensing authority that determines fitness to drive in BC. Ultimately, the decision about maintaining or revoking a driver’s licence is up to the Superintendent, not to the individual physician. Your responsibility is to provide supporting documentation to RoadSafetyBC so that their staff can make a fitness to drive decision that is well substantiated. If RoadSafetyBC feels they have insufficient information to make a determination, they will request additional information or request that the patient undergo further medical or functional assessments, such as an ERA.
What I recommend (practice tips)
Older adults with cognitive decline are a population requiring targeted attention with regards to fitness to drive, given the progressive nature of dementia and the fact that those with moderate to severe dementia are not able to compensate for their functional impairment, thus should not be driving. Our responsibility as physicians is to initiate early dialogue about driving issues with patients with mild cognitive impairment or mild dementia, so as to allow planning for the eventual, inevitable loss of driving privileges. Of note, no cognitive test has sufficient sensitivity or specificity to be used on its own to determine fitness to drive and, thus, there are no specific test score cut-off values. The SIMARD MD is a screening test that can be used; however, it casts too wide a net, often failing those who pass other standardized cognitive tests, thus its results can’t be used to provide specific fitness to drive determinations. Rather, the results will be reviewed by RoadSafetyBC as a component of the individual’s file. If results of a cognitive screening test (Montreal Cognitive Assessment – MoCA, Mini–Mental State Examination – MMSE, Trail making A&B – view) and clinical assessment suggest that cognitive impairment is present such that you have concerns about your patient’s ability to drive, this can either be highlighted on a DMER or on a Report of a Condition Affecting Fitness and Ability to Drive form (view).
Given the progressive nature of dementia, individuals with mild dementia who are deemed fit to drive by RoadSafetyBC will automatically receive notice for re-evaluation in 6-12 months by RoadSafetyBC. Discussing alternatives to driving, such as HandyDART, taxi savers, grocery shop by phone services, is often met with resistance. The situation can be especially challenging for those in remote communities where travelling distances are greater and services offering alternatives to driving may be scarce. The RoadSafetyBC website has some information about region-specific organizations providing alternate transportation for seniors, as well as a short section about retiring from driving. Remember, the ultimate decision about an individual’s fitness to drive is made by RoadSafetyBC. It is handy to know that RoadSafetyBC has a dedicated phone line (250-953-8612) for medical professionals to help with complex fitness to drive cases.
References:
- RoadSafetyBC Fitness to Drive website https://www2.gov.bc.ca/gov/content/transportation/driving-and-cycling/driver-medical/driver-medical-fitness
- CMA Driver’s Guide, 9th edition https://joule.cma.ca/en/evidence/CMA-drivers-guide.html
- Seniors Transportation Access and Resources https://starcanada.ca
- The Driving and Dementia toolkit, for patients and caregivers http://www.rgpeo.com/media/30695/dementia%20toolkit.pdf
- Byszewski et al. Driving and dementia toolkits for health professionals and for patients and caregivers. CGS Journal of CME: 2(3), 2012. https://www.researchgate.net/publication/297700849_Driving_and_Dementia_Toolkits_for_Health_Professionals_and_for_Patients_and_Caregivers
Resources:
- Driver Medical Fitness Information for Medical Professionals, RoadSafetyBC (view)
- Form: Driver’s Medical Examination Report (DMER), RoadSafetyBC (view)
- Form: Report of a Condition Affecting Fitness and Ability to Drive, RoadSafetyBC (view)
- Enhanced Road Assessment (ERA) FAQ for patients (view)
- RoadSafetyBC dedicated phone line (250-953-8612) for medical professionals
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A relative, who has presumably been driving with the patient, is the expert.
No one wants to have their relative’s license taken away but they recognize the danger first. If they do not feel safe with the patient, they know best.
It then is in everyone’s best interest to have the doctor make the move to have the license take away.
Sometimes doctors have to make difficult decisions.
I remember the day a very elderly patient of mine didn’t show up for his 3pm appointment. He had crashed his car, at high speed, on the Parkway. But he wasn’t alone when he went to heaven: a young motorcyclist, a father of 3, was killed too. I remember that (a) driving is a privilege, not a right (b) we have a duty to protect other members of the public if drivers lack the vision, hearing, cognition and reflexes needed to pilot a high-momentum vehicle.
When I ask a frail elder with obvious health challenges “how did you get to clinic?”, it is partly in their interest, partly in mine but mostly for the safety of others. “How would you defend yourself in court if you were in an accident (even if innocent)?”.
Most understand that alternative transport is cheaper (cost, gas, maintainance, insurance, etc) than owning a car. As Diane points out, there are other modes of transport. I can see why a busy physician, unwilling to make enemies, might defer the argument on this topic. But if it is my 6 year old grand-daughter who is the casualty of our lack of professional diligence, I would have strong emotions.
Is there an appetite for annual road testing after a certain age? Or at least a publicity blast on the topic? Thank you Brenda for highlighting resources for doctors: I will use them. But the key must be verbal engagement, early on.
There is no debate about testing on demand, but most accident researchers are now opposed to age-based testing. They point out that everywhere in the world where there is age-based testing there are fewer older drivers, identical or slightly higher serior crash rates, and significantly higher senior pedestrian and cycling fatalities.
When used for driving and then compared to subsequent driving test results, the MMSE has a false positive rate of 50%, the MoCA has a specificity of 50%, and a fail on the Trail Making B test could lead to a wrong diagnosis nine out of ten times.
We can express older driver risk from different statistical perspectives, but the fact remains that in terms of crashes per capita older drivers have a relative risk of about 50% and that age-based testing does not reduce crash rates.
When older drivers crash they are more often at fault, but they crash so rarely that they have fewer at-fault crashes than any other age category. Also, they are driven into three times as often. Defensive driving bias should be an important consideration.
There is an alarming trend with older people dying on our roads, but it isn’t about older drivers, it is about younger drivers killing older pedestrians. In Ontario, older driver crash rates have remained enviable and flat, but pedestrian fatalities keep going up until they are now at 23% of total road related fatalities. In Toronto, in 2016, 70% of pedestrian fatalities involved seniors. In 2017 and 2018 senior involvement in pedestrian fatalities went up to 80%.
Bill Bears
Maple Ridge
Dr Villanyi,
Candrive, which is funded by the Canadian Institutes of Health Research, has discovered that all current cognitive tests are much too severe and not associated with at-fault crash rates. This at least shows us what is associated with actual crashes. There is a warning that these tests are to be used “only when there is genuine uncertainty by the primary care provider regarding fitness-to-drive.” Candrive, and most accident researchers are opposed to age-based testing. All jurisdictions have targeted testing when there is a genuine concern, but they haven’t been using decent tests. There will be more because Candrive has discovered more: the driver’s record, the ability to work the steering wheel and the pedals, the ability to see patterns (motor free vision test), and not being too nervous should follow. Candrive is very cautious, so the results are very slow to be released.
https://academic.oup.com/biomedgerontology/advance-article/doi/10.1093/gerona/glad044/704198
Bill Bears
Maple Ridge