Banner-Physician's Guide to Assessing and Counseling Older Drivers

Chapter 6
Counseling the Patient Who is No Longer Safe
to Drive

Mr. Phillips returns for follow-up after undergoing driver assessment and rehabilitation. From the Driver Rehabilitation Specialist (DRS) report, you know that his DRS has helped fit his car with a steering wheel spinner knob to compensate for decreased hand grip and a wide-angle rearview mirror to compensate for decreased neck rotation. Mr. Phillips has successfully undergone training with these adaptive devices and now states that he is driving more confidently with them. You counsel him on the Tips for Safe Driving and Successful Aging Tips, advise him to continue exercising, and encourage him to start planning alternative transportation options.

You continue to provide care for Mr. Phillips’ chronic conditions and follow up on his driving safety. Three years later, Mr. Phillips’ functional abilities have declined to the extent that you believe it is no longer safe for him to drive. You also feel that further driver rehabilitation is unlikely to improve his driving safety. Mr. Phillips has decreased his driving over the years, and you tell him that it is now time for him to retire from driving. Mr. Phillips replies, “We’ve talked about this before, and I figured it was coming sooner or later.” He feels that rides from family, friends and the senior citizen shuttle in his community will be adequate for his transportation needs, and he plans to give his car to his granddaughter.

One week after this visit, you see a new patient. Mrs. Allen is a 76-year-old widow who has not seen a doctor in the past five years despite urging by her daughter, who accompanies her to the clinic today. She presents with a sore throat, fever and chills. Mrs. Allen is unable to provide you with any history, and she has trouble following instructions throughout the clinic visit. Your rapid strep test confirms strep throat, and you prescribe antibiotics and ask her to return in one week for follow-up and a full physical exam. You are concerned about her cognitive state, and wonder if it is due to the infection. You confirm that Mrs. Allen’s daughter drove her to the clinic, and you ask Mrs. Allen to refrain from driving until you see her for follow-up.

Two days later, you receive a phone call from Mrs. Allen’s daughter. The daughter reports an improvement in her mother’s symptoms, but now wishes to speak to you about her mother’s mental decline. She reports that her mother, who lives alone, is having increasing difficulty dressing herself, performing personal hygiene tasks, and completing household chores. She is particularly concerned about her mother’s daily trips to the grocery store two miles away. Mrs. Allen has gotten lost on these trips and—according to the store manager—has handled money incorrectly. Dents and scratches have appeared on the car without explanation. Mrs. Allen’s daughter has asked her mother to stop driving, but Mrs. Allen responds with anger and resistance each time. The daughter would like to know how to manage her mother’s long-term safety and health, and—most urgently—how to address the driving issue. What do you tell her?

For many, driving is a source of independence and a self-esteem. When an individual retires from driving, he/she not only loses a form of transportation, but all the emotional and social benefits derived from driving.

For various reasons, physicians may be reluctant to discuss driving retirement with their patients. Physicians may fear delivering bad news or depriving the patient of mobility and all its benefits. Physicians may avoid discussions of driving altogether because they believe that a patient will not heed their advice.

These concerns are all valid. However, physicians have a responsibility to protect their patients’ safety through assessment of driving-related functions, exploration of medical and rehabilitation options to maintain their patients’ driving safety, and—when all other options have been exhausted—recommendations of driving restriction or driving retirement. Physicians are influential in a patient’s decision to stop driving; in fact, advice from a doctor is one of the most frequently cited reasons that a patient retires from driving.1

In this chapter, we discuss the key steps in counseling a patient on driving retirement and provide strategies for managing challenging cases.

How Do You Recommend Driving Retirement to Your Patient?

If you must recommend driving retirement to your patient, there are several things you can do to make this conversation more comfortable for both of you. First, use the term ‘driving retirement’ to help normalize the experience. After all, retirement is generally considered a more natural and positive life experience than “quitting” or “giving up.” Second, involve your patient in the decision making process by openly discussing why his/her driving safety is at risk and addressing his/her needs and concerns. Third, acknowledge that safe mobility is a priority by encouraging your patient to develop a list of alternative transportation options.

When discussing driving retirement with your patient, you may find it helpful to follow these four steps:

Explain to your patient why it is important to retire from driving.

If your patient has undergone ADReS or assessment by a driver rehabilitation specialist, explain the results of the assessment in simple language. Clearly explain what the results tell you about his/her level of function, then explain why this function is important for driving. State the potential risks of driving, and end with the recommendation that your patient retire from driving. (If your patient presents with significant cognitive impairment and/or lacks decision-making capacity, see the suggestions in the later part of this chapter.)


For example, you could say to Mr. Phillips:

“Mr. Phillips, the results of your eye exam show that your vision isn’t as good as it used to be. Good vision is important for driving, because you need to be able to see the road, other cars, pedestrians, and traffic signs. With your vision, I’m concerned that you’ll get into a car crash. For your own safety and the safety of others, it’s time for you to retire from driving.”


This recommendation may upset or anger your patient. Let him/her know that this is normal, and that you understand his/her reaction.

While you should be sensitive to the practical and emotional implications of driving retirement, it is also necessary for you to be firm with your recommendation. At this time, it is best to avoid engaging in disputes or long explanations. Rather, you should focus on making certain your patient understands your recommendation and understands that this recommendation was made for his/her safety.

Discuss transportation options.

Now that you have recommended driving retirement, the next step is to explore alternative transportation options with your patient. Encourage your patient to maintain his/her mobility by creating a transportation plan—a list of alternatives to driving.

You can begin discussing transportation options by asking the following questions:

Discuss whether these options can fulfill all of your patient’s transportation needs, and suggest other options for your patient to consider. (A list of alternatives to driving can be found in Figure 6.1 and in the patient resource sheet, Getting By Without Driving, found in Appendix B.) Address any barriers your patient identifies, including financial constraints, limited service and destinations, reluctance to depend on family and friends for rides, and challenging physical requirements for accessibility (eg, unsheltered bus stops and steep bus stairs).

Figure 6.1
Alternatives to Driving

  • Walking
  • Public transportation
  • Rides from family and friends
  • Cabs
  • Paratransit services
  • Community transportation services
  • Hospital shuttles
  • Medi-car
  • Delivery services and house calls
  • Volunteer drivers (through the church, synogogue, or community center)

Help your patient choose the most feasible transportation options and encourage him/her to use the patient resource sheet, Getting By Without Driving, as a tool for developing and utilizing a personal transportation plan. In developing this transportation plan, recommend to your patient that he/she contact the local Area Agency on Aging (AAA) for information about local resources such as taxis, public transportation, and senior-specific transportation services. (This contact information is included in the patient resource sheet.)

Remind your patient to plan for transportation to social activities because it is important—especially at this time—for him/her to maintain a strong social support system.

In addition to exploring transportation options, your patient should also consider how to eliminate unnecessary trips by combining activities and utilizing delivery and house-call services. For example, your patient can reduce the number of trips needed by scheduling all appointments in the same area for the same day, or arranging to have groceries and medications delivered.

Encourage your patient to involve family members in the creation of a transportation plan. With your patient’s permission, contact family members and encourage them to offer rides and help formulate a weekly schedule for running errands. They can also arrange for the delivery of groceries, newspapers, medications, and other necessities/services. (See Figure 6.2 for more tips.)

Figure 6.2
Tips For Involving the Family

  • Encourage family members to promote the health and safety of their loved one by supporting your recommendations and assisting in the creation of a transportation plan.
  • Encourage questions regarding patient care.
  • If a third party accompanies your patient into the examination room, involve all parties in the discussion. Take care not to ignore your patient.
  • Provide resources to the family, including the How to Help the Older Driver resource sheet found in Appendix B.
  • Refer the family to the National Family Caregivers Association (NCFA) at 800 896-3650 or www.nfcacares.org to find resources and tips on caring for their loved one.
  • Be alert to signs of caregiver burnout.

Reinforce driving cessation.

Because your patient may initially offer resistance or fail to comprehend your recommendation for driving retirement, it is important to reinforce this recommendation at the current and future office visits.

To reinforce this recommendation:

Figure 6.3
Tips to Reinforce Driving Cessation

Tip 1:

Give the patient a prescription on which you have written “Do Not Drive.” This aids as a visual reminder for your patient and also emphasizes the strength of your message.

Tip 2:

Remind your patient that this recommendation is for his/her safety and for the safety of other road users.

Tip 3:

Ask the patient how he/she would feel if he/she got into a crash and injured someone else.

Tip 4:

Use economic arguments. Point out the rising price of gas and oil, the expense of car maintenance (tires, tune-ups, insurance), registration/license fees, financing expenses, and the depreciation of car value.

Tip 5:

Have a plan in place that involves family member support for alternative transportation.

Follow up with your patient.

At your patient’s one-month follow-up appointment, you should:

You can begin the discussion by asking your patient how he/she got to the appointment that day. For example, you could say to Mr. Phillips:

Physician: Good morning, Mr. Phillips. It’s good to see you again. Did you have any problems getting to the office today?

Mr. Phillips: No, not at all.

Physician: How did you get here today?

Mr. Phillips: My son dropped me off. We’ve worked out a schedule so that he and his wife can give me rides to all my appointments.

Physician: That’s wonderful! Aside from these rides, have you found any other ways to get around?

During the office visit, remember to be alert to signs of depression, neglect, and isolation. Driving cessation has been associated with an increase in depressive symptoms in the elderly.2, 3 In addition to direct effects on the patient’s well-being, depressive symptoms have been linked to physical decline and mortality in the elderly.4 Ask your patient how he/she is managing without driving and assess for depression (see Figure 6.4) and neglect (see Figure 6.5) as indicated. Educate family members and caregivers about signs of depression, and encourage them to contact you if they have concerns about their loved one’s well-being.

Figure 6.4
Questions to Assess for Depression
(adapted from the DSM-IV-TR)5

  • How has your mood been lately?
  • Have you noticed any changes in appetite?
  • Have you noticed any changes in sleeping habits?
  • Have you noticed feeling particularly tired or anxious lately?
  • Have you been taking part in and enjoying your usual activities?

Figure 6.5
Signs of Neglect or Self-Neglect

  • Patient has an injury that has not been properly treated
  • Symptoms of dehydration and/or malnourishment without illness-related cause
  • Weight loss
  • Soiled clothing
  • Evidence of inadequate or inappropriate administration of medications

Continue to assess and manage your patient’s functional impairments and the underlying disorders. If they improve to the extent that your patient is safe to drive again, discuss this with your patient and help him/her develop a plan for a safe return to driving. This can include a driver evaluation performed by a driver rehabilitation specialist (see Chapter 5), limiting driving to familiar, uncongested areas until the patient regains his/her confidence, and/or reviewing the Safe Driving Tips found in Appendix B.

Situations That Require Additional Counseling

It may be necessary to provide additional counseling to encourage driving retirement or to help your patient cope with this loss. In this section, we discuss situations that require additional counseling and offer recommendations for the management of these situations.

Situation 1: The resistant patient

If your patient is belligerent or refuses to retire from driving, it is important for you to understand why. Knowing this will help you address your patient’s concerns.

In the care of your patient, you may find it helpful to:

Use empathetic statements when addressing your patient’s concerns. Remind your patient that you are an advocate for his/her safety and health.

For example, you could say to your patient:

Physician: Mr. Adams, it worries me that you drove yourself to your appointment today. At our last visit, we talked about why it was no longer safe for you to drive, and I recommended that you retire from driving. Can you tell me why you’re still driving?

Mr. Adams: Well, Doctor, I don’t understand it. My driving is just fine. Frankly, I don’t think you have the right to tell me not to drive.

Physician: I know this is a frustrating situation for you. I also know that it’s not easy for you to retire from driving, but I still think it’s best for your safety and health. As your doctor, your safety and health are my concern. I want to make sure we understand each other, and I’d like to help you as much as possible. Can you tell me some of your concerns about retiring from driving?

This may help your patient become involved in the decision to retire from driving, and help you assess his/her judgment and insight.

Physician: Mr. Adams, when do you think it’s best for a person to retire from driving?

Mr. Adams: Well, when they’re running red lights and getting into crashes, I guess.

Physician: Do you know anyone who drives like this?

Mr. Adams: A friend of mine doesn’t drive too well. He drives all over the road and runs red lights. I don’t want to get into the car with him anymore because I don’t trust his driving.

Physician: That sounds like a scary situation for your friend and for other people on the road. I think it’s time for him to retire from driving. Do you think it’s a good idea for people to retire from driving when they’re a danger to themselves and others?

Many older drivers are able to identify peers whose driving they consider unsafe, yet may not have the insight to make similar observations about their own driving. By asking your patient about friends whose driving is unsafe and why he/she considers their driving unsafe, your patient may be able to recognize similarities in his/her own driving performance.

Assure your patient that he/she will not be alone in driving retirement. After all, many people make the decision to restrict or retire from driving when safety becomes a concern. Encourage your patient to seek a second opinion if he/she feels that additional consultation is necessary.

Ask your patient to list friends and relatives who have retired from driving and ways that they have continued to remain active and mobile. Also, your patient can list family members, neighbors, church groups, and other support groups that are able and willing to help with transportation decisions. Remind your patient to plan for transportation to social activities so that he/she can maintain a social life.

Often, discussions of driving retirement tend to focus on the negative aspects, such as “losing independence” or “giving up freedom.” Help your patient view the positives by pointing out that this is a positive step towards his/her safety and the safety of other road users. Mention the benefits of not owning a car and of utilizing community services (such as decreased costs and the potential to meet new people).

Your patient may need additional help securing resources and transitioning to a life without driving. Social workers can provide counseling to patients and their families, assess your patient’s psychosocial needs, assist in locating and coordinating community services and transportation, and enable your patient to maintain safety, independence, and a high quality of life. The National Association of Social Workers Register of Clinical Social Workers is a valuable resource for locating a social worker in your area who has met national verified professional standards for education, experience and supervision. You can access the Register or place an order online at www.socialworkers.org. (See Appendix B for more details.)

Situation 2: Your patient presents with symptoms of depression.

Driving cessation has been associated with an increase in depressive symptoms.2, 3 This can result from a combination of factors, including social isolation, feelings of loss, and perceived poor health status. If your patient presents with signs or symptoms of depression, assess further by asking specific questions (see Figure 6.4).

Talk to your patient and appropriate family members about the symptoms of depression and available options. These can include referral to a mental health professional for full assessment and treatment or direct referral for individual therapy, group therapy, or social/recreational activities. Acknowledge that your patient has suffered a loss and that this is a difficult time for him/her. Let your patient know that these feelings are normal.

Situation 3: Your patient lacks decision-making capacity.

If your patient presents with significant cognitive impairment and/or lacks insight and decision-making capacity, it is imperative that you employ the aid of the appointed guardian or caregiver to help the patient comply with your recommendation of driving retirement. Let family and caregivers know that they play a crucial role in helping the patient find safer alternatives to driving.

If necessary, an expert evaluation can be used to appoint a legal guardian for the patient. In turn, the guardian may forfeit the patient’s car and license on behalf of the safety of the patient. These actions should be used when needed, but only as a last resort.

Situation 4: Your patient shows signs of self-neglect or neglect.

At times, a patient may not be able to secure resources for himself/herself and may lack support from family, friends, or the appointed caregiver. If you suspect that your patient does not have the capacity to care for himself/herself—or that family and caregivers lack the ability to adequately care for your patient—be alert to signs of self-neglect and neglect (see Figure 6.5).

Self-neglect is defined as the failure to provide for one’s own essential needs, while neglect is the failure of a caregiver to fulfill his/her caregiving responsibilities due to willful neglect or an inability arising from disability, stress, ignorance, lack of maturity, or lack of resources. If you identify signs of neglect or self-neglect, notify the Adult Protective Services (APS). APS will investigate and confirm cases of neglect and self-neglect, and arrange for services such as case planning, monitoring and evaluation, and medical, social, economic, legal, housing, law enforcement, and other emergency or supportive services. To obtain contact information for your state APS office, call the Eldercare Locator at 1 800 677-1116.

Figure 6.6

July 1, 2003


Clayton Phillips
123 Lincoln Lane
Sunnydale, XX 55555


Dear Mr. Phillips:

I am writing to follow up on your clinic visit on June 20, 2003. During the visit, we talked about your safety when you drive a car. I tested your vision (eyes), strength, movement, and thinking skills, and asked you about your health problems and medicines. Because your vision, strength and movement might make you drive unsafely, I recommended that you retire from driving.

I know that driving is important to you, and I know that it is hard to give up driving. Still, your safety is more important than driving. To help you get around, you can ask for rides from your son and your friends. You can also use the senior bus in your neighborhood. The Patient Resource Sheet (enclosed) has some other ideas that we talked about. As we agreed, I am also sending a copy of these materials to your son so that the two of you can read them together.

I want to make sure you can still do your chores, visit your friends, and go other places without a car. It is important for you to maintain your lifestyle. Please see me again in one month—we will talk about how this is working for you.

As we discussed, the state of _____ requires me to refer unsafe drivers to the Department of Motor Vehicles (DMV). Because I am required by law to do this, I have sent a report to the ____ DMV. The DMV will send you a letter in a few weeks to discuss your driver’s license.

Please call my office if you have any questions. I look forward to seeing you next month.

Sincerely,



Your Physician


Enc: Patient Resource Sheet
cc: Your son

* Note that this sample letter has been written at a 5th grade reading level, as measured by the SMOG Readability Formula.

References

1 Persson D. The elderly driver: deciding when to stop. The Gerontologist. 1993;33:88-91.

2 Marottoli RA, Mendes de Leon C, Glass TA, Williams CS, Cooney LM, Berkman LF, and Tinetti M. Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Journal of the American Geriatrics Society. 1997;45:202-210.

3 Fonda SJ, Wallace RB, Herzog AR. Changes in driving patterns and worsening depressive symptoms among older adults. Journals of Gerontology. 2001:56(6):S343-351.

4 Berkman LF, Berkman CS, Kasl S, et al. Depressive symptoms in relation to physical health and functioning in the elderly. American Journal of Epidemiology. 1986;124:372-388.

5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington DC: American Psychiatric Association; 2000.


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