Two stories, same basic question. Story #1: Elderly gentleman, kyphosis with limited neck mobility, oxygen dependent, severe COPD, walker dependent, very mentally sharp but medically fragile- refuses to stop driving in spite of his family doctor's order to do so. Office nurse fills out state referral form requiring him to be retested by the Department of Transportation. The patient becomes angry and leaves the practice. Story #2: Elderly woman with mild to moderate dementia, designated driver for a couple. One family member works hard to get all of family in unity to get driving, especially on busy interstates, limited. In spite of strong advocacy from one son, their internist supplies letter to husband, per his request, that she is "clear to drive." When questions arise in the family, he sites the written memo as proof that she is ok to drive. The family and the parents are at bitter odds over this difference of opinion and are at an impasse. In both of these cases, the persons involved are hovering at around 90 years of age
So what is going on here? Is this a common problem? As nurses, it seems that we often face questions in our practice, in our families, and in our communities about what to do and how to proceed when there is a question about whether or not an elder is safe to continue to drive. While cities with extensive public transport may not face this issue in exactly the same way, large swaths of our suburban-based country are inaccessible unless someone is able to drive. When driving is restricted or prohibited, the affected person finds their independence drastically curtailed. In a culture where self-reliance is a high value, this can be tantamount to a sentence of isolation and confinement, a perceived end to life as it has been.
As a whole, seniors tend to be careful, safe, responsible drivers. Many studies confirm the fact that age alone does not preclude safe driving. However, as age and co-morbidities increase, so do numbers of accidents with fatalities. This is especially noticeable in the 85+ age group, where increasing loses associated with aging-hearing, vision, neck mobility and reflexes-appear to hamper safe driving. "Three behavioral factors in particular may contribute to these statistics: poor judgement in making left-hand turns; drifting within the traffic lane; and decreased ability to change behavior in response to an unexpected or rapidly changing situation.(Older Drivers, Elderly Driving, Seniors at the Wheel)."
The CDC site states:
- Involvement in fatal crashes, per mile traveled, begins increasing among drivers ages 70‒74 and are highest among drivers ages 85 and older. This trend has been attributed more to an increased susceptibility to injury and medical complications among older drivers rather than an increased risk of crash involvement.
- Age-related declines in vision and cognitive functioning (ability to reason and remember), as well as physical changes, may affect some older adults' driving abilities. (Older Adult Drivers | Motor Vehicle Safety | CDC Injury Center)
The problem of impaired drivers affects us all and as nurses we are part of the supportive community that surrounds our seniors. How can we best contribute to assisting with a solution-oriented approach?
Encourage our seniors to self-monitor
If we begin to make driving safety a part of our "normal" conversation and assessments, it will seem less accusatory and invasive when the topic comes up. This suggestion is not intended to add another check box to the already cluttered EMR but to simply add another topic to our usual office-visit preventive medicine conversations or even our discharge plans post-op. Sometimes simply asking the question can plant the seed of more careful thought. By being good listeners, we can pick up on cues that our patients have concerns about their own driving; when we realize this, then we can focus in on their concerns and help them decide whether or not to limit driving. If someone says, "I wonder if I am ok to drive at night? I don't feel like I can see as well at night," then it is our professional responsibility to pick up on this and follow through: do they need an appointment with an ophthalmologist? Can the patient themselves suggest what they need to do about it? Many times, if our patients are able to suggest their own solutions, they are more able to accept the limitations rather than those imposed on them by outside forces.
Involve family and physician
Many seniors have family or significant others that are concerned about their driving. Most families will admit that they simply do not know whether their elders are ok to drive. When a nurse opens the topic, in a non-threatening way, it can help push the conversation forward, to a point where action is possible. If the patient has a family physician/internist, these professionals can also be valuable allies in the decision-making process. A nurse who has experience with her own family in this process once told me: "It was a tricky subject for me to discuss with my dad when the time came to do so. I found it was easier for him (and me) to have the doctor discuss it and let him deliver the news that driving needed to cease. It helps the senior 'save face' by being able to say, 'My doctor says it's time for me to leave the driving to others because of my health condition,' rather than having to say 'My daughter won't let me drive any more because I am too old.' It helps keep family relations open and supportive which is so important as health issues start cropping up."
Support community transportation initiatives
Safe communities don't just happen. We all have to invest our tax dollars to make general accessibility happen. While this sounds like more government intervention, it is, in reality, contributing to all our convenience and safety and well-being. If our seniors are able to get around, then we are all better off. Sometimes our seniors need help in figuring out the logistics of using uber, taxi service, bus routes or volunteer community drivers. Nurses can play an important role in getting their patients comfortable using alternative transportation.
Encourage seniors to take a safe driving class
The AARP offers classes to help seniors be better drivers, helping them learn how to compensate for deficits and how to improve their driving habits.
Use Department of Transportation reporting as a tool-if all else fails
While most states have a form for reporting an unsafe driver, these are most useful when an unsafe driver is unwilling to acknowledge that he/she has any limitations and refuses all other offered interventions.
As professional nurses, we are concerned about promoting safe driving for people of all ages. When it comes to our elders, we approach the topic with respect for their dignity and with an eye toward positive outcomes. What practical suggestions do you have in terms of addressing this community challenge?
