“I will build a car for the great multitude. When I’m through, everybody will be able to afford one, and about everybody will have one.”

— Henry Ford (1909)

Henry Ford probably didn’t consider when “everybody” should reassess his or her capacity to drive. The ability to drive an automobile provides us with independence, convenience, and self-sufficiency, which is why it’s an integral part of the well-being of many elderly.

For instance, my 90-year-old father, who resides in Florida and recently had a cardiac catheterization, drove himself to the emergency department because he had chest pain. The physician told Dad there was no blockage or need for angioplasty, so he would be discharged the next day. When I spoke to Dad by phone, I told him he wouldn’t be allowed to drive himself home from the hospital. He had difficulty understanding this because 3 years ago when he had a cardiac stent inserted he drove himself home from the hospital the same day of the procedure. (Did I mention he has a five-speed automobile that requires him to use the clutch?).

Dad came home by taxi, but early the next day he insisted I drive him past his car in the hospital parking lot. That’s when I realized how important this car was—it represented his independence and autonomy.

A growing challenge

By 2040, the US Census Bureau estimates 19% of the US population will be over 65 and almost 4% over 80. While the literature suggests older people are the safest drivers on the road, driving skills decline with age, and older drivers will have to stop driving at a time when they still need to travel to meet their needs. How do we discuss with our patients (and our loved ones) when to give up the car keys?

Knowing when to stop

According to the “Physician’s Guide to Assessing and Counseling Older Drivers,” an assessment of a person’s driving abilities should focus on the three key functions of vision, cognition, and motor/somatosensory function. Any deficit in these functions has the potential to increase the individual’s risk for an accident. If a deficit is identified, the healthcare provider should determine if the person needs further assessment by a specialist. At this time, the healthcare provider can start a dialogue about the individual’s driving abilities, while making the referral for further testing/assessment. The Physician’s Guide also contains educational materials, including a checklist to assess when an individual’s driving safety may be at risk.

As a group, the elderly are at risk for traffic accidents, but how can we identify individuals at risk? Warning signs include:

• Stopping at a green light or when there isn’t a stop sign
• Mistaking the gas pedal for the brake pedal
• Finding traffic signs and signals confusing
• Accidentally running stop signs or red lights
• Unknowingly hitting or nearly hitting people, cars, or other objects
• Getting lost in familiar places
• Moving from one lane to another without looking
• Unexplained dents or broken mirrors or lights on the car

The following driving behaviors are ranked from minor to serious and could indicate safety problems. Because driving ability seldom changes drastically in a short time, use this list to observe and track driving changes over a period of time, which for some individuals may be a week or month and others, years.

1. Decrease in confidence while driving.
2. Difficulty turning to see when backing up.
3. Riding the brake.
4. Easily distracted while driving.
5. Other drivers often honk horns.
6. Incorrect signaling.
7. Parking inappropriately.
8. Hitting curbs.
9. Scrapes or dents on the car, mailbox, or garage.
10. Increased agitation or irritation when driving.
11. Failure to notice important activity on the side of the road.
12. Failure to notice traffic signs.
13. Trouble navigating turns.
14. Driving at inappropriate speeds.
15. Not anticipating potentially dangerous situations.
16. Using a “copilot” (driving with a passenger who will assist them with the driving)
17. Bad judgment on making left hand turns.
18. Near misses.
19. Delayed response to unexpected situations.
20. Moving into wrong lane.
21. Difficulty maintaining lane position.
22. Confusion at exits.
23. Ticketed moving violations or warnings.
24. Getting lost in familiar places.
25. Car accident.
26. Failure to stop at stop sign or red light.
27. Confusing the gas and brake pedals.
28. Stopping in traffic for no apparent reason

Once an obvious medical condition is ruled out, retracting an individual’s drivers license and assessing driving ability becomes murky. Many older drivers impose self-restrictions such as driving only during the daytime, driving locally, or avoiding highways. Older drivers might avoid driving in arduous situations such as rain, snow, and rush hour.

Placing the onus of removing an individual’s driver’s license on the physician can affect, among other things, the physician-patient relationship. Reaching a certain age does not necessarily suggest (or indicate) that someone can no longer drive. The physiological changes across the lifespan are variable and multifaceted, which negate the ability to use a formula to assess an individual’s driving ability.

Assessing an older individual’s driving abilities requires a targeted but holistic physical and psychosocial assessment. Healthcare professionals should examine changes in habits or personality; review medication use, alcohol use, prior history of accidents; and assess functional limitations. The physical exam should include vision, hearing, range of motion and strength, neurological integrity, cognition, and pain. Another assessment option is the Folstein Mini Mental Status Evaluation followed by a neurological evaluation as needed to assess driving safety.

How to have the conversation

How do you approach someone about reducing or ceasing to drive?

The AARP publication “We Need to Talk…Family Conversations With Older Drivers” suggests having a series of small conversations. Most older adults prefer to hear about driving cessation first from their spouse and then from an adult child or doctor; they dislike being told to cease driving by the police.

Do your homework before you ask an older driver to restrict or cease driving. Having a caring communication that takes into account sensitivity for the feelings of older drivers can aid in a successful conversation. Keep in mind that the older person sees giving up driving as a loss of independence. At a time when the elderly experience many losses, such as spouse, original home, and friends, to stop driving could be one loss they cannot accept.

Here are some ways to start the conversation:

• “I’m worried about your getting lost.”
• “I’m glad that you’ve cut down on night driving. I would never want you to drive when you’re not comfortable or feel that it’s too risky.”
• “If you don’t want to drive at night, we can arrange for someone to pick you up.” Commend the older driver for being cautious and help arrange transportation.
• “Have you asked your doctor about the effects of your new medication on your driving?”
• “Let’s take the bus so we don’t have to deal with the parking downtown.” Practice using public transportation together before it becomes a necessity.
• “You could save hundreds of dollars if you sold your car.” Insurance, maintenance, depreciation, and gasoline costs make owning and operating a car expensive.
• “What if something happened and you couldn’t drive? What would you do?” Ask what-if questions to encourage advance planning.

License renewal policies differ across states, with some requiring in-person renewal, some renewal by mail, and yet others renewal by mail with age-related restrictions. A number of variables influence license renewal. For example, policies can’t be age discriminatory, making it difficult to mandate a universal driving renewal/restriction policy. You can access more information about individual state policies, including recommendations related to reporting drivers who may put people at risk, at http://www.ama-assn.org/resources/doc/public-health/older-drivers-chapter8.pdf.

Is it time?

So how does one know when to take away the car keys? If you begin to question whether your elderly relative or patient should be driving, perhaps it is time to initiate the conversation.

Barbara Blozen is assistant professor in the college of nursing at Seton Hall University, South Orange, New Jersey.

Selected references

American Geriatrics Society. Seniors Behind the Wheel: Recognizing When Driving Is, and Isn’t, a Problem – and Responding Accordingly. http://www.americangeriatrics.org/press/reporter_resources/clinical_story_topics/id:148 Accessed October 7, 2012.

Edwards JD, Lunsman M, Perkins M, Rebok GW, Roth DL. Driving cessation and health trajectories in older adults. J Gerontol A Biol Sci Med Sci. 2009;64(12):1290-5.

Marshall SC, Man-Song-Hing M, Molnar F, Wilson KG, Blair R. (2007). The acceptability to older drivers of different types of licensing restriction. Accid Anal Prev. 2007;39(4):776-93.

Messinger-Rapport BJ. Assessment and counseling of older drivers A guide for primary care physicians. Geriatrics. 2003;58(12):16-8.

Sharp EB, Johnson PE. (2004). Taking the keys from grandpa: http://onlinelibrary.wiley.com/doi/10.1111/j.1541-1338.2005.00129.x/abstract.

Silverstein NM. (2008). When life exceeds safe driving expectancy: implications for gerontology and geriatrics education. Gerontol Geriatr Educ. 2008;29(4):305-9.

The Hartford Financial Services Group, Inc. We Need to Talk…Family Conversations with Older Drivers. Hartford, CT: The Hartford Financial Services Group, Inc; 2010.

US Bureau of the Census. US Population Projections; National Population Projections Released 2009. No. Table 2 Projects of the Population by Selected Age Groups and Sex for the United States 2010-2050). Washington, DC: US Bureau of the Census; 2009.

US National Highway Traffic Safety Administration & American Medical Association. Physician’s Guide to Assessing and Counseling Older Drivers. 2nd ed. Washington, D.C.; Chicago, Ill.: U.S. Dept. of Transportation, National Highway Traffic Administration; American Medical Association; 2010.