David Naimark, MD

There are currently 23 million automobile drivers over the age of 65 years. This number will increase by another 15% in the next 20 years, making the total number of older drivers equal to 25% of individuals on the highways (Fain, 2003). Of concern is the safety of our roadways as the effects of aging take their toll upon drivers nationwide. Organizations such as the National Highway Transportation Safety Administration are now considering potential solutions and fearing a problematic future (National Highway Transportation Safety Administration, 2002).

Certainly, there would be detrimental effects to prohibiting the elderly from driving. Depression and substantial physical inactivity may follow driver's license revocation. Driving may represent more than a means of transportation; for some it represents health and connection with family and friends--"therefore the loss of the ability to drive has both emotional and pragmatic consequences" (McGregor, 2002). In addition, the current transportation system is inadequate to meet the needs of the older population. While public transportation may be convenient and adequate for some, it may fail to provide the resources, pace and safety necessary for the older person.

Males 16 to 34 account for the majority of traffic accidents in the United States, but also drive the most miles per year of any group. In contrast, those 65 and older drive the fewest miles per year, but do so with a statistical risk factor similar to that of the just licensed teen-age group. On average, fatality rates (per 100 million miles driven) show teenagers with 17.9 deaths in comparison to 14.3 deaths in the elderly. There are, however, some differences between the groups with regard to the nature and type of traffic accidents. Juvenile drivers are involved in traffic accidents largely as a result of excessive speed or recklessness, whereas accidents involving the elderly driver commonly occur as a result of a physical malady or cognitive impairment. Furthermore, the juvenile driver's risk of causing an accident is predicted to decrease with additional experience behind the wheel, whereas the elderly person's risk to self and others is expected to increase with continued effects of aging (Howe, 2000).

Media attention was brought to this issue in an event occurring in June 2003 (Santa Monica Mirror, 2003). Russell Weller, age 86, drove his 1992 Buick through a crowded farmers' market, killing 10 and injuring 30. When detained and questioned regarding the event, Weller stated that he was unable to stop the vehicle. Witnesses told police that he appeared confused and disoriented during and after the event. Naturally, this tragedy has led to an investigation into Weller's mental and physical condition prior to the accident to determine if license revocation would have been proper. There has been concern as to whether there was negligence by the Department of Motor Vehicles (DMV), Weller's personal physician and Weller's family.

Age alone does not cause impairment behind the wheel; it is the mental and physical changes associated with aging that cause the problem. Currently, all drivers who suffer from a reported cognitive deficit are screened for a high-risk classification by the DMV. Screening test administrators are looking for four necessary mental requirements in the driver: proper integration and interpretation of sensory input, focus of attention, proper association of thought, and appropriate judgment. Failure in any of these areas may be cause for license suspension or revocation. The presence of mild dementia, however, is not necessarily a cause for a license revocation (as an elderly person may be able to drive safely in the initial development of such a state) (Ott et al., 2003). A clinical finding of Alzheimer's disease is almost always grounds for the revocation of driving privileges, as the nature of such impairment will rapidly render a person unsafe behind the wheel.

Rosen et al. (2002) found that only two-thirds of clinicians regularly utilize standardized tests when screening for cognitive deficits among suspected high-risk elderly drivers. Of those who do regularly test their patients, many find the Mini-Mental State Examination (MMSE) to be reliable in accurately predicting the future driving status of an elderly individual. (Adler and Kuskowski, 2003). The MMSE has gained popularity as a preliminary tool for assessing driving risk but may be insufficient for the assessment of overall cognitive status (Folstein et al., 1975).

Because available tests exhibit limitations, efforts are being made to further expand driving competence evaluations beyond the written formats and existing road examinations. Suggestions for improvement include the utilization of visuo-spatial tests, mazes and technologically based solutions. One of the most fascinating technological tests in development is the Global Position Satellite (GPS) model (Porter and Whitton, 2002). This procedure involves outfitting the elderly person's vehicle with a GPS receiver and a dash-mounted camcorder for a specified duration of time. The GPS receiver provides the physical location of the vehicle, thereby providing the driver's position with respect to intersections, roads and heavy traffic areas. Visual data from the camcorders, coupled with the GPS location data, can later be reviewed to provide information about the exact events of the driving test as they occurred. Oncoming traffic flow, pedestrian activity and road hazards can all be considered in the evaluation of the elderly driver. The GPS test would also address discontinuity of testing standards in vehicle test administrators.

While intelligence testing and mental status examination tools may suggest the presence or absence of driving difficulties in a cognitive sense, they do not include substantial information as to the physical and operational abilities of the elderly individual when driving. Physical faculties must be pristinely functioning in order to successfully operate a vehicle. Deficits in sight and hearing, arthritic conditions, muscular degenerative conditions, connective tissue diseases, and Parkinson's disease all may render an individual unable to operate a vehicle with the precision necessary for safe driving.

Medicinal treatments of physical impairments come with their own inherent set of problems. Certain medications may actually interfere with safe vehicle operation. Statistically, older drivers are far more likely to be on medications than any other driver age bracket (McGregor, 2002). Medications that commonly affect driving ability are hypnotic anxiolytics, narcotics, antipsychotics, sedatives, antidepressants, anti-inflammatory agents, muscle relaxants and ophthalmic drugs. While many drivers are able to function normally on medications, the additional factor of multiple physical maladies and comorbidities may create a decisive impairment in driving ability.

Current legal thinking suggests that responsibility for this problem must be shared between the DMV and the health care system. The American Medical Association's Council on Ethical and Judicial Affairs opines that the physician has an ethical duty to report patients who may suffer from dementia or related deficits (Howe, 2000). In 1988, California adopted a law that requires physicians to submit reports on all patients diagnosed with Alzheimer's disease or related cognitive disorders to the Health Department. In turn, these reports are sent to the local DMV office so that a driver's test can be administered immediately. However, a recent study suggested "more than 28% of all geriatricians do not know how to report patients with dementia who are potentially dangerous drivers" (Cable et al., 2000). The DMV, while mandated to make administrative decisions regarding driving privileges, has no enforcement ability. Enforcement falls to the police, who may have little time or interest in tracking down elderly drivers who are operating their vehicles with revoked licenses.

Since a single individual or instrument cannot examine elements of cognition, physical ability and psychological well-being, some investigators have proposed new solutions. Fitten (2003) suggested the implementation of graduated driver licensing programs in order to provide for a better system of screening. Fitten argued that age-appropriate testing is a necessity. He advocated a program with action plans and resources to respond to issues such as confidentiality, post-driving cessation education, and alternative transportation options. Fitten opined that it is in the interest of the greater good "to identify impaired elderly drivers through scientifically derived and health-related screening methods."

Taking an opposing stance is Fain (2003) who proposed that the perceived threat of the elderly driver is indicative of societal bias with respect to age. She argued that the rights of the elderly are being trampled upon to avoid inconvenience to the general populace. Fain also called attention to the fact that national studies of morbidity rates and crash data are designed to average accident information, but do not give any consideration to the percentage of capable elderly drivers who maintain spotless driving records. She suggested that the data reflects an unfair bias toward the elderly in that it proposes restrictions on both problematic drivers and capable drivers alike. Essentially, Fain proposed a return to examinations based solely on driving history and functional performance, regardless of age.

The arguments on both sides have merit and both also miss the point--we propose to reframe the issue. We take no specific position on whether the elderly should be permitted to drive, because this is up to the will of society. Essentially, we are speaking of a balance between personal (an individual's right to drive) versus collectivity (society's right to be protected from harm) autonomy. Similar to the sexually violent predator (SVP) statutes (which derived out of several notorious cases; e.g., Kansas v Hendricks, 1996), we perceive that society now wants to impose a liberty limitation on the elderly driver (also as a result of a few tragic instances). If this is the case, let us then, as a society, be honest about this desire. Let us cease to lay the responsibility into the laps of the DMV, the physician and the family, because these parties do not currently have legal guidance as to what society wants and do not have enforcement power. If, as we suspect, society no longer wants many elderly people to drive, specific guidelines for making the determination of driving incapacity must be legislated (in a similar manner to how SVP legislation was enacted), and we should then put our energies toward intelligently dealing with the resulting fallout.

Until legislative guidelines can be enacted to further address the issue of driving in the elderly, improvements can be undertaken to reduce the rate of accident occurrence. Efforts are being directed toward three key areas: the driver, the roadway and the vehicle (Fain, 2003). Current training programs are now offered for the elderly driver to improve driving performance and refresh knowledge of driving laws. Recognizing that drivers vary in operational ability in later years, engineers are also designing automobiles with additional safety features and driver assist capabilities. Car companies promise such features as automatic braking and proximity alert devices. Roadway improvements are focused on lessening turning gradients, increasing sign visibility and introducing reflective pavements.

Loss of driving privileges is--after nursing home placement--probably the most feared of events for an elderly person. Supportive psychotherapy combined with a cognitive-behavioral focus on emphasizing "bad" consequences of continued driving can be helpful. Caution should be paid to the possible onset of a mood or adjustment disorder in the context of loss of driving privileges and, should it occur, may require psychopharmacologic intervention.

What alternatives to driving can be offered to the older citizen? Many suggest that the current transportation system is inadequate. While public transportation may be convenient for some, it may fail to provide the resources necessary to aid the elderly person. Furthermore, mass transit in large cities often introduces an element of danger to the elderly person. Not only does the criminal element pose a threat, but also the pace at which the transportation system operates may be too rapid. If society intends to reduce driving privileges for older people, then society must provide an efficient, cost-effective and safe alternative.

Mr Rinkert is forensic psychology intern in the Forensic Psychiatry Clinic at the Superior Court of San Diego.

Dr Naimark is associate clinical professor of psychiatry at the University of California, San Diego, and adjunct professor of law at the University of San Diego.

Adler G, Kuskowski M (2003), Driving cessation in older men with dementia. Alzheimer Dis Assoc Discord 17(2):68-71.

Cable G, Reisner M, Gerges S, Thirumavalavan V (2000), Knowledge, attitudes, and practices of geriatricians regarding patients with dementia who are potentially dangerous automobile drivers: a national survey. J Am Geriatr Soc 48(1):14017 [see comment].

Fain MJ (2003), Should older drivers have to prove that they are able to drive? Arch Intern Med 163(18):2126-2128; discussion 2132 [see comment].

Fitten LJ (2003), Driver screening for older adults. Arch Intern Med 163(18):2129-2131 [see comment].

Folstein MF, Folstein S, McHugh PR (1975), "Mini-mental state." A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3):189-198.

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Kansas v Hendricks (1996), No. 95-1649. Argued December 10, 1996--Decided June 23, 1997. Available at: supct.law.cornell.edu/supct/html/95-1649.ZS.html. Accessed Oct. 7, 2004.

McGregor D (2002), Driving over 65: proceed with caution. J Gerontol Nurs 28(8):22-26; quiz 54-55.

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Ott BR, Heindel WC, Whelihan WM et al. (2003), Maze test performance and reported driving ability in early dementia. J Geriatr Psychiatry Neurol 16(3):151-155.

Porter MM, Whitton MJ (2002), Assessment of driving with the global positioning system and video technology in young, middle-aged, and older drivers. J Gerontol A Biol Sci Med Sci 57(9):M578-M582.

Rosen CS, Chow HC, Greenbaum MA et al. (2002), How well are clinicians following dementia practice guidelines? Alzheimer Dis Assoc Disord 16(1):15-23.

Santa Monica Mirror (2003), Disaster at farmers' market claims tenth victim. July 16-22. Available at: http://www.smirror.com/volume5/issue5/disaster_at_farmers.asp. Accessed Oct. 7, 2004.

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Of concern is the safety of our roadways as the effects of aging take their toll upon drivers nationwide. Are there accurate ways to test the cognition and response ability of elderly drivers?

David Naimark, MD

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