Enhancing Safety for Older Drivers: Addressing Vulnerabilities and Risks

1. www.EUGMS2010.org

5. Economic vulnerability Heterogeneity Wisdom Domestic violence Ageism Gerontolism Child abuse Disability Changing care patterns

6. Acute Geriatric Medicine Geriatric Rehabilitation Reduce death/disability by 25% Ellis, 2004 Bachmann, 2010

7. ..my mother can’t go home, it’s far too dangerous…

8. Key points • Geriatricians as mediators of complexity • Older people most responsible road users • Clinical need for compromised groups • Immediate decision • Co-morbidities • Driver assessment must not victimize older people but support safe mobility • More understanding of doctors and risk

9. April 2010

11. Nature variable Nature capricious • Constructivism not objectivism • Typology-based discourse analysis not single-metric Nature precarious Nature benign

12. be clear about the nature of the risks we seek to manage • hesitate to seek to manage voluntary risks taken by adults • avoid the costs of excessive risk aversion • eschew optimising, single-metric methods; they cannot embrace all stakeholders • be aware of, and seek to accommodate, diverse societal concerns about risk

13. We do not respond blankly to uncertainty; we impose meanings upon it • The demand for certainty is one which is natural to man, but is nevertheless an intellectual vice Bertrand Russell

14. Circulation. 2009;120:928-934

15. Youth, speed, alcohol and “Fill her up with testosterone!”

16. 10% of referrals • 50% more likely to be male • Younger • Slightly more heart and stroke disease • More (non-driving!) injuries • Causes similar, except less syncope mimics • More nausea, palpitations, chest pain, dyspnoea • Recurrence similar • 12% @ 6/12, 14-17% @ 1 year

17. Recurrence • 3,877 • 380 syncope while driving • 37 recurrences within 6/12 • 44 within 1 year • 10 recurrences while driving… • 2 within 6/12 • 3 within 1 year • Injurious?

18. Why? • Venous pooling • Vasodilation • Emotional stimulation

19. Simple Faint • No barrier • Low risk recurrence • 4/52 • High risk recurrence • Dx and Rx 4/52 • No cause 6/12 • Seizure markers • 6/12+ • No clinical pointers • 6/12

20. Naughtiness • The peak among the elderly patients in the driving group is intriguing and has potential public health implications because this peak corresponds to an age range with a higher frequency of accidents per driver-year…

21. Further naughtiness! • …lower than the risk of serious accidents in high-riskgroups, such as young drivers, the elderly, or those drivingwhile intoxicated.

22. 2001 1985

24. Accident risk • Lowest of the driving population

25. U-shaped curve? • Older people drive less miles • Drive on more risky roads • Lower mileage intrinsically risky

26. Smeed’s Law Revisited.. • ….a relative decrease over time in older drivers' accident involvement per driver license and per active driver from 1983 to 1999 Hakamies-Blomqvist, AAAP, 2005, 37, 675-80

27. Less Crashes - More Deaths • Fragility • Children and air-bags • Design of the environment • Design of safety features

28. Schema • Routine transportation inquiry • Assessment • Provisional decision pending full assessment • Intervention(s) • Societal obligations • Review McMahon, 1996

29. Full clinical assessment • Neuro, Ophth, Musc-skel, MMSE • Collateral History • Drugs • Occupational Therapy • Neuropsych • Specialist driving assessor • Social worker

31. Driver models • Procedural, personality and behaviour • Cognitive tests of limited value • Hierarchical • Strategic • Tactical • Operational • Michon 1986 • Operationalized • De Raedt 2000

32. On Road Testing

33. Medication • Positive impacts • Anti-parkinsonian • Antidepressants • Anti-inflammatories • Anti-dementia drugs? • Negative impacts • Less clearly demonstrated

34. Co-pilot

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