Assessment of Older People's Health and Social Care Needs and ...

Risk assessment in older drivers is affected not only by our understanding of models of drivingbehaviour. and empirical studies of disease and crash risk, but also by clinical attributes common tothe assessment of function in older patients. Inter-individual variability is extremely important andnecessitates a case by case approach.Factors relating to age-related diseases include not only adifferent spectrum of illness to younger people, but also the presence of multiple illnesses. In anyone patient, is it the arthritis, the dementia, the visual acuity or even the multiple medications whichis affecting driving? Within the rubric of one iilness there may be multiple facets. For example, thereis an increased risk of crashes with Parkinson's disease's. ". The illness may involve problems ofmotor function, depression and impaired cognitive function. Rather than stating Parkinson's disease isdangerous for driving, it is vital to take a phenomenological approach. The depression and the motorfunction must be treated and cognitive function assessed and managed before any decisions aremade about fitness to drive.Any broader assessment of group risk due to illness will require careful scrutiny of the relevantliterature. The source of information is critical to decision-making. Did it come from a specialisedclinic or from the community? Was it a large study? What level of risk is implied for our patients? Astudy on diabetes, epilepsy and risk of crashes is a useful illustration of this". Epilepsy and diabetesare both illnesses that have been very clearly defined in many fitness-to-drive manuals, often withstringent licence restrictions and/or punitive insurance loadings. This large-scale community studydemonstrated that the increased risks were in fact quite small. It is probably no coincidence that theUnited Kingdom Driver and Vehicle licencing Authority has sub?equently relaxed the restrictions onboth diabetes and epilepsy". If a more selected group is studied, for example people over 65 in ahealth maintenance organisation, the relative risk for diabetes and crashes may be higher'''. As in anyapplication of the medical literature, the physician has to relate the sample population to his ownpractice.The Insurance Corporation of British Columbia's gives a wider driving population-based perspective ofrisk of driving and dementia'·, but many studies of driving and illness have originated fromspecialised clinics in cardiology, dementia or syncope. Studies of dementia and driving which aretaken retrospectively from dementia clinics tend to show a high risk, whereas those which are quasiprospectiveand which look at the early stages of dementia show a less pronounced pattern of risk.In the first two years of dementia the risk approximates to that of the general population". This is animportant finding because many physicians assume that dementia is an absolute contra - indicationto driving. In a UK study of dementia deterioration in driving skills was a phenomenon of the earlystage in 10% of the patients studied". A higher than expected number of tangles and plaques have65 Dubinsky, R.M., Gray, C, Husted, D., Busenbark, K., Vetere-Overfield, B., Wiltfong, D. et al. 'Driving in Parkinson'sdisease'. Neurology 1991; 41 (4):517-20.66 Lings, S., Dupont, E. 'Driving with Parkinson's disease. A controlled laboratory investigation'. Acta Neurol Scand1992;86 (1):33-9,67 Hansotia, P., Broste, S.K. 'The effect of epilepsy or diabetes mellitus on the risk of automobile accidents' N Engl J Med1991;324 (1):22-6.68 Medical Advisory Branch D. 'At a glance guide to the current medical standards of fitness to drive'. 1994 (November).69 Koepsell, T.D., Wolf, M.E., McCloskey, L, Buchner, D.M., Louie, D., Wagner, E.H., et al. 'Medical conditions and motorvehicle collision injuries in older adults'. J Amer Ger/atr Sac 1994;42: 695-700.70 Cooper, P.J., Tallman, K., Tuokko, H., Lynn Beattie, B. 'Vehicle crash involvement and cognitive deficit in older drivers'.Journal of Safety Research 1993; 24(1):9-17. .71 Drachman, D.A., Swearer, J.M. 'Driving and Alzheimer's disease: the risk of crashes' [published erratum appears inNeurology 1994 Jan;44(1):4). Neurology 1993;43(12):2448-56.72 O'Neill, D., Neubauer, K" Boyle, M" Gerrard, J., Surmon, D., Wilcock, G.K., 'Dementia and driving'. J R Sac Med 1992;85 (4):199-202.Assessment of Older People's Health and Social Care Needs and Preferences