Physical and Medical Impairments in Elderly Drivers

Transcription

1 Physical and Medical Impairments in Elderly Drivers Kam Hunter, MD PhD AzGS Summer Interdisciplinary Conference August 3 rd, 2011 Physiology Pertinent Systems Affected by Aging Visual Decreased central visual acuity Decreased peripheral vision (170 o 140 o over age 50) Decreased ability to accommodate Decreased contrast sensitivity Decreased visual processing Difficulties with both selective and divided attention Heightened sensitivity to glare Physiology Pertinent Systems Affected by Aging Psychomotor Increased reaction time Decreased muscle strength, flexibility, and endurance Grip strength declines after age 75 Decreased joint stability Restricted neck, shoulder, and wrist ROM Auditory decreased hearing

2 Prior history of motor vehicle crashes History of falls in past years Walking less than 1 block per day Male gender Living alone Risk Factors Failed UFOV (Useful Field of View Testing) Decreased performance on agility testing Impaired knee flexion Inability to reach above the shoulder Foot abnormalities Risk Factors Medical Conditions - Vision Visual Acuity Cataracts, retinopathy, keratoconus,, macular degeneration Visual Fields Glaucoma Hemianopia Monocular vision Ptosis Contrast Sensitivity Defective color vision Poor night vision / glare recovery Recommendations Medical Conditions - Vision Visual Acuity 20/40 or better Less than 20/70: On-road assessment Less than 20/100: No driving unless safe ability demonstrated in on-road assessment Keratoconus Only if correctable with hard contact lenses Diplopia No driving Visual Field Defect No consistent standard 100 degrees in many states Refer to Ophthalmolgy and/or Driver Rehabilitation Specialist Acquired monocularity Restrict driving for several weeks Contrast sensitivity (?) Defective color vision (?)

3 Risk Factors Medical Conditions - Cardiovascular Unstable coronary syndromes Sudden, unpredictable LOC Arrhythmias (e.g.: AFib with RVR, WPW, high- grade AV block) Structure or functional abnormalities CHF, HOCM, valvular disease Cardiac procedures ICD placement Recommendations Medical Conditions - Cardiovascular No driving if symptomatic at rest or behind the wheel CAD: May resume driving after weeks symptom- free Arrhythmias: May resume driving after mos. without symptoms Structural functional deficits No driving if syncope, presyncope, dyspnea at rest, or extreme fatigue Recommendations Medical Conditions - Cardiovascular Time to Resume Driving after Procedures: PTCA: 48 hrs. to one week Pacemaker insertion/revision: One week Cardiac surgery: weeks depending upon type of operation / recovery course ICD placement: 3-63 mos.(same as for arrhythmias)

4 Risk Factors Medical Conditions - Cerebrovascular Stroke TIA Subarachnoid hemorrhage Vascular malformation Syncope Sensory deficits Motor deficits Cognitive impairment Recommendations Medical Conditions - Cerebrovascular Stroke, TIA, subarachnoid hemorrhage If persistent deficits when stabilized, refer to Driver Rehabilitation Specialist Vascular malformation Neurosurgery evaluation recommended Syncope determined by cause Cardiac: As for arrhythmias Neurally mediated: Likelihood of recurrence? Infrequent, clear precipitating cause: No restriction Unpredictable symptoms despite treatment: Driving cessation Medical Conditions - Neurologic Brain tumor, closed head injury Similar recommendations as for stroke Migraine / recurrent HA syndromes No driving while symptomatic Movement disorders, MS, paraplegia/quadriplegia, Parkinson s, s, peripheral neuropathy Refer to Driver Rehabiliation Specialist

5 Medical Conditions - Neurologic Seizure Disorder Need 3 months seizure-free to resume driving Favorable modifiers (e.g.: medication changes, prolonged aura, purely nocturnal, specific cause) Unfavorable modifiers (e.g.: non-compliance, EtOH or drug abuse, structural brain lesion) Medical Conditions - Neurologic Narcolepsy No driving until controlled Tourette s syndrome Refer to Driver Rehabilitation Specialist Vertigo Acute: Driving cessation until fully resolved Chronic: On-road assessment with Driver Rehabilitation Specialist Medical Conditions - Psychiatric Depression, bipolar disorder Anxiety Psychotic illness Personality disorders ADHD Substance abuse Should not drive while experiencing significant symptomatic impairment, including suicidality Treatment for ADHD? No driving while intoxicated

6 Medical Conditions Metabolic Diabetes mellitus Hypoglycemia unawareness Extensive hypo/hyperglycemic attacks no driving until attack-free for 3 months Hypo- and hyperthyroidism Should refrain from driving if experiencing significant symptoms (e.g.: fatigue, anxiety) until treated and symptoms controlled Medical Conditions Musculoskeletal Arthritis Foot abnormalities Loss of (use of) extremities Muscle disorders Orthopedic surgeries Assess and treat limitations in ROM, strength, function Refer to Driving Rehabilitation Specialist Often week restriction after surgeries Medical Conditions Pulmonary Asthma No restrictions if controlled COPD No restrictions if controlled No driving if dyspnea at rest, excessive fatigue, or cognitive impairment Use O2 while driving Sleep apnea No driving if severe sleep apnea or hx of falling asleep at while, until condition treated

7 Medical Conditions Miscellaneous Vascular disease Aneurysm No restrictions unless imminent risk of rupture DVT Resume driving when INR therapeutic Chronic renal disease No restriction unless significant symptoms Surgery/anesthesia Recommendations vary depending upon type Risk Factors PDI Medications and Substances Anticholinergics Antihistamines Anticonvulsants Antiemetics Antihypertensives Antiparkinsonians NSAIDs Muscle relaxants Benzodiazepines Antidepressants esp. Tricylics Antipsychotics Narcotics Stimulants Alcohol Tips / Recommendations PDI Medications and Substances Crash risk increases when multiple PDI drugs prescribed Attempt to use safest class of medications Counsel patient regarding potential side effects First few dosages in a safe environment with no driving Subjective impairment does not always correlate

8 PMH: Ischemic heart disease Cerebral vascular disease Movement disorders DM Epilepsy Sleep disorders Arthritis Evaluation History Visual Problems Macular degeneration Glaucoma Cataracts Diabetic retinopathy Medications Driving History Social History Social Support Evaluation Physical No single, easy-to to-use battery of tests has been developed that predicts crash risk AMA recommends use of ADReS Assessment of Driving Related Skills 1) Vision 2) Cognition 3) Somatosensory Function Evaluation - Physical Strength at shoulders, wrists, hands, hips, and ankles 35 lbs. in dominant hand ROM of neck, shoulders, wrists, fingers, ankles Get Up and Go test or Rapid Pace Walk Functional reach test Mobility

9 Evaluation - Physical Visual acuity 20/40 in better eye Peripheral vision 120 degrees horizontal Fundoscopy Useful Field of View Test Hearing whisper test Sensory Treatment Medical interventions shown to reduce crash risk: Treating obstructive sleep apnea Performing cataract surgery Discontinuing a benzodiazepine