The AMA says doctors should play a pivotal role in deciding whether the elderly remain behind the wheel.
By STEPHEN NOHLGREN
Published August 10, 2003
[Times photo: Ken Shimizu]
Karen kearney demonstrates a device that helps people with a weak grasp drive.
ST. PETERSBURG - Twelve numbers and 12 letters are sprinkled on a notebook-sized paper. Draw a line from No. 1 to the letter A; then from A to No. 2, and from No. 2 to the letter B. Alternate letters and numbers until they are all connected.
It's called a trailmaking test, and it could pass for a maze a restaurant might hand out on paper place mats to occupy bored toddlers.
The American Medical Association wants doctors to start using the test to help keep dangerous drivers off the road.
Experts on aging know doctors can play pivotal roles as patients balance declining driving skills with dignity and independence. People who shouldn't be driving often will ignore family members who beg them to stop, then forfeit their licenses because a doctor offers the same advice.
Other people end up driving longer because a doctor changes their medication or offers physical therapy. Even stroke victims who have lost use of an arm or leg sometimes can stay behind the wheel with the right help.
But such doctor-patient exchanges can be tense and embarrassing. To ease the way, the AMA has released guidelines that encourage doctors to make driving checkups as common as cholesterol counts or blood-pressure cuffs.
The guidelines, available on the AMA's Web site (see box), include written tests like the trailmaker. Other tests measure patients' peripheral vision or require them to walk quickly up and down a hallway. Just as important, the guidelines advise doctors how to talk frankly to their patients and, when all else fails, how to turn them in.
Florida recently passed laws requiring vision testing for drivers 79 years old and older. But those tests, conducted in the driver's license offices, measure only acuity - whether someone can distinguish letters on an eye chart. A more pressing problem is field of vision - whether a driver can react properly when another car, pedestrian or bicyclist approaches quickly from the side. Aging often narrows the field of vision.
The AMA guidelines include a more sophisticated test for measuring field of vision. A doctor and patient face each other, looking straight ahead. The doctor moves his or her hand off to the side, between them, until it is just at the edge of the doctor's vision. The patient must say how many fingers the doctor is holding up. If the doctor sees the fingers, but the patient doesn't, the patient's field of vision is narrowing.
Doctors also are urged to measure range of motion in the patient's neck. Being able to scan side to side to see blind spots is more important than 20/20 or even 20/70 vision, the AMA says. If arthritis is restricting the patient's movement, medication often can remedy that problem.
In another test, the patient must walk rapidly up and down a hallway, 10 feet in both directions. One study of drivers over 72 years old showed that people who could not navigate this course in seven seconds were twice as likely to experience a crash or traffic violation in the next year as people the same age who passed the test.
Few would call Nancy Denison elderly. She's 64 years old, runs an appraisal business with her husband and drives a red convertible. The front license plate reads, "My owner is a recycled teenager."
But according to one AMA self-test, Denison should have a conversation with her doctor about driving because she doesn't like driving at night and the headlight glare bothers her. She's far-sighted, so when the glare hits, she removes her bifocals to see.
But Denison said the recent outcry about older drivers ignores bad driving by people of all ages. Take the entrance to a Wal-Mart Supercenter in Pinellas Park.
"There are left-turn lanes going in and coming out. You watch those left-turn lanes when the light turns red. Six to eight cars go through that red light, holding up traffic coming in the other direction."
At Sunshine Senior Center in St. Petersburg on Friday afternoon, three women in their 70s reviewed the AMA's new checklist.
"I think if a lot of people were truthful they would check a lot of these," said Dorris Bell, 73, a St. Petersburg retiree who stopped driving when she developed cataracts four years ago.
"Yeah, but it doesn't have to do with being old," said Esther McDonald, 73, a retiree who lives in St. Petersburg and drives a 2000 Kia Sephia.
"What man could get away without checking that?" she said, pointing to the first question on the checklist, "I get lost while driving."
The AMA says older drivers are more conscientious than younger ones. They tend not to tailgate, speed or drive drunk. And they drive fewer miles and less at night.
But the AMA's question about headlight glare has Denison thinking: "Maybe I'll talk to an eye doctor about getting a different set of glasses for night-time driving."
That's the kind of re-evaluation the AMA hopes to provoke.
Doctors are urged to particularly watch for patients who walk slowly, struggle with directions or exhibit poor hygiene or other signs of depression. "How did you get here today?" can set off an inquiry about driving. The most important red flag, says the AMA, is when a patient's family members are expressing concern.
Serious problems don't always doom a patient to public transportation and rides from friends. Medication reactions could be slowing the patient down, as could hypothyroidism or vitamin deficiencies. These are treatable conditions.
A doctor might write a "prescription" for daylight driving only or for trips just to the store and church, coupled with frequent followup visits to make sure the patient hasn't deteriorated.
Stroke victims and others can be referred to a driving rehabilitation specialist. In the Tampa Bay area, that means Karen Kearney at Bayfront Medical Center. For $350 or so, she conducts 21/2- to three-hour assessments that include a road test in a 1992 Buick LeSabre equipped with dual brakes.
Sometimes a knob on the steering wheel can help people who lack strength. Extra-wide mirrors can help with blind spots. Someone whose right leg is deadened by stroke can get a left-foot accelerator or hand controls.
Kearney hopes the AMA guidelines will encourage more doctors to talk driving with their patients.
"It's a very touchy subject," she said. "Doctors hate to estrange their patients. It's difficult for people to give up that independence."
The AMA knows that this initiative is an uphill battle that will take time. In one survey, only one stroke victim in three reported that their doctors talked to them about whether they should continue driving.
Dr. Richard Orlan, a St. Petersburg geriatrician, said he discusses driving during every office visit. Among other things, state law requires doctors to report risky drivers to the Department of Highway Safety and Motor Vehicles, which will instruct the driver to get medical clearance or forfeit their license.
One common problem, the AMA says, is the "co-pilot syndrome." One spouse drives while the other gives instructions. A few states allow people to take their driving test using a co-pilot, but the AMA says that is never safe.
Orlan recalls a patient with dementia who couldn't remember where to go. Her husband's memory was fine, but he was blind. She would drive and describe their location while he told her where to turn.
Orlan turned her into the DMV.
"We have to identify things that put our patients at risk, whether it's illness or safety at home," he said. "Driving is no different."
- Times staff writer Kelly Virella contributed to this report.
For help with driving issues
For training and driving tips, plus a discount on car insurance: AARP Driver Safety Program 1-888-227-7669
To arrange an assessment of driving capacity: Getting in Gear, Area Agency on Aging (727) 570-9696 ext. 234
To report a driver who might be impaired: Department of Highway Safety and Motor Vehicles, Division of Driver Licenses, ATTN: Medical Review Section, Neil Kirkman Building, Tallahassee, FL 32399-0500
