For most older adults, driving cessation is an inevitability, since research suggests that both male and female drivers aged 70-74 years can expect to outlive their safe driving ability by an estimated seven and ten years, respectively. (Betz, 2017)  Primary care providers often find the topic of driving cessation or “retirement” for older patients difficult to discuss. Since there is not specific age at which people should stop driving, the clinician needs to trust assessments of physical and cognitive capabilities of the older driver, as well as concerns communicated by family members or caregivers.  The clinician’s responsibility to public safety often conflicts with a competing commitment to maintain patients’ trust, as well as their patients’ autonomy and self-esteem.

The Perspective of the Older Adult

A recent survey found that older adults agreed that physicians and family members should help make driving decisions; in fact, their input is cited as the two most common reasons for driving cessation by an older driver. Studies indicate that patients want discussions about fitness for driving in the healthcare setting, either by a physician, nurse, or other member of the clinical team. In addition, they reported that they would consider a driving evaluation if recommended by their physician. (Betz, 2012).  One study reported a 45 percent reduction in the annual rate of crash injury in medically unfit drivers after they received warnings from their physician, thus demonstrating benefits of clinician intervention to both patient care and public safety. (Chichuri, 2016.)

If driving retirement is not well managed, older adults can suffer negative physical and emotional consequences, particularly in terms of increased isolation and lack of control in their lives. For example, five recent studies indicate that driving cessation nearly doubles the risk of greater depressive symptoms in older adults. Craik)

The clinician can serve as an advocate for the patient with a well-planned and compassionate discussion that can offer options, alleviate stress, and result in solutions amenable to the drivers and those individuals supporting the older driver.

Start the Conversation Early

A clinician can initiate a discussion about driving before cessation is required. “Planting the seed” about safe driving in an older adult’s mind years before the onset of any problems can be accomplished by asking simple questions, such as “Did you drive here today,” and “Are you have any challenges driving recently that we could address today?” Making driving a routine topic in an older patients’ annual wellness visits paves the way for any later discussions about safe driving and possible cessation. This type of discussion will ease any discomfort and surprise later when “giving up the keys” becomes a topic.

Primary care providers can recommend tools to support the older driver in controlling decision-making for driving reduction or cessation. The ChORUS Older Driver Transportation Planning Tool provides individuals a roadmap to allow for safe driving as long as possible and to plan transportation options as the capacity for safely diving diminishes. Using this tool, individuals identify their transportation needs, explore options in their community, and establish alternate plans so that when it is time to give up their keys they are prepared.

Another valuable tool is the Driver Planning Agreement (DPA) – sometime referred to as an Advanced Driving Directive. This form, analogous to those related to end-of-life care, serves as a facilitator for discussing and planning driver retirement. This directive can be reviewed and signed by the older adult and the individuals that help ensure the safety of the driver and others while maintaining mobility and independence. Older drivers identify those who can help them decide when to stop driving—a physician, family members, caregiver, or friend—and thus maintain control of decision making to reduce or stop driving. (Betz, Medscape, p. 2.)

Prepare for the Talk About “Giving up the Keys”

It is important that primary care providers are caring, respectful, and non-threatening during this discussion, offering an understanding and concern for the driver’s situation, while maintaining the patient’s independence and self-esteem. There are several steps a member of the clinical team who meets with the older driver can take to assure a positive outcome for all participants.

  • Ask the patient to bring a family member or caregiver to the visit who can provide additional information about the driver’s current situation and who can receive from the clinician up-to-date health information. However, it is important to remind them that, by law, primary care providers cannot share medical information without a patient’s permission, unless they have medical power of attorney or the older patient has signed a HIPAA release.
  • Provide the patient and others at the appointment with resources related to older adult driving safety and retirement. The ChORUS Older Driver Resources Handout offers a number of websites for individuals to start the process. This handout can also be tailored to include specific resources in your community.
  • Become familiar with transportation options in your community and ask family members or caregivers to do the same--from public transportation to rides from family or friends. Some practical questions include: What transportation alternatives exist? How can they be accessed? How much do they cost? Are the older drivers comfortable with app-based services, such as Uber or Lyft, if they are available in their communities? Are city or county-sponsored free vans with lifts available for medical appointments or shopping? Are there volunteer organizations in your community that provide drivers for older adults who can no longer drive? Given a clinician’s limited time for appointments, this task is one that can be recommended to family members and caregivers.
  • Give the patient a “Do Not Drive” prescription to provide a tangible reminder of your recommendation.
  • Explain to the older patient and family members or caregivers that primary care providers in some states may be required to report patients whom they consider unsafe, based on clinical evaluation. If the clinician needs to report, they should inform the older adult about documents that the older adult may receive from the licensing agency.

Addressing the Resistant Older Patient

If the older patient is resistant to becoming a retired driver, a clinician can counsel concerned family members about information on safe driving assistance programs and licensing laws of each state by directing them to the ChORUS website and visiting My State Info for more information. Each state has a process for reporting a potentially unsafe driver to its licensing office or department of motor vehicles. Law enforcement officers and physicians represent the majority of those submitting reports but concerned family members and citizens also can do so.

If a state agency finds a complaint reasonable and credible, it may ask the reported driver to submit additional information, which could be used to help determine if a screening or assessment is justified. Some states keep the person submitting the report anonymous, while others will identify to the older driver the name of the person issuing a complaint.

Next Steps

After having the discussion with the patient, primary care providers should:

  • Prepare and submit a report to the state licensing agency if required. Visit My State Info to identify reporting requirements and state points of contacts.
  • Document the discussion in the patient’s medical record.
  • If the older adult has agreed to driver retirement, the clinician should follow up in future visits to check for adverse effects, such as depression, decreased cognitive abilities, or other negative impacts and recommend treatment.