An 89-year-old man is brought to the office by his daughter for a routine visit. The daughter says she is worried about her father's continued insistence on driving. The patient has had 2 minor accidents in the past 6 months, one in which he hit a mailbox while backing up in the dark and another in a supermarket parking lot where he backed into another car that was also backing out. The patient has not gotten lost while driving. Medical history includes mild cognitive impairment, hypertension, diminished hearing, osteoarthritis, and benign prostatic hyperplasia. Corrected vision is 20/40 in both eyes. Current medications include lisinopril, hydrochlorothiazide, and as-needed ibuprofen. He does not drink alcohol. Vital signs are normal. Physical examination shows decreased range of motion in his neck and mild pain in his hands and knees bilaterally. Mini-Mental State Examination is 23/30, 1 point lower than his score last year. Which of the following is the most appropriate next step in management of this patient?

Question

An 89-year-old man is brought to the office by his daughter for a routine visit.  The daughter says she is worried about her father's continued insistence on driving.  The patient has had 2 minor accidents in the past 6 months, one in which he hit a mailbox while backing up in the dark and another in a supermarket parking lot where he backed into another car that was also backing out.  The patient has not gotten lost while driving.  Medical history includes mild cognitive impairment, hypertension, diminished hearing, osteoarthritis, and benign prostatic hyperplasia.  Corrected vision is 20/40 in both eyes.  Current medications include lisinopril, hydrochlorothiazide, and as-needed ibuprofen.  He does not drink alcohol.  Vital signs are normal.  Physical examination shows decreased range of motion in his neck and mild pain in his hands and knees bilaterally.  Mini-Mental State Examination is 23/30, 1 point lower than his score last year.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Decisions regarding driving restrictions in elderly patients are complex, requiring a careful evaluation of the patient's functional capacity to drive and balancing patient autonomy with public safety. Patients often minimize or are unaware of their deficits and see cessation of driving as a loss of independence and self-esteem. Factors that can contribute to impaired driving in older patients include medical conditions (eg, cerebrovascular disease, movement disorders, arthritis, epilepsy), medication effects (eg, benzodiazepines, anticholinergics), delayed reaction time, hearing and vision loss, and cognitive impairment (eg, impaired spatial processing, executive dysfunction, impaired judgment). This patient insists on driving but has several risk factors for impaired driving, including history of recent accidents, decreased mobility (eg, decreased range of motion in his neck), and mild cognitive impairment. Although degree of cognitive impairment correlates to impaired driving, mild cognitive impairment is not in and of itself a reason to restrict driving since these patients may be able to drive safely for some period of time. Because it is difficult to adequately simulate driving performance in an office visit, the best approach is recommending an on-road driving evaluation, which can provide an objective assessment of the patient's functional driving ability. (Choices A and E) Although restricting driving to local trips and daylight hours can be considered, it is unclear whether this patient's impaired driving is limited to unfamiliar surroundings or nighttime driving. Further evaluation of his driving ability with an on-road driving test is the appropriate next step. (Choice C) It would be premature to recommend revoking this patient's license without conducting further evaluation of his functional driving ability. Legal statutes regarding a physician's authority to intervene in cases of concern for driving ability vary by state. (Choice D) Although neuropsychological testing can provide more detailed information regarding cognitive dysfunction, it would not adequately evaluate the patient's functional driving ability. Educational objective: Evaluating older drivers requires a careful evaluation of the patient's functional capacity to drive and balancing patient autonomy and confidentiality with public safety. In addition to the performance of a history and physical examination, an on-road driving evaluation is recommended in complex cases. References: Evaluation of the older driver. (http://www.ncbi.nlm.nih.gov/pubmed/28797372)

An 89-Year-Old Man Is Brought to the Office by His