Ep45: Medical Fitness to Drive
Ep45: Medical Fitness to Drive
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Australia and NZ are made up of sprawling cities and far-flung towns, and driving is often viewed as a fundamental freedom. It can be hard for clinicians to challenge that freedom with patients who they consider unfit to drive safely. And harder still to deal with the consequences if a patient does have a crash.
Clinicians are drawn into the question of driving fitness in two main ways. The more clearcut is when a patient presents with a medical assessment form. It’s the Driver Licencing Authority in each state which ultimately issues the driving permits and may require the recommendation of a medical professional.
The other way in which health professionals become involved is when they detect a new or worsening condition in a patient who is already licenced. Clinicians are expected to warn their patients off driving, and to potentially report them to the DLA if this advice isn’t being heeded.
There are diagnoses that should raise red flags for clinicians of all stripes. In this podcast we speak to a GP, a neurologist and an occupational therapist about how to discuss cessation from driving with patients, and where responsibilities lie in reporting to the Driver Licencing Authority.
Dr Genevieve Yates FRACGP (Principal Medical Educator RACGP, MDA National’s Education Services Advisory Group, Black Dog Institute)
Prof Roy Beran FRCP FAFPHM FRACP FRACGP FACLM (UNSW, Griffith University, Liverpool Hospital)
Dr Marilyn Di Stefano (Senior Policy Officer VicRoads, La Trobe University)
Serge Zandegu (Manager of VicRoads Medical Review)
National Guideline Documents
New Zealand Transport Agency
: Medical Aspects of Fitness to Drive
: Assessing Fitness To Drive
QLD Department of Transport and Roads (medical certificate, health assessment notification/ online)
NSW Roads and Maritime Service (assessment and notification forms)
VIC VicRoads (medical certificate, reporting, AMA)
TAS Transport (medical assessment, notification)
SA Driving and Transport (certificate private, commercial, self, report 13 10 84)
NT Transport (assessment, notification)
WA Department of Transport (assessment, reporting online)
ACT Access Canberra (assessment, commercial)
Functional Changes and Driving Performance in Older Drivers: Assessment and Interventions
Evaluation and management of driving risk in dementia
Are older drivers’ on-road driving error rates related to functional performance and/or self-reported driving experiences?
[di Stefano, Accident Analysis & Prevention]
Issues relating to the efficacy of mandatory medical reporting of drivers with medical and other fitness to drive relevant conditions by medical and other health practitioners
[Journal of Transport & Health]
Dementia and driving: An approach for general practice
Are medical reports on fitness to drive trustworthy?
[BMJ Postgraduate Medical Journal]
Driving and dementia: Efficient approach to driving safety concerns in family practice
[Canadian Family Physician]
Driving assessment for people with dementia
[Canadian Family Physician]
Trail Making Tests
[Regional Geriatric Program of Eastern Ontario]
When should the driver with a history of substance misuse be allowed to return to the wheel? A review of the substance misuse section of the Australian national guidelines
Clinal Communiqué – case studies and expert commentary
[Victorian Institute of Forensic Medicine]
Opinions, attitudes and practices of Australian neurologists with regard to epilepsy and driving
[Beran 2007, IMJ]
Don’t just sign on the dotted line
[Dr Genevieve Yates]
Doctors shouldn’t be forced to dob in unfit drivers
VicRoads report back to the Coroners Court
Usefulness of Austroads’ fitness-to-drive guidelines: lessons from the Gillett case [Beran 2009, MJA]
Medical certificates attesting fitness to drive [Beran 2017, IMJ]
Written and produced by Mic Cavazzini. Recording assistance in Melbourne from Sam Loy of Human/Ordinary. Music courtesy of Free Music Archive; ‘John Stockton Slow Drag’ and ‘What True Self? Feels Bogus, Let’s Watch Jason X’ by Chris Zabriskie, ‘Noir’ by Daniel James Dolby, ‘Hélice’ by Monplaisir,. Image courtesy of iStock.
Editorial feedback for this episode was provided by members of the RACP’s podcast editorial group Atif Slim, Adrianus Thio, Alan Ngo, Nele Legge, Michael Herd, Stella Sarlos, Seema Radhakrishnan, Li-Zsa Tan, Rebecca Grainger, Lisa Mounsey, Angela Chen, Ilana Ginges, Leah Krischock, Adrienne Torda, Rhiannon Mellor, Andrew Whyte, Oscar Russell, Jenae Valk, Philip Gaughwin, Andrea Knox and Paul Jauncey. Thanks also to RACP Fellows Natasha Cook and Bruce Hocking for their input.
GENEVIEVE YATES: So my partner was on holidays visiting some friends in Los Angeles in 2015. I was back here in Australia and I was pregnant at the time.
MIC CAVAZZINI: That’s general practitioner Dr Genevieve Yates from Ballina, New South Wales. She's also an educator with the RACGP and the Black Dog Institute.
GENEVIEVE YATES: And it was the day after his 39th birthday - a young, very healthy doctor - and he went for his usual morning jog and he was hit by an elderly driver. He was just crossing at an intersection, legally, on the green ‘walk’ sign and the driver says he didn’t see him initially, then when eventually he did see him, he mistook the accelerator for the brake pedal and plowed straight into my partner. And he died of his injuries a few hours later in hospital.
MIC CAVAZZINI: Age-related decline is just one of many conditions that can impair fitness to drive and there are just as many reasons that doctors often don’t feel comfortable discussing the issue with their patients.
GENEVIEVE YATES: When this came to light - the driver was a man whose family had been very concerned about his ability to drive for some time and had expressed those concerns to the family doctor. But the family doctor had signed off on his fitness to drive only a few weeks prior to the crash. So when that happened in 2015, initially I was of course in extreme shock. But I then became really angry, and then the anger really lit a fire in me to try and do something about it. At least that makes that senseless tragedy that happened to me just that little bit less senseless.
MIC CAVAZZINI: Australia and NZ are made up of sprawling cities and far-flung towns, and driving is often viewed as a fundamental freedom. It can be hard for clinicians to challenge that freedom with patients who might be unfit to drive safely. And harder still to deal with the consequences if a patient does have a crash.
Medical fitness to drive is the theme of this episode of Pomegranate Health. I’m Mic Cavazzini, from the Royal Australasian College of Physicians. For clinicians of all stripes there are diagnoses that should raise red flags, like seizures and diabetes. These are listed online in the national guidelines of Austroads and the New Zealand Transport Agency. These documents also list the driving restrictions that patients must observe, or those cases where suspension is appropriate.
We’ll hear about this later from a neurologist and an occupational therapist working for the Victorian licencing authority. But first, Genevieve Yates explains why fitness to drive is not something that comes up routinely in medical consultations.
GENEVIEVE YATES: Until this tragedy happened in 2015, essentially it wasn’t really part - it wasn’t on my radar. I knew it was important, but I didn’t really go the extra mile. So often when we’re treating medical conditions, unless someone comes in with a form or asks specifically about driving, for many of us, driving isn’t in the forefront of our minds—we’re too busy thinking about how to treat, diagnose, et cetera our patients. And so I think the first barrier is to actually think about driving fitness.
MIC CAVAZZINI: Yeah. So with the podcast editorial group, we chatted about this problem. Many members said that the question of assessing fitness to drive had been mentioned during their basic training, but they didn’t feel up to speed with the requirements and the paperwork.
GENEVIEVE YATES: Absolutely. The other complicating factor in Australia is that although the standards are national, the way the standards are actually applied as far as what forms to fill out and where the age-based requirements kick in, they're all different in the state-based jurisdictions. Even the reporting requirements differ quite a lot around different states and territories. I think it is a lack of awareness and lack of confidence in being able to apply the standards.
The second barrier is the fact that as physicians we are very much primed to doing the best by our patients. And particularly when we’re looking at those in the older age group, loss of driving can lead to loss of independence and can have significant implications on people’s ability to live in the community. That’s particularly the case for rural and regional areas where public transport options are limited or not available at all in a cost-effective way.
I think this goes a bit against the grain - we really have to think in a public health way about this topic, not just about the individual patient. Sometimes the greater public good needs to outweigh the individual’s preferences, or even what is best for that particular individual.
MIC CAVAZZINI: You're a GP in a regional area and you must encounter this every day. How touchy a subject is it?
GENEVIEVE YATES: Assessing fitness to drive, or just the ability to drive, is a very touchy subject. As I often say, driving is a privilege, not a right. And that’s a type of attitude which I think people don’t really appreciate and is really important to get across.
I think the other sort of barrier that doctors need to be aware of - and this is particularly about the fragmentation of care between GPs and specialist physicians. Sometimes GPs also just assume that if the relevant sub-specialist has not mentioned driving fitness that it must be okay.
The other problem that can come across is while a sub-specialist—take, for example, a cardiologist—they may say yes, the person is fit to drive, thinking only about their heart condition without appreciating that there are many other factors that may mean the person is not fit to drive. Then it makes it very difficult for the GP to actually say no, you're not really fit to drive because of other reasons.
So it would be very helpful to general practitioners if a specialist is asked to comment on the assessing fitness to drive, it’s made very clear that they are commenting within their scope of practice, and when talking to the patient, saying, “I can't comment about your overall fitness but I can say as far as your heart goes, you are okay as far as your heart goes.”
MIC CAVAZZINI: But is there any—this often starts with the GP, but as you said, you're hearing from the cardiologist, or the diabetician, or the geriatrician—is there any clarity as to whose job it is to make the final call about driving fitness, Or is there some diffusion of responsibility?
GENEVIEVE YATES: That is one of the problems. It very much depends on what condition is being described. Quite a lot of the standards will actually say it needs to be signed off by neurologists, or by a consultant cardiologist, or endocrinologist. So they actually say that in the guidelines. They're the relatively easy ones because there are quite clear standards. By far the more complicated ones are when there is multimorbidity, or sometimes things like around alcohol and drug use. Those kind of areas are much more difficult to try and work out is this person fit or not and whose responsibility it is.
MIC CAVAZZINI: Clinicians are drawn into the question of driving fitness in two main ways. The more clearcut is when a patient comes to you with a form to sign. It’s the Driver Licencing Authority in each state or DLA which ultimately issues the driving permits, but for some drivers they won’t do so until they have the recommendation of a medical professional. This prerequisite might be triggered automatically based on the driver’s age, or their application for a commercial licence to drive trucks or buses.
The other way in which health professionals become involved is when they detect a new or worsening condition in a patient who is already licenced- who may well intend to drive home from the consultation. This results in an awkward situation where clinicians have to warn their patients off driving, and potentially to report them to the DLA. How clearly marked out is this responsibility? And whose fault is it if someone does have a car crash while impaired by a medical condition or therapeutic drugs?
These are questions being asked by the Victorian DLA after a cluster of six fatal road crashes between 2016 and 2018 involving medically unfit drivers. Only one of the six had reported their condition to the VicRoads Medical Review Panel. Coronial investigations found that few of the drivers had even been advised to self-report by their treating clinicians. In one crash, the 88 year old driver had been diagnosed with Alzheimer’s six years prior, but when a treating psychiatrist was asked by the court if driving had ever been discussed, he said it had never entered his mind that the patient would still be doing so. The man’s family, and the Coroner, advocated for a mandatory reporting law that would compel doctors to notify the DLA of patients they considered medically unfit to hold a licence.
VicRoads assessed the feasibility of this in a working group with representatives from the Colleges of psychiatry, ophthalmology and physicians. Two members of the group were Serge Zandegu, the manager of VicRoads medical review, and Dr Marilyn Di Stefano, an occupational therapist with VicRoads whose research is focused on assessing older drivers.
Before getting into mandatory reporting, I asked them about the discomfort that many clinicians express at being the gatekeeper’s of someone’s driving freedom. In Victoria, this responsibility can be referred off to an expert review panel under the roof of the Institute of Forensic Medicine.
SERGE ZANDEGU: Yes, we have a formal structure in Victoria and it involves a number of levels. There's the medical review department that assesses a case by case basis and then it can refer to an external medical review panel that includes specialist transport physicians. Panel members are provided with records around the person’s driving status, driving needs and medical history. And they in turn can then refer to an expert review panel that involves neurologists, and ophthalmologists for the more complex cases. Obviously not everyone goes through every stage.
MIC CAVAZZINI: In a 2007 news article I read that this kind of model was being considered by national bodies. But there are, of course, questions about funding and bringing jurisdictions together. Do you think that the Victorian example has demonstrated the successful outcomes and the economic case?
SERGE ZANDEGU: The panel has been in existence for quite a while and we review about 85 000 cases a year.
MIC CAVAZZINI: So, yeah, it definitely has capacity then.
SERGE ZANDEGU: Well that’s right. That formal structure that we talked about allows us to process cases as efficiently as possible and it helps us get consistency. It’s worked quite effectively in Victoria.
MIC CAVAZZINI: Let’s move on to the question of reporting and the questions of liability around that. I'm going to preface this by acknowledging that the Austroads guidelines do put the driver themselves first and foremost with regards to responsibility. But in a consultation where a new or a worsening condition is detected that could impair driving, the role of the doctors is to advise patients to stay off the road for a while and, if serious enough, to self-report to the licensing authorities. But let’s say I do have an accident after my doctor told me not to drive. Is it important for the doctor to have a record that this conversation took place or that they advised me in writing?
MARILYN DI STEFANO: Well we would recommend that all health professionals keep a record of any advice that they offer. It’s obviously easy to forget what you advise a patient on a day.
MIC CAVAZZINI: Now the tricky part comes when you think - if you think a patient isn’t going to heed your warnings and may be continuing to drive. You know, there are some states - South Australia and the Northern Territory - that have a mandatory reporting law. As soon as a condition is diagnosed, that is reported to the licensing authorities. But in the absence of this, the guideline documents end up with some wishy-washy language. Austroads says you should consider notifying a DLA. Queensland Transport writes “you are encouraged to notify us”. In New South Wales “you may feel obliged”. Does this create an awkward situation where a clinician is in a position of also having to assess the patient’s honesty? And it doesn’t really make the legal responsibility clear.
MARILYN DI STEFANO: I guess the main concern around black and white guidelines is that it’s very difficult to record every potential set of circumstances. There has to be some degree of consideration of individual factors, that have escalated the person’s anxiety, other issues around employment and financial circumstances. Then there has to come a point where the doctor has to make the call around what risk that driver may have, not just for the public but also for themselves.
MIC CAVAZZINI: Yeah, so these are human relationships and you need room for some qualitative assessment, I guess. I should say that this line of questioning isn’t entirely theoretical. The Head of Clinical Forensic Medicine Services in Victoria, Associate Professor Morris Odell, has written, “to our knowledge, no Australian doctor has faced criminal charges over certifying fitness to drive inappropriately”. Doctors sometimes worry about the confidentiality that hangs all over this, but it is spelled out in the Austroads document that health professionals who report patients without the patient’s consent but in good faith are protected from civil and criminal liability.
SERGE ZANDEGU: Yeah. We find that’s an important statement for the doctors to understand. Particularly when they're talking about patients with cognitive impairments where the advice that they're giving may not always be understood.
MIC CAVAZZINI: Now VicRoads has been considering a move towards mandatory reporting following a 2017 coronial report. Can you describe the report and the cases behind it?
MARILYN DI STEFANO: So you're right. We commissioned a Monash University systematic literature review to try to understand what the evidence base was for mandatory medical reporting. We identified that whilst the research showed that there was an increase in health professional awareness around fitness to drive in those jurisdictions where there was mandatory medical reporting, there were also significant impacts on the doctor-patient relationship. For example, verbal and physical abuse of doctors when they tried to exercise their obligations. There was also an identification of instances where patients are not seeking appropriate treatment for fear of being reported and/or licence loss. So overall, the findings were inconclusive around whether there was any value in terms of increasing or, in fact, reducing crashes.
MIC CAVAZZINI: And the ball isn’t just in the health professionals’ court. Victoria also has another pathway for reporting. There’s also exists an anonymous reporting phone line or web service where family members or the public can lodge a report about someone they consider to be a danger on the road. Have you heard from health professionals whether this takes some of the pressure off? And is this service widely used?
SERGE ZANDEGU: So we do have a self or community reporting model and, yes, we do receive referrals from certainly health professionals but also from Victoria Police, from third parties, including family and friends, and members of the public. And it seems to work quite well, we get a lot of referrals through the community reporting model.
It’s probably worth noting the majority of people that we see through the medical review process retain their licence. There are some that retain their licence and we actually no longer need to follow them up. The vast majority we have conditions, or we follow them up. And there's only a small percentage that actually lose their licence for being assessed as not fit. It’s about 12 per cent of cases that we review result in a suspension or cancellation of their licence. So it’s not a foregone conclusion. The majority of people retain their licence.
MIC CAVAZZINI: There are scores of medical diagnoses detailed in the national guidelines that can affect driving ability—including those that impair cognitive function, coordination, haemodynamic stability or even the mobility to operate the controls and turn one’s neck. Most in-patients will have at least one such issue to be considered .
A common example is diabetes which is implicated in many ways with driving fitness. Patients should be advised to test blood sugar before getting behind the wheel, particularly as those with hypoglycaemic unawareness can black out without the usual warning signs. Also, a common comorbidity of diabetes is sleep apnoea which can severely impact daytime alertness of drivers.
Finally, chronic patients who develop end-stage kidney disease can experience lethargy, low blood pressure and cognitive impairment. On top of that, dialysis treatment itself adds cardiovascular stress. In a 2010 survey of 186 chronic dialysis patients in Wisconsin, over half of patients were still driving though there were reports of dizziness and fainting after treatment. Tellingly 40 percent had been involved in collisions after starting therapy.
But patients may need to make three visits a week to the dialysis unit, which is taxing for families who step in to do the driving. Patient transport services or home dialysis might be an option for some patients with the economic means, but what this example highlights is the systems pressures that lead a patient to drive.
To skim over a few of the other common impairments to driving fitness I spoke to neurologist, sleep physician and medicolegal academic, Professor Roy Beran. When not practicing at Liverpool hospital, he has a small private clinic on the top floor of a windblown office block where this recording took place. Professor Beran has several books to his name with titles such as “Epilepsy and Driving” “Epilepsy and the law.” He starts by explaining the non-driving period required for patients with this condition.
ROY BERAN: Well the rule of thumb is that somebody who’s known to have epilepsy has to be seizure free for a year. They have to be compliant with treatment. If a patient is newly diagnosed and they're treated appropriately, they can drive in half a year. You’ve also got the issue then - the person who’s got well controlled epilepsy and wants to come off their medication. They’ve still got to not drive a) while they're coming off the medication; and b) for a period after they’ve come off the medication. Now what I do in that situation is I’ll do a provoked EEG before I take them off and once they're off. But I’ll still monitor them for a year afterwards, even though that may not be necessary.
Where we have more difficulty is not everybody who comes to the doctor having had a collapse - we don’t know if it’s , or seizure. If it’s a vasovagal attack, they're allowed to drive with a vasovagal attack. The problem being we may not be certain in our own mind that it is such. And what I do in those situations is I keep the patient under observation for a year. They don’t come every week. They come, you know, maybe two or three times in that year. But it’s enough to keep a handle on what's going on. And I know if they don’t come back, that’s saying they're not following advice and they have probably not been honest with me in the first place.
MIC CAVAZZINI: The other big one that perhaps isn’t - well that’s my question, really. So sleep apnoea is common in anyone with a BMI over 40. Excessive sleepiness can be a huge - - -
ROY BERAN: BMI a lot lower.
MIC CAVAZZINI: Even lower. So sleep apnoea, is that something that probably doesn’t get picked up as often as it should?
ROY BERAN: Yes, it is a big issue. And what's more, people don’t realise epilepsy and sleep apnoea go hand in glove. Such that if you control the sleep apnoea, you may well control the epilepsy. I have another experience that a lot of my elderly patients with Parkinson’s disease, the majority have sleep apnoea. If you treat the sleep apnoea, they function better. But I will bet a pound to a peanut that most people with Parkinson’s disease have never had a polysomnograph.
It’s interesting - the other issue is even a commercial driver or an airline pilot can fly if they're using the CPAP. But how do you know they're using the equipment unless you monitor it and see the print out? Because all these machines have a print out that tells you whether they’ve used it for four hours a night and for how many nights out of the period under scrutiny.
MIC CAVAZZINI: I want to just mention in passing mental health disorders. There's some evidence that psychiatric disorders are more prevalent in car crash victims than for the general, but who knows what this means - whether it’s psychiatric disorder or whether it’s dementia, can you assess things like judgement or impulsivity or things like that?
ROY BERAN: If you’ve been around as long as I have you kind of get a sixth sense for those sort of things. I mean your consultation with a patient doesn’t start when they sit down. It starts when you say Mr or Mrs Jones, it’s your turn. You know, if you ask a person a question and they give you a straight answer, you can go to the next question. If you ask a person a question and they obfuscate, you know there's something there as a red flag.
MIC CAVAZZINI: So you’ve written in the IMJ and the MJA about the legal repercussions of medical assessments and reporting. You made some comments that the guidelines didn’t seem watertight, or if they weren’t being regarded by the court, they weren’t much help to clinicians?
ROY BERAN: The protection is actually in favour of reporting the patient. The bottom line is, the doctor who reports in good faith is protected against litigation.
MIC CAVAZZINI: And you’ve published the results of a survey of 236 neurologists which shows that around 60 percent of them rarely or never went through with reporting. Behind this there was a feeling that clinicians don’t like being a gatekeeper of a person’s freedom or their livelihood.
ROY BERAN: Very much so, and as I say, that’s why I have quite a number of colleagues who use me as the reporteur…
MIC CAVAZZINI: You’re the bad cop.
ROY BERAN: I’m the bad cop, which means I also get some terrible ratings on Google, but, I also go the other way where I think it is inappropriate to stop someone driving. There’s a few of us that the RMS knows and what we say usually carries weight with them, because they know we’ll argue both ways. And I actually often send a copy of the letter I’m sending to the GP to the RMS, but I do it in front of the patient. I also explain to the patient that if I’ve let them drive, and if something goes amiss—which it still can—but if the RMS has been fully appraised of what’s happening then they have some modicum of protection themselves. And I think that’s the safest way to go.
MIC CAVAZZINI: As we’ve heard, each medical condition and intervention discussed in the guideline documents comes with a specific non-driving period. Note that these periods are usually much more conservative for licences to drive trucks or buses. For example after coronary bypass surgery a person should not drive for at least four weeks on private vehicle licence, but for a commercial and heavy vehicle licence it’s three months. It’s best for a clinician to record in writing the date when a patient would be permitted to take they wheel again.
One should also be explicit about the side-effects of any prescription medications like dizziness or sedation. You can’t assume that patients will take note of the package warnings.
And those who have some history of abuse or misuse of drugs pose other questions when assessing driving risk. First, their licence can be made conditional on periodic assessment of their remission. But even those who have quit for good, can be permanently impaired. For example, long-term alcohol abuse is associated with cerebellar damage that may affect coordination for life.
Now to older drivers. Of all crashes associated with medical impairment, age-related factors contributed to about 20 percent, according to New Zealand police data from the period 2003 to 2007. When viewed as crashes per kilometre, this cohort is the most risky after young inexperienced drivers. And it’s a cohort that’s increasing in number.
In 2017, people over the age of sixty made up 1 in 4 drivers on Victorian Roads, but by 2030, it’s predicted to be one in three. Of course, older people are making up a greater proportion of the society all the time as population health has improved. And society has ever increasing expectations of independence- though this is a double-edged sword. Now that families and social networks are more scattered, the elderly can be left isolated unless they have the ability to travel.
We know how much social interaction can contribute to psychological wellbeing of older people, but how to you weigh that against the risk of continuing to drive? As well as vision and hearing, age-related decline can affect cognitive domains like reaction time and attentional load capacity. These domains aren’t as easy to quantify objectively as blood pressure or seizures frequency. But Marilyn di Stefano says there are appropriate psychometric tools available to generalists as well as geriatricians.
MARILYN DI STEFANO: So in the 2016 Assessing Fitness to Drive Guidelines, there are a range of different standardised tools that can be used by clinicians in their offices. For example, for visual acuity there's the standard Snellen chart. There are different tools used to assess cognition, such as the Min-Mental State Examination. And sleep physicians would also be quite familiar with the Epworth Sleepiness Scale.
MIC CAVAZZINI: And Marilyn, you published a study looking at the correlation between assessment of abilities and how this correlates to driving performance. What did that study uncover?
MARILYN DI STEFANO: Myself and several researchers from Monash Uni Accident Research Centre have been studying, in a longitudinal fashion, a group of healthy older drivers to understand how their driving needs, and performance, and behaviour, and perceptions, and functional status changes as they get older. So in this particular study, there was an increase in error rates made during the driving performance measures.
MIC CAVAZZINI: Yeah. That’s interesting and I think for the time being, across Australia and New Zealand, in the national guidelines, people above the age of 75 need to renew their licence every year to maintain a private driver’s licence. In New South Wales, this even involves a medical assessment from that age. Some people have suggested that elderly drivers be required to carry out driving tests or simulation tests to remain licensed after a certain age. Would that iron out the measurement issues?
MARILYN DI STEFANO: So in Victoria, we don’t have any population based functional assessments because there's so much heterogeneity across older age groups. On-road tests do have strengths and weaknesses. If you're talking about occupational therapy on-road tests, then they are a much more comprehensive overall assessment of a person’s functional ability.
MIC CAVAZZINI: So the OT isn’t just looking to see if you can reverse park. But are they also explicitly testing reaction time and things like that?
MARILYN DI STEFANO: That’s right. They are considering all of the aspects of a the person’s performance. Not just with a view to determine pass or fail, but also to look at well how can the driver be assisted to rehabilitate? So this is where we start moving into the area of vehicle modifications and training techniques to optimise somebody’s functional ability, to help them be more independent and safe when they drive.
MIC CAVAZZINI: Yeah, and I think that’s a great lens to view this. It’s not just a punitive process but a constructive one for many people. Now I've read that it’s about $600 for such a test and it’s not covered by Medicare or the hospital so doctors are sometimes reluctant to refer to an occupational assessment.
MARILYN DI STEFANO: Whether or not a person has to pay that full amount will depend on whether they're compensable. Of course now with the National Disability Insurance Scheme we’re seeing more and more people under the age of 65 having access to OT assessments for the purpose of improving their independence. What I have personally experienced as a previous driving assessor myself is that most people don’t understand, until they actually go through the process, the amount of attention and customisation, if you like, that they can gain from having the advice of an OT.
MIC CAVAZZINI: And there are other ways to try and get people back on the road as well. This might be through a conditional licence. Can you give me an example of conditions that might be attached to a person’s licence?
SERGE ZANDEGU: We have the opportunity to apply a variety of conditions, but the most common conditions are things like corrective lenses or even vehicle types - automatic transmission. Area or radius restriction - local area driving only. No night driving, or specific vehicle modifications that Marilyn was talking about.
MARILYN DI STEFANO: The local area licence condition is applied quite a lot in Victoria. It’s quite helpful to support people as part of a, if you like, transition process to non-driving. So, for example, if someone is going through a health condition that involves cognitive decline, it’s going to be quite challenging for them to drive to new, unfamiliar places because they don’t know what to expect and they may not be familiar with the road conditions or the traffic.
But it can also work the opposite way, in the sense that if someone has had, for example, quite a traumatic head injury, for example, it may be quite a number of months or even years before they're able to manage driving anywhere they want at any time. So the application of a local area licence helps them to gradually move back into driving in circumstances that they're familiar with, within which we hope that they can be relatively safe.
So the issue is really around trying to get driving on the agenda more routinely with people who have chronic long-term health conditions. If the issue of general mobility and activities of daily living are raised in an ongoing, empathetic, regular way with the doctor, people have more time to adapt and to actually acknowledge and accept the fact that at some point along the disease progression they may have to look at alternatives to driving. Rather than leaving it to the last minute, you know to the kind of crisis management stage. That can create a lot of angst and concern for them.
MIC CAVAZZINI: Forward planning for ‘retirement’ from driving is essential in patients with progressively declining function. Starting the conversation early and putting other routines in place helps reduce the shock of the final step. As just described, conditional restrictions can help with this, but it’s equally important that these are not applied only to avoid confrontation with patients whose driving abilities are already marginal, in whom suspension would be more appropriate.
Even relatively contained environments can present challenges to some drivers. Just last year, an 86 year old woman on the Sunshine Coast reversed from a shopping centre car park into a family at a pedestrian crossing. A six year old girl was killed, while her sister and grandmother suffered severe leg fractures.
A 2010 systematic review in the American Academy of Neurology suggested that insight into ones limitations might not be enough to ensure safety on the road. The study found a correlation between self-reported situational avoidance, such as not driving in the rain or at night, and the likelihood of failing an on-road licencing test
But while age is often a focus of road safety regulation, it shouldn’t be blamed for every crash involving an older person. Anyone can be overwhelmed by the cognitive and physical demands of driving, and the conversation about fitness to drive needs to take social factors into account as well as medical ones, according to oncologist Dr Ranjana Srivastava.
In an article for the Guardian, she says that as well as a 90 year old lady, she’d seen in the week several much younger patients whose driving ability was uncertain. Dr Srivastava writes, “All these patients lacked insight into their health issues, all of them drove. Yet, no one had even thought to question their appropriateness to hold a driver’s licence, assuming that they would simply desist driving when … drug-addled, or when their blood sugar was dangerously low.”
She provides a reminder that all health services have a role to play in asking these questions routinely, and in coordinating to support this patients affected. Conversations about driving will often be tricky, but Genevieve Yates suggests some ways to broach the topic with patients.
GENEVIEVE YATES: One part that I find important is talking about car insurance. So saying something like if you do have an accident and you run into a Mercedes-Benz and cause a whole heap of damage, your insurance won't pay out if you have not reported a medical condition or you're not driving under the restrictions in which that medical condition has been imposed on you. And then you're very unlikely to regain your licence or you may lose your licence for an extended period of time. Not only that, you can face criminal prosecution. Particularly if you are driving without - specifically against medical advice and there are injuries or fatalities associated with that.
Sometimes you need a bit of the fear of God into people about the consequences of this. But, ultimately, it shouldn’t really be about scaring people. It should be also about explaining why these rules are and, you know, I think people can relate to not wanting to have unsafe people on the road for their families or for themselves, and how it’s really important that we do our best to try and keep people safe as much as possible.
MIC CAVAZZINI: It’s interesting that the AMA has a statement about this and they recommend that fitness to drive assessments be conducted by an independent practitioner to avoid the tension between the long-time ally. Meanwhile, on the website of one of the medicolegal insurers, they make the point about being cautious perhaps of new patients who aren’t regular patients asking for you to sign off; that these people may be shopping around to find a doctor who doesn’t know their specific clinical history. Are you particularly careful with new patients who turn up with these forms to sign?
GENEVIEVE YATES: I'm very, very cautious of someone coming as a new patient with the form to sign. Particularly if they're coming as an age-based assessment, because there are very few 75 year olds who don’t have GPs. So I'm particularly cautious. As far as the point about whether or not it should be an independent body, the proviso is that the person that is doing that independent assessment has a copy of the full medical records. So it’s like a referred service, as opposed to someone coming off the street and just telling you whatever they want about their medical condition.
MIC CAVAZZINI: Yeah and a few of our fellows said that if you're worried about this putting tension on the relationship, you can always fall back on the legal requirements. You can say, “it’s not me, it’s what I'm required to do.” And if you definitely make conversations about driving a routine part of any social history, then it’s not seen as, you know, you're stepping out to pick on someone. It’s just a routine assessment.
GENEVIEVE YATES: Sometimes we talk about having a shared enemy. Like I'm really on your side, but I'm legally bound to do this. It does make things easier. Particularly when there are clear standards involved. Much more complicated are those grey areas where there's more of an art to it and when you're making more of a judgement call. Those can be more difficult conversations.
I would say, “Look, I really can't make that judgement call, so what I'm going to need you to do is go and get a driving assessment and if you pass that? Fine. But, really, we need an objective someone to tell us are you safe or are you not safe.” And sometimes when you delve into that a bit more, sometimes they’ll actually sort of go, “Yeah, I'm not really sure I actually do feel safe and maybe it’s best that I do have someone to test and make sure I'm okay.”
MIC CAVAZZINI: It was also suggested that when you do have to break the news to a patient that their driving is going to be limited or their licence should be revoked, if you do that in the presence of a friend or a family member, that can help.
GENEVIEVE YATES: I actually actively seek history from family members with older people, of course with consent. You cannot get information or talk about the patient without their consent. You can often say I just need a bit more information about how you're driving, Fred, so I'd like to talk to your wife, to your daughter, et cetera. I can't really sign the form off until I get some more information. So it really is useful, doing that.
Interestingly, there was a big review by the American Academy of Neurology in 2010 which suggested that if a family member rates the driver as either unsafe or marginal, that’s quite helpful. If they rate them as good, that’s not necessarily helpful—don’t necessarily trust that.
MIC CAVAZZINI: And again, a couple of our editors shared stories where family members were relived at having had their own concerns about the patient vindicated. And, in some cases, the doctor would then adopt them as allies, perhaps by hiding the car keys, or disconnecting the car battery, or in one case even selling the car.
GENEVIEVE YATES: Absolutely. You hear that kind of story all the time.
MIC CAVAZZINI: Ranjana Srivastava talks about some creative tailored solutions specific to the patient. She suggested to a lady that she might get the hairdresser to come and give a home visit. Or I heard an example from New Zealand, from the Wellington area, where the DHB actually offers half price taxi vouchers to those who have been deemed unfit to drive.
GENEVIEVE YATES: There's some good information available online. For example, in Queensland the Department of Transport and Main Roads has an information sheet that’s titled Support Services for Loss of Driving Independence. There is a support line - Seniors Enquiry Line. They talk about taxi vouchers. There's community transport and organisations like St John. I think it is the responsibility of a practitioner, if we are going to take away someone’s licence in a situation like that, that we do provide access to those that can support, so that person can maximise their quality of life.
MIC CAVAZZINI Many thanks to Marilyn di Stefano, Serge Zandegu, Roy Beran, and particularly to Genevieve Yates for their contribution to this episode of Pomegranate Health. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians.
I hope you’ve found this episode helpful. There’s much more information about support pathways at our website racp.edu.au\podcast. You’ll also find links to the assessment and reporting forms in each jurisdiction. The AustRoads and the New Zealand Transport Agency guidelines are available in pdf and online form. Note there are slight differences in the recommendations they provide, but these are quite clearly laid out in tables for each cluster of conditions.
I’m Mic Cavazzini. Feel free to send me your thoughts on the show to firstname.lastname@example.org.Thanks for listening.