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May 26, 2015

Seniors: Losing a License

Reuel S. Amdur

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"You can't take my driving license away. If you do I will die!" That was the title of a talk given at Ottawa's Civic Hospital Campus on May 22 by Doctors Frank Molnar and Anna Byzewski.

Molnar is the Medical Director of the Regional Geriatric Program of Eastern Ontario and Byszewski is Ottawa Civic’s Undergraduate Medical Students Training Director in the Division of Geriatric Medicine at Ottawa Civic.

The issue is how to deal with increasing safety concerns as driver’s age.  It is a commonplace, emphasized at the lecture, that unsafe driving is often age-related. 

The youngest and oldest represent the greatest risks.  Even people in early stages of Alzheimer’s may drive safely, but at some point they cannot. 

When a doctor assesses ability to drive, he does not pull a person’s license.  It is his responsibility to report his assessment, in Ontario to the Ministry of Transportation.  The government makes the decision.  Yet, the doctor’s role is undoubtedly central.

The doctor needs to be aware of the consequences of the assessment, as loss of a license has important implications that require attention. 

That does not mean that a report should withhold the reality, only that the consequences of loss of a license need to be addressed.  Molnar listed some of these: impinging on autonomy and self-reliance, on spontaneity and convenience, on freedom and sense of control over one’s life, on socialization and sense of belonging, and on sense of capacity and self-worth.  Thus, the losses are particularly important in the suburbs where it is more difficult to get around without a car.  He did not mention rural areas, where the same is true.

Most seniors are, Molnar said, responsible and respond to diminishing capacity by slowing down, driving less, avoiding adverse conditions, and driving more defensively.  For Molnar, the jury is still out on the effectiveness of limited licenses—for example, to locations near home, or daytime only.  Do such licenses serve to prevent accidents?

But what does a person need in order to be able to drive? 

Cognition is important: vigilance, attention, judgment, insight, and capacity to plan.  Vision is essential, in all its aspects and complexities.  Then there are motor skills. In older people especially, arthritis and stroke may present barriers.  Sometimes changes in medication can help or hinder factors affecting ability to drive.

Many doctors are unsure how to assess driving capacity.  As well, they may be fearful of backlash from the patient and family.  And then there is the matter of how to communicate bad news. 

At age 80 and every two years after, the Ontario Ministry of Transportation requires a vision test, a simple cognitive assessment, and a group information session.  Molnar sees this procedure as missing many people who are at risk, especially since it is easy to study for the test.  He believes that the test rules out only the most extreme cases.  Then there are more specialized evaluations on the road, but they are quite expensive and have waiting lists. 

Because driving is part of identity for many people, loss of a license can bring about depressed feelings and might even lead to entry into a care facility. 

Thus, communication with a patient affected is part of medical treatment and should not be a one-off event.  The person needs to know that loss of license is inevitability for all of us.  The doctor needs to expect emotional reactions.  It is best where possible to involve the family in the process.  Rather than focusing on mental capacity, it is better to talk about such things as reaction time.

And when a person can no longer drive, alternatives should be explored—public transit, taxis, family and friends, and so on.

There was an expectation that the physician would carry the full load here along with the family.  The doctors did not consider having a role for social workers. 

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