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A Multicenter Survey of Older Adults in Subacute Care on Their Current Driving Efficacy and Their Intention to Resume Driving After Discharge
Abstract: Motor vehicle accidents (MVAs) are the leading cause of accidental death in adults aged 65 to 74 years. Older adults’ attitudes on resuming driving after hospital discharge were studied in 3 subacute rehabilitation (SAR) facilities. A survey was administered to alert and oriented residents measuring their perceptions about their driving efficacy. Of 200 eligible residents, 67 participated. Asked whether a discussion had been initiated about their ability to continue to drive, the majority of participants responded that no such conversation had taken place before or during their current hospitalization or in SAR. Findings revealed that, in the facilities studied, driving counseling is rarely provided before discharge from SAR to the community, despite published data about the increased risk of MVA-related fatality among drivers in older age groups. Because older adults are unlikely to ask their health care provider about driving cessation, it is incumbent upon health care providers to recognize the need for and to initiate the “driving conversation” with their older patients.
Key words: aging, cognition, older drivers, motor vehicle accidents, subacute care rehabilitation
In 2015, more than 40 million licensed drivers in the United States were 65 years or older.1 By 2020, an estimated 53 million people in the United States will be older than 65 years, 40 million (75%) of whom will be licensed to drive.2 Many older drivers will outlive their driving ability—by an estimated 6 years for men and 10 years for women—as a result of changes in their health and functional status.3 Yet, they will continue to drive despite being at increased risk of unsafe motor vehicle operation.3 Motor vehicle accidents (MVAs) are the leading cause of injury-related deaths among US adults aged 65 to 74 years and the second leading cause among those aged 75 to 84 years.2 Although reported fatalities of drivers aged 85 and older have decreased by approximately 18% over the last 20 years, even with an increase in the number of older drivers, they are still 9 times higher than in drivers aged 25 to 69 years.4,5
In a 2002 report by Ritter et al, 86% of 2500 adults surveyed aged 50 or older reported that driving was their mainstay of transportation.6 Yet, Adler and Rottunda found that one-third of 12 older adults surveyed were unrealistic about their driving abilities, and all participants had similarly aged friends whom they felt should not be driving.7 In a study of 755 older adults by Hill et al, 17.8% of participants failed at least 1 of 7 screening tests of vision, strength/frailty, and cognition.8 Similarly, Baird et al found that 20% of 397 licensed drivers older than 60 were considered at high risk of age-related driving disorders after failing at least 1 of the same 7 screening tests.9 Several other studies have yielded comparable results.10-12 While Dellinger et al, in their study of 1950 participants aged 55 or older, found that those who had stopped driving had fewer medical conditions than did those who continued to drive,13 other studies have cited health problems such stroke, diminished visual acuity, and diminished cognition as the most commonly mentioned reasons for driving cessation.7,14-16 In addition, when presented with a challenging driving scenario, older women have been found to be more likely than older men to self-regulate by not driving.17,18
With regard to the role of health care providers in driving counseling, Tuokko et al reported that 45% of 86 older participants of a driver education program believed that a physician should make the final decision about driving cessation.19 Carmody et al found that the discharge summaries of only 20% of 41 older patients of all ages leaving the hospital after a stroke included driving advice.20 Other studies have confirmed a frequent lack of documented driving advice in discharge summaries for patients who had undergone a surgical procedure21 or who had sustained a transient ischemic attack or stroke.22 Indeed, driving cessation, both temporary and permanent, remains an important issue that is not often discussed between health care providers and their patients.23-25
The objective of this study was to determine patients’ attitudes and beliefs regarding their driving abilities during their subacute care rehabilitation (SAR), after a recent hospitalization, and before discharge to the community. The specific aims were as follows: (1) to explore older patients’ driving habits and patterns using a validated scale, the Adelaide Driving Self-Efficacy Scale (ADSES)26; (2) to determine whether patients’ reported levels of ability to ambulate, based on activities of daily living (ADL) responses prior to hospitalization, had any association with their attitudes and beliefs regarding driving after rehabilitation; and (3) to assess whether communication with regard to driving counseling occurred between the older adults and health care professionals. It was hypothesized that patients and their physicians or other health care professionals would be unlikely to initiate a conversation about driving cessation during the course of the patients’ SAR stay.
Methods
Participants and Setting
Study investigators reviewed the medical records of patients who were admitted to 1 of 3 SAR facilities after hospitalization in the New York metropolitan area from September 2016 to November 2016 to check for eligibility. Candidates aged 65 years or older with a Brief Interview for Mental Status (BIMS) score of at least 8 of 15 were approached by the primary investigator, were provided with a description of the study, and were informed that all data collected would be reported in aggregate form and that participation in the study was voluntary. This study was approved by the facilities’ institutional review board.
Study Design and Data Analysis
Candidates who verbally agreed to participate in the study were given a 32-question survey orally (Supplementary Box 1. See PDF). The 32-question survey was administered face-to-face to alert and oriented residents in the 3 SAR facilities. The survey included a validated tool (ADSES) to measure driving efficacy perceptions, an ADL section, and a brief demographics section.
A 2 test or a Fisher exact test, as appropriate, was used for categorical responses, and a Kruskal-Wallis test was used for continuous variables. Data were stored using Research Electronic Data Capture (REDCap) software and analyzed using SAS version 9.4 statistical analysis software.27
Results
Of the 200 eligible candidates who were approached, 67 (33.5%) agreed to participate. The mean age of participants was 77 years (± 9.3); 50% were men, and 50% were women (one participant’s gender was not recorded).
The majority of participants (75%) reported that driving was “extremely important” to them, while 12% stated it was “moderately important.” Sixty-two percent reported driving 5 days a week or more prior to their hospitalization. Participants rated their overall driving skills, on average, as 8.5 (range, 0-10, with 10 being “excellent”), and their driving self-efficacy scores in 12 specific driving activities (as assessed with ADSES) averaged 88.8 (standard deviation [SD], 33.2; range, 0-120 where 120 is “completely confident”).
Forty-two percent of participants stated that they should stop driving, and 39% stated that they would stop driving (temporarily or permanently) after their hospitalization. Women were more decisive than men about stopping, responding with either “No” (61% vs 39%, respectively) or “Yes, permanently” (21% vs 9%, respectively), whereas men were less decisive than women, responding with “I don’t know” (15% vs 3%, respectively) or “Yes, temporarily” (36% vs 15%, respectively) (P = .035).
Age was a significant factor; younger participants (average age, 74) did not think that they should stop driving, while older participants agreed to temporary (average age, 78) or permanent (average, age 85) cessation (P = .008).
There was a strongly significant association (P = .0003) between participants’ mean self-rated ADSES score (range, 0-120) and their perception to stop driving as described, “Yes, permanently” (mean ADSES score, 36.4), “I don’t know” (mean ADSES score, 87.0), “Yes, temporarily” (mean ADSES score, 97.9), or “No” (mean ADSES score, 100.1). Likewise, participants’ mean self-ratings of driving skills (range, 0-10) were associated with their perception regarding driving cessation (P = .097) as “Yes, permanently” (mean rating, 6.4), “I don’t know” (mean rating, 8.0), “Yes, temporarily” (mean rating, 8.7), and “No” (mean rating, 9.1) (Figure 1 shows these values in percentages for comparison purposes).
In terms of mobility/ambulation or mobility/transfer, regardless of whether the participant required no assistance (n = 30 and n = 34, respectively), some assistance (n = 32 and n = 30, respectively) or complete assistance (n = 2 and n = 2, respectively), no significant difference was found between groups when participants were asked whether they should stop driving (P = .139 and P = .754, respectively). There was a significant association between the responses to the questions, “Is driving important to you?” and “Do you think you should stop driving?” (P = .005). This striking result was largely related to the greater proportion of participants who stated they should stop driving permanently and who also stated that driving was “not at all/slightly” important to them.
When asked whether a discussion had been initiated about the participants’ ability to continue to drive, the majority responded that no such conversation had taken place prior to the current hospitalization (71.6%), during the hospitalization (80.6%), or during their SAR stay (82.1%). When participants were asked specifically who had initiated a conversation about their driving prior to their hospitalization, either a physician (10.5%) or a family member (20.9%) had “expressed concern about their ability to drive.” None of the patients said that a nurse initiated a discussion or expressed concern. The remaining participants reported having no conversations about driving prior to their hospitalization (Table 1).
Comparing counseling during their hospitalization to counseling during their SAR stay, 7.5% and 6.0%, respectively, of participants reported having had a conversation with a physician, and 9.0% and 6.0%, respectively, with a family member. In addition, 9.0% of participants reported that a physical therapist (PT) or occupational therapist (OT) during the SAR stay did initiate a discussion about their ability to drive (Table 1). During hospitalization, 25% of participants reported that temporary driving cessation had been recommended, while only 3% reported a permanent driving cessation recommendation. The remaining participants did not report or recall having any conversations regarding driving cessation at any time.
Responses to the question, “What do you think is one compelling reason why a person should stop driving?” were categorized as follows: visual impairment, 27%; physical impairment, 27%; impaired reflexes/reaction time, 23%; old age, 11%; loss of confidence, 8%; and other reasons, 5% (Figure 2). Although most patients mentioned a reason to stop, none mentioned “recommendation by others” or “failing a skills test.” Rather, it seems they would prefer to make the decision themselves.
Discussion
In the facilities studied, driving counseling was rarely provided prior to discharge back to the community. Driving cessation continues to be perceived as an off-limits subject among patients and health care professionals.
OTs and PTs were the health care professionals most likely to discuss driving with participants in this study. Of interest, the study’s findings suggest that nurses, who often have most common interactions with patients, are particularly reluctant to approach the driving cessation discussion.
Since SAR residents are unlikely to bring up the subject with health care professionals, it is incumbent upon physicians and other health care professionals to recognize the need for and to initiate the “driving discussion” with older patients. Furthermore, health care professionals should consider the practical opportunities to initiate these discussions during hospitalization as well as during SAR, where PTs and OTs are readily available for counseling and training.
Increasing awareness among health care professionals of the specific physical and mental health problems that can adversely affect driving, such as vision impairment, hearing loss, decreased mobility, and cognitive impairment, may offer opportunities to improve their performance with regards to driving cessation discussion. In addition, family members should consider an occasional ride in the car driven by their older relative as an excellent way to assess firsthand the older person’s ability to drive safely. The driving cessation process could be an easier transition with family support taking on some of the driving responsibilities, particularly at night, in bad weather, and on long trips.
In terms of study limitations, we did not explore whether health care professionals raised “the driving issue” spontaneously, or whether they were prompted to do so by their patients or the patients’ concerned relatives. Because so few patients agreed to participate, we believe that they were afraid that poor survey results would lead to an insistence that they stop driving. In addition, the low BIMS score cutoff may have included participants who were unable to remember whether or not they had had a driving cessation conversation. Other limitations of this study included the relatively small sample size, a lack of demographics about those candidates who refused to participate, and a reliance on participant self-reported data.
Conclusion
Driving cessation in older adults represents a major life change at any time, including after a hospitalization and during SAR. It is often difficult for health care professionals and family members to initiate the conversation. In view of the growing safety concern for older drivers, their passengers, and the public at large, educational initiatives need to be developed.
Supplementary materials can be accessed in the PDF version of this article. PDF download available at end of article.
References
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