Doctors, Dementia, and Driving: Impaired Operators Behind the Wheel (and Behind the Stethoscope?)

January 27th, 2018 by Dr. G. Moak

My colleague, a seasoned primary care physician, admitted that he hadn’t seen it coming. Worse yet, despite his years of experience, he felt ambushed and hadn’t known what to do.

An eighty-four year-old retired librarian we’ll call Millie, though that wasn’t her name, came in for a six-month checkup. She had been my colleague’s patient for many years, and they had enjoyed a warm doctor-patient relationship. Other than mild dementia, Millie had been fairly healthy. Just fifteen minutes had been scheduled for her appointment, and my colleague expected a straightforward, routine visit. So he entered the examination room unprepared to find himself in the middle of a minefield.

The first inkling of a problem was that Millie’s daughters sat with her in the examination room, awaiting my colleague. Millie had always come alone, and there had been no occasion to meet any of her children before. Initially they sat quietly, appearing on edge. But not two minutes into the visit, the older daughter interrupted my colleague, blurting that THEY had decided that their mother was no longer a safe driver. They wanted her to surrender her car keys but she was being “unreasonable” and had refused. So they expected my colleague to “talk sense into her” and to “order her to stop” driving.

Before my colleague could react to this startling demand, Millie, who had always been mild-mannered, erupted in snarling outrage. Scolding my colleague, she reminded him that she’d started driving long before he was born and had a perfect record; not even a parking ticket. Hissing a rebuke, she declaring that she’d always suspected him to be a “treacherous quack” who couldn’t be trusted. And she threatened to find a new doctor and sue him.

Reading this account, were you as stunned as my colleague? Did you find the behavior of Millie and her daughter surprising? If so, then you might be additionally surprised to learn that situations like this are not rare. I’ve found myself in similar encounters more times than I care to remember.

Each year the number of older drivers increases. Until age sixty-four, people become safer drivers as they age. But after that, declining health, both physical and mental, begins taking its toll on many abilities, driving included. Some elders remain safe drivers into their late nineties. On average, though, older adults outlive their driving ability by seven years.

Many older drivers recognize when this happens and gracefully “retire” from driving. Others need to be convinced of the necessity. Physicians’ opinions often are sought as part of this process. Whether because of, or in spite of their doctors’ input, most initially reluctant older adults eventually quit driving “voluntarily”.

And then there are those, like Millie, who present a greater challenge. Unable to face facts (in Millie’s case, symptoms of dementia and a combination of psychological and family factors conspired against her), they steadfastly deny that there’s anything wrong with their driving. They refuse to quit, often becoming angry, unreasonable, hostile, or paranoid. Not knowing how to handle this, or where to turn for help, family members can become overwhelmed. Some seek guidance from geriatric psychiatrists.

Driving cessation can be an emotional crisis for older adults; many do not cope well with it. Some, like Millie, behave maladaptively, severely challenging healthcare professionals and family members alike. I’ve worked with many such patients. Their family members all say that the struggle to curtail their older relative’s driving is the most stressful challenge they’ve ever faced. Invariably they experience one or more symptoms of anxiety, dread, anger, resentment, depression, or insomnia. They’re afraid to let their relative drive, but they’re also afraid to take away his or her keys. These are thorny problems, and usually there is no solution anyone is happy about, doctors included.

From time to time my colleague sought “curbside” consultations from me, so later that day he called me for help with Millie. He was shaken up. No novice at handling emotionally charged, contentious, patient encounters, this one had flummoxed him. Discovering what he hadn’t known rattled him: he hadn’t known how to assess Millie’s driving ability; he hadn’t known what responsibility he had to report Millie to the motor vehicle department; he hadn’t known how to respond to the daughters’ demand that he “order” Millie to stop driving. Somehow, despite his years of experience, he’d not confronted a situation like this before. But physicians increasingly are facing such challenges, and most are no better prepared than was my colleague.

Studies show that physicians generally feel untrained and unqualified to assess mildly demented patients’ driving ability. You’d think this wouldn’t be the case given the aging of the population and the increasing numbers of older adults with mild dementia who still drive. But it is.

The vast majority of physicians has had no training in assessing driving risk and don’t know how to do it. They worry about their patients’ driving safety, but they also worry about the detrimental consequences of driving cessation: loss of independence, declining wellbeing, deteriorating health, and depression. And taking away the car keys can irreparably damage both family and doctor-patient relationships, making it that much harder to provide older adults the help and support they need.

Doctors have no clear guidelines for weighing these competing harms. Society has set no standards for how much driving risk is acceptable. We let teenagers drive, and they are very risky drivers, as a group. Older drivers, on the whole, are not worse drivers than teenagers, those with dementia being a possible exception. To make things even more impossible for doctors, studies show that the tests doctors can perform in the office (other than vision tests) do not reliably predict driving safety; a behind-the-wheel, roadside test, conducted by a driving professional, is the gold standard. Lacking “rules of the road” to follow, doctors often do not know the right course of action to take. Believe me, it’s a lot harder than it seems.

In my experience, family members desperately want to prevent their older relatives, whom they feel no longer drive safely, from getting behind the wheel. But they want to accomplish this with as little emotional trauma as possible. They don’t know what to do, don’t want to do the wrong thing, and don’t know where to find the help they need. All too often they feel left in the lurch by healthcare professionals. Geriatric psychiatrists often can help, and that’s why my colleague called me. He wanted to pick my brain, but he also wanted to refer Millie and her family, to me.

Unfortunately, few families have access to geriatric psychiatrists (that’s another, even more complicated story, for another day). So, what can you do if you are worried about an older driver? If you’re a family member (or other caregiver), start by seeing your relative’s doctor. He or she may be able to offer some helpful advice or guidance. But be realistic. Understand that you may be dealing with a complicated situation beyond the doctor’s expertise.

If you find yourself in this predicament, an excellent resource you can download and read to help you understand better what to do is A Clinician’s Guide to Assessing and Counseling Older Drivers, published jointly by the National Highway Transportation Safety Administration and the American Geriatrics Society. And if you are a physician, other type of healthcare professional or elder services worker, concerned about the driving of one or more of your older patients or clients, this is an excellent resource for you too.

Two weeks later Millie and her daughters came to my office for an appointment. Despite having no idea about why she had come to see me, Millie was her usual, pleasant, mild mannered self. She had no recollection of her recent encounter with my colleague, and had nothing but glowing praise for him.

In contrast, her daughter, yes, that one, the one who demanded action of my colleague, entered my office spitting nails and breathing fire. Not granting me even the two-minute courtesy she gave my colleague, she demanding to know whether I intended to order her mother to stop driving, or was I going to be as “lame” as the other doctors (She also wasn’t too pleased with a neurologist they’d consulted). Yikes!

Want to find out how I handled this situation? Watch for an upcoming post in which I’ll describe what happened, and I’ll discuss what geriatric psychiatrists can do to help older drivers and their worried family members.

CUTE AS A BUTTON

September 8th, 2017 by Dr. G. Moak

It happened again!   A psychiatric nurse, well experienced, well trained, and well meaning, described the newest admission to our service, a ninety-year-old, very frail looking woman with severe dementia, as “cute as a button”. Hearing this, I cringed. Not only because this nurse said it, but also because it’s commonplace in so many healthcare settings, including specialized geriatric programs, where staff members ought to know better. They don’t!

I know this nurse well. She really cares about the older patients on our geriatric psychiatric service. She’ll go out of her way to ensure their needs are met. I’m sure she means to treat them with the dignity and respect they deserve. So why does she not understand that describing geriatric patients as “cute as a button” is not a good way to do this? Why do so many other equally well-meaning healthcare professionals describe frail elders as cute? And is there anything truly cute about advanced, old age?

Toddlers, puppies, and kittens are cute, little old ladies and men not so much. I doubt that you know anyone hoping to be cute in old age? Quite the opposite, they want to avoid that fate, maintaining their dignity and independence. Think about what old-age “cuteness” signifies. It signifies that formerly robust, capable, independent adults have turned into shrunken, frail, feeble, confused waifs with elfin or gnomish qualities. Not an attractive picture.

My guess is that seeing such elders as cute is a defense mechanism for healthcare workers, a way they can ward off their own fears of decrepitude triggered by close proximity to frail patients nearing death. Emotional contact precautions, that’s what it is. It says, “You’re infected with old age, and I don’t want to catch it”. Contact precautions work by providing a barrier, blocking infection. “Cuteness precautions” provide a barrier too, blocking the emotional reality check staff members need to empathize with older adults and help them maintain their dignity. When you’re ninety years old, there’s nothing dignified about being cute.

We teach cultural competence to healthcare professionals to help them be more sensitive to the personal needs of all kinds of patients. Isn’t it about time we added elderly patients to the list?

DOES STICKING TO LOCAL TRIPS IMPROVE OLDER DRIVERS’ SAFETY?

March 20th, 2017 by Dr. G. Moak

I’ve heard it hundreds of times: “But I only drive locally, in familiar neighborhoods!” That’s how my patients try to convince me that it’s still safe for them to drive. Their family members similarly rationalize, “But Dad only drives three places, the bank, the post office, and the supermarket. He knows the way very well and doesn’t get lost!” People assume that limiting driving to short, local, trips is a good way for older drivers with declining abilities to remain safe behind the wheel. It makes common sense, but it is not correct.

My patients and their families are always surprised to learn (and you might be too) that driving fewer overall miles, generally by sticking to local routes, doesn’t lower an older driver’s risk of having an accident, it raises it. Drivers over sixty-five years old, on average, have higher accident rates than younger drivers, but older drivers who drive more than 3,000 km (just under 1,900 miles) per year have lower accident rates, equivalent to those of middle aged individuals.

What’s going on here? Why isn’t driving fewer miles and keeping to shorter, local roads, safer? Shouldn’t short, familiar routes be easier for forgetful older adults to remember? Of course, but much more goes into safe driving than memory. Navigating local streets demands more of drivers than does highway driving. There’s more to deal with: more signs, more turns to make, traffic lights to obey, more intersections to negotiate, and more parked vehicles, bicyclists, and pedestrians not to hit; in short, more opportunities for error.

Being able to remember the route and recall details on the way, such as speed limit, of course, are important. But it is the ability to take note of, and quickly react to, a complex and rapidly changing landscape that determines safety most. Aging takes a toll on the mental abilities needed to stay vigilant, anticipate the unexpected, properly judge the speed and distance of other vehicles, and make quick decisions about passing, pulling out, and yielding the right of way. This shows in the types of crashes that older drivers most commonly have: left turns across traffic, failure to yield the right of way, failure to stop at a signal, and failure to judge speeds correctly. Intersection crashes account of two fifths of crashes involving senior drivers versus only one fifth of those of younger drivers.

So rationalizing that it’s still safe for an older adult to drive because he or she only drives locally may be just that, a rationalization. Each person’s abilities, fitness, health, and circumstances are different, and obviously there are exceptions. But if an older adult has given up longer distance driving due to worries about safety, then keeping to shorter, local routes may not be any better.

References

R Robertson and W Vanlaar, “Elderly Drivers: Future Challenges”, Accident Analysis & Prevention 2008; 40: 1982-1986.

J Langford and S Koppel, “Epidemiology of Older Driver Crashes: Identifying Older driver Risk Factors and Exposure Patterns”, Transportation Research 2006; Part F, 9: 309-321

Think Medications for Dementia Produce No Meaningful Benefit? Don’t Be So Sure

January 14th, 2017 by Dr. G. Moak

Currently available anti-Alzheimer drugs – donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon), and memantine (Namenda) – are not the miracle cures patients hope for, and many clinicians are skeptical, and don’t prescribe them. Consumers nevertheless have heard that these drugs at least “slow it down”, and many accept this as better than nothing.

But do anti-Alzheimer medications “slow it down”? Unfortunately, scientists do not know for sure. Some research demonstrates actions in the brain of anti-Alzheimer drugs that could be helpful, but there has been no proof that these effects interrupt the disease process. Specialists who recommend these medications mostly believe that their benefits are limited to temporary improvement of symptoms, stabilizing their patients’ conditions for a time, before they resume relentlessly losing ground to dementia. What remains unknown is whether treated patients continue to decline at the same rate as before or slower. A new study provides reason to think that anti-Alzheimer drugs actually might slow down patients’ decline.

Last month French researchers published a study of patients with mild cognitive impairment.*  Mild cognitive impairment (you may hear it referred to as mild neurocognitive disorder) is a milder condition not severe enough to be considered a dementia. About half of the time, however, MCI is a preliminary stage of Alzheimer’s disease: such patients gradually get worse and sooner or later develop dementia.

In this French study, patients with MCI were treated for one year: half received donepezil (Aricept) and half placebo. At the beginning of the study, and again at the end of the year, patients had brain MRI scans, and the thickness of their cerebral cortex was measured. The cortex is the outer layer of the brain, where memory and other higher mental abilities reside. As Alzheimer’s disease worsens the cerebral cortex gets thinner and thinner. Researchers compared the amount of thinning in those who received donepezil with those who did not. The good news is that the patients treated with donepezil had much less cortical thinning than those who received placebo. In some brain areas, the cortex even got thicker! This finding suggests that treatment with anti-Alzheimer medications may actually slow down the rate at which patients decline

While encouraging, this study has many weaknesses, so it is far from a slam-dunk proof of anything. But it does provide another bit of evidence that anti-Alzheimer drugs may not be as worthless as many think. If these drugs do slow the rate of decline, the benefit might not be apparent early in treatment, but would be more and more obvious, and meaningful, as time goes on because patients stay further and further ahead of where they would have been without treatment. This is a different way to think about medical treatment, but nonetheless a meaningful one, especially for Alzheimer patients and their families.

Dementia, By Any Other Name, is Still Dementia

November 22nd, 2016 by Dr. G. Moak

Have you adopted the DSM-5 nomenclature “major neurocognitive disorder”, or have you continued to use “dementia”, as I have? DSM-5 was released in 2013, introducing neurocognitive disorders, major and minor. In the years since, I’ve noticed that many psychiatrists, but not all, have adopted the new nosology. But other physicians, including primary care physicians and neurologists, and most geriatric psychiatrists, still use “dementia”. And ICD-10 uses the tried and true term “dementia”. Nevertheless, as a medical school faculty member, responsible for the training of medical students, residents, and fellows, I suppose I should toe the DSM-5 line, but I’m not going to do it. It’s a pet peeve.

It’s almost 2017, and you might wonder what took me so longer to get around to expressing my objections to the reclassification of dementia as a neurocognitive disorder. Fair question. Suffice to say I’ve been busy. “What could have been more important this this?” you ask. For one, there’s Medicare, moving target par excellence, source of endlessly changing rules, regulations, and (dis)incentives, and general bane of existence. And then there’s my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, published earlier this year. It’s a terrific book and easy to read, if I do say so myself. I assure you that nary a page deals with ICD-10, but there is a terrific chapter, suitable for the lay public and clinicians alike, on the differential diagnosis of depression, covering the different types of depression, other conditions that masquerade as depression, and how to tell them apart. Ironically, I used DSM-5 terminology. I’d highly suggest getting a copy: no, not DSM-5, my book! Even before you finish reading this post, you may wish to order it on amazon.com.  You won’t regret buying my book, but, back to DSM-5 and dementia.

First my “minor” major neurocognitive disorder objections. I simply like the term “dementia” better. It’s traditional, having been in use for well over 100 years. Healthcare professionals all know what it refers to, and much of the public does. And it’s shorter and easier to say. “Major neurocognitive disorder” doesn’t exactly roll off the tongue.

And now my “major” major neurocognitive disorder objections. Actually I don’t object to “neurocognitive” for the category of syndromes, generally, but I don’t see the advantage for dementia specifically. True, “neurocognitive” does describe a major aspect of dementia. But is also seems too narrow, the most disruptive and disabling manifestations of dementia being their psychiatric and behavioral complications. And, and the same time, it also seems non-specific, schizophrenia clearly also being a disorder involving severe neurocognitive impairment. Had they asked me, I’d have suggested letting dementia be dementia, and calling the category of disorders “acquired disorders of widespread brain impairment usually first manifest in late life”. Nobody asked me, but, no matter, there’s always DSM-6 to look forward to.

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