Dr. William H. Roccaforte

Collaborating with the Elderly Driver - presented by William Roccaforte, M.D., associate professor of psychiatry, UNMC Department of Psychiatry. He will talk about the risks faced by the elderly driver and methods to evaluate functions. Counseling, adaptive strategies and community resources will be discussed.

William H. Roccaforte, MD, Program Director, Department of Psychiatry, 985580 Nebraska Medical Center, Omaha, NE 68198-5580 or wroccafo@unmc.edu
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William H. Roccaforte, MD, Program Director 402-354-6892 (Phone)

William H. Roccaforte, M.D.Associate ProfessorDirector, Geriatric Psychiatry FellowshipDepartment of PsychiatryUniversity of Nebraska

Training Director for General Psychiatry: William Roccaforte, MD; Associate Professor, UNMC
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Training Director, Geriatric Psychiatry: William Roccaforte, MD; Associate Professor, UNMC
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William Roccaforte, M. D., Chair

"There are some consequences to asking people not to drive anymore," said William H. Roccaforte, MD, at the 15th Annual Meeting of the American Association for Geriatric Psychiatry."The biggest is loss of independence, a huge lifestyle change for these folks.Some will feel like they're now a burden on their family even if the family is very willing to drive them wherever they need to go.And this all really can diminish quality of life."Dr. Roccaforte is an Associate Professor and Director of the Geriatric Psychiatry Fellowship, Department of Psychiatry, University of Nebraska, Omaha.
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Currently, said Dr. Roccaforte, about 12.7% of the US population is older than age 65.By the year 2030 it is expected to be 20%, which means that the number of people 65 and older will increase from about 34 million to approximately 70 million.Seventy-five percent of the elderly have a driver's license, and 72% of all elderly people live in suburban or rural areas."So they're in places where there's a great deal of distance between different services and where having ready access to transportation is even more important," said Dr. Roccaforte.
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"The elderly get a disproportionate number of prescriptions for benzodiazepine, so we need to check on what medications they are taking," said Dr. Roccaforte.

Elderly people adapt their driving behavior as they get older, he said."They almost self-police in that way.
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"One of the frustrating things of reading in this area is that you can find studies that almost directly contradict each other, even when you try to make sure that they are reasonably comparable in the way that they were done," said Dr. Roccaforte.
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The prevalence of dementia increases dramatically with age, said Dr. Roccaforte, and several characteristics of dementia can have a profound impact on driving, beginning with memory loss."If you can't remember the rules of the road, or you can't remember where you're going or the routes that you've taken before, you could run into some trouble," he said.Another symptom and potential driving hazard is agnosia, which could lead someone to have trouble recognizing road signs or controls inside the car.Apraxia, or loss of ingrained motor memory, can impede the handling of the instruments in one's car or remembering how to use a cell phone to call for help.Although not a criterion for dementia, visuospatial distortion frequently accompanies dementia, said Dr. Roccaforte.
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Three ways to assess how safely people drive have been reviewed-caregiver reports, Department of Motor Vehicle (DMV) records, and driving performance tests, which most people consider the gold standard, said Dr. Roccaforte.

In one study involving 72 elderly individuals with mild to moderate dementia (those with an average Mini-Mental State Examination score slightly higher than 17), Lucas-Blaustein and colleagues interviewed the drivers' caregivers.Thirty percent of the subjects were still driving, and of those 30%, their caregiver thought 60% of them were safe drivers.In a three-year span since onset of dementia, 30% of the drivers had an auto accident, and another 11% caused someone else to have an accident.

The DMV can revoke an unsafe driver's license, but many times that doesn't stop the person from driving, said Dr. Roccaforte."So really, it comes down to what the family is able to do with that person on a day-to-day basis.One of the things I feel real comfortable in doing is to try and take the blame off the family with regard to the patient.For some patients, it still works if they say, ‘Well, the doctor said that you can't drive anymore.' In this age-group, it still carries a little more weight, I think, than it does in some of the younger age-groups.... However, we're not experts at making this kind of determination.When there is any doubt about driving safety, we should refer them to experts."

Dr. Roccaforte reviewed four separate studies that have assessed the driving skills of mildly demented individuals: In the best case, 24% failed the test, and in the worst case, 60% failed.Overall, he said, the studies showed that a substantial proportion of even mildly demented drivers are not safe drivers.

"We don't have a simple screening test," he said."There is a growing opinion that something has to be done, but we don't have a good way to do it yet, unless we use a fair amount of resources.I think that's really the bottom line in all of this.We have to have a way to individually test folks if we want to assess people fairly."

Most states do not require physicians to report anyone diagnosed with dementia, said Dr. Roccaforte.
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Dr. Roccaforte advised a systematic approach toward dealing with elderly patients with dementia and the topic of driving.The first thing to do, he said, is ask if the person is driving and if there are any problems while he or she is driving."I always ask both the patient and the caregiver to see if there's a discrepancy in their perceptions.Often there is."He also recommended asking the caregiver if he or she is comfortable driving with the person.
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"The other important thing is to document what you recommend to the person and why," said Dr. Roccaforte."There's a lot of concern about legal liability."To date, there has been no lawsuit against a physician who has not reported a demented driver to the DMV."I imagine there's going to be a time when that happens, but so far the legal risk doesn't seem to be that high.If you document really well what you did and why you did it, even if you do get sued, the chances of the lawsuit being successful are substantially diminished."

Dr. Roccaforte said the family is "front line," ie, the ones who are actually going to have to stop a person from driving.

"There are some consequences to asking people not to drive anymore," said William H. Roccaforte, MD, at the 15th Annual Meeting of the American Association for Geriatric Psychiatry."The biggest is loss of independence, a huge lifestyle change for these folks.Some will feel like they're now a burden on their family even if the family is very willing to drive them wherever they need to go.And this all really can diminish quality of life."Dr. Roccaforte is an Associate Professor and Director of the Geriatric Psychiatry Fellowship, Department of Psychiatry, University of Nebraska, Omaha.
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Currently, said Dr. Roccaforte, about 12.7, of the US population is older than age 65.By the year 2030 it is expected to be 20,, which means that the number of people 65 and older will increase from about 34 million to approximately 70 million.Seventy-five percent of the elderly have a driver's license, and 72, of all elderly people live in suburban or rural areas."So they're in places where there's a great deal of distance between different services and where having ready access to transportation is even more important," said Dr. Roccaforte.
...
"The elderly get a disproportionate number of prescriptions for benzodiazepine, so we need to check on what medications they are taking," said Dr. Roccaforte.

Elderly people adapt their driving behavior as they get older, he said."They almost self-police in that way.
...
"One of the frustrating things of reading in this area is that you can find studies that almost directly contradict each other, even when you try to make sure that they are reasonably comparable in the way that they were done," said Dr. Roccaforte.
...
The prevalence of dementia increases dramatically with age, said Dr. Roccaforte, and several characteristics of dementia can have a profound impact on driving, beginning with memory loss."If you can't remember the rules of the road, or you can't remember where you're going or the routes that you've taken before, you could run into some trouble," he said.Another symptom and potential driving hazard is agnosia, which could lead someone to have trouble recognizing road signs or controls inside the car.Apraxia, or loss of ingrained motor memory, can impede the handling of the instruments in one's car or remembering how to use a cell phone to call for help.Although not a criterion for dementia, visuospatial distortion frequently accompanies dementia, said Dr. Roccaforte.
...
Three ways to assess how safely people drive have been reviewed,caregiver reports, Department of Motor Vehicle (DMV) records, and driving performance tests, which most people consider the gold standard, said Dr. Roccaforte.

In one study involving 72 elderly individuals with mild to moderate dementia (those with an average Mini-Mental State Examination score slightly higher than 17), Lucas-Blaustein and colleagues interviewed the drivers' caregivers.Thirty percent of the subjects were still driving, and of those 30,, their caregiver thought 60, of them were safe drivers.In a three-year span since onset of dementia, 30, of the drivers had an auto accident, and another 11, caused someone else to have an accident.

The DMV can revoke an unsafe driver's license, but many times that doesn't stop the person from driving, said Dr. Roccaforte."So really, it comes down to what the family is able to do with that person on a day-to-day basis.One of the things I feel real comfortable in doing is to try and take the blame off the family with regard to the patient.For some patients, it still works if they say, 'Well, the doctor said that you can't drive anymore.' In this age-group, it still carries a little more weight, I think, than it does in some of the younger age-groups.... However, we're not experts at making this kind of determination.When there is any doubt about driving safety, we should refer them to experts."

Dr. Roccaforte reviewed four separate studies that have assessed the driving skills of mildly demented individuals: In the best case, 24, failed the test, and in the worst case, 60, failed.Overall, he said, the studies showed that a substantial proportion of even mildly demented drivers are not safe drivers.

"We don't have a simple screening test," he said."There is a growing opinion that something has to be done, but we don't have a good way to do it yet, unless we use a fair amount of resources.I think that's really the bottom line in all of this.We have to have a way to individually test folks if we want to assess people fairly."

Most states do not require physicians to report anyone diagnosed with dementia, said Dr. Roccaforte.
...
Dr. Roccaforte advised a systematic approach toward dealing with elderly patients with dementia and the topic of driving.The first thing to do, he said, is ask if the person is driving and if there are any problems while he or she is driving."I always ask both the patient and the caregiver to see if there's a discrepancy in their perceptions.Often there is."He also recommended asking the caregiver if he or she is comfortable riding with the person.
...
"The other important thing is to document what you recommend to the person and why," said Dr. Roccaforte."There's a lot of concern about legal liability."To date, there has been no lawsuit against a physician who has not reported a demented driver to the DMV."I imagine there's going to be a time when that happens, but so far the legal risk doesn't seem to be that high.If you document really well what you did and why you did it, even if you do get sued, the chances of the lawsuit being successful are substantially diminished."

Dr. Roccaforte said the family is "front line," ie, the ones who are actually going to have to stop a person from driving.

"I've had other doctors tell me that it's just as difficult as telling someone they have a potential terrible illness like cancer," said Dr. William Roccaforte, a geriatric psychiatrist at the University of Nebraska Medical Center."It's a very hard thing for doctors or families to do."

Roccaforte said it's important to be aware of problems some elderly people have with driving.