䉷 1999, British Geriatrics Society
Age and Ageing 1999; 28: 53–57
A survey of attitudes and knowledge of
geriatricians to driving in elderly
patients
NEIL D. GILLESPIE, MARION E. T. MCMURDO
Ageing and Health, Department of Medicine, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
Address correspondence to: N. D. Gillespie. Fax: +44 1382 660675. Email: [email protected]
Abstract
Objective: to assess the attitudes of consultant members of the British Geriatrics Society to elderly patients driving
motor vehicles.
Design: an anonymous postal survey assessing knowledge and attitudes to driving in elderly people. A standardized
questionnaire was used and five case histories were offered for interpretation.
Setting: the study was co-ordinated from a teaching hospital.
Subjects: the 709 consultant members of the British Geriatrics Society. Four hundred and eighteen responses were
obtained, which represents a 59% response rate.
Results: 275 respondents (68%) correctly realised that a person aged 70 had a duty to inform the Driving and
Vehicle Licensing Authority (DVLA) about their eligibility to drive. The remainder did not. Most (315; 75%) believed
that the overall responsibility for informing the DVLA was with the patient. If a patient was incapable of
understanding advice on driving because of advanced dementia, 346 (83%) would breach patient confidentiality
and inform the authority directly. Where a patient was fully capable of understanding medical advice but ignored it,
72% of geriatricians would have legitimately breached patient confidentiality and informed the DVLA. Most
geriatricians (88%) saw their main role as one of providing advice on driving to patients and their families. Enforcing
DVLA regulations was not seen as an appropriate function, unless the patient was a danger to themselves or other
drivers.
Conclusions: there is a wide variation in knowledge of driving regulations and attitudes to driving in elderly
patients. Better education of geriatricians should improve awareness of when elderly drivers can safely continue to
drive.
Keywords: confidentiality, dementia, driving, Driving and Vehicle Licensing Authority, geriatricians
Introduction
There will be a marked increase in the number of
elderly drivers in the future as a result of the ageing
population and the increasing number of privately
owned cars [1]. Elderly drivers have a higher accident
rate per mile driven than their younger counterparts
[2]. Several studies have suggested that drivers with
dementia may have an increased crash risk [3], and a
high proportion of elderly crash victims have Alzheimertype neuropathology. However, other carefully controlled studies suggest no increase in crash rates for
drivers with dementia [4, 5]. In addition to dementia
sufferers, patients with heart and neurological disease
often require assessment and advice on whether they
should continue to drive [6].
Most current research is directed to assessing and
validating objective methods of assessing whether
people should continue to drive [7]. Little is known
about the attitudes of practising physicians to elderly
patients who drive. This survey was performed to
assess the views and attitudes of consultant geriatricians to elderly drivers with a range of common
medical conditions.
Methods
The 709 consultant geriatrician members of the British
Geriatrics Society were sent an anonymous questionnaire
consisting of five single-response questions (Table 1)
followed by five brief clinical histories. The case histories
were based on two patients with dementia (one mild, one
severe), a patient with Parkinson’s disease, a patient
53
N. D. Gillespie et al.
Table 1. Results of questionnaire
Response (%)
................................................................
Question
Yes
No
Don’t know
........................................................................................................................................................................................................................
a
1. At what age is there a legal responsibility to reapply for a driving licence?
67
26
7
75
1
1
14
–
–
–
–
3. If a patient is incapable of understanding the advice that their medical condition is likely to
make them a danger at the wheel, can a medical practitioner breach patient confidentiality
and inform the DVLA?
83
11
6
4. If a patient understands the advice that their medical condition is likely to make them a
danger at the wheel, but ignores it, can a medical practitioner breach patient confidentiality
and inform the DVLA?
72
20
8
5. The main role of the geriatrician should be to offer patient information and advice regarding
driving rather than enforcing the DVLA regulations unless the patient is a danger to
themselves or other drivers.
88
4
8
2. Who has the responsibility of notifying the DVLC of a patient’s medical condition which
could affect their ability to drive?
(a) the patient
(b) the hospital physician (geriatrician)
(c) the general practitioner
(d) any one of the above
9
–, not applicable; DVLA, Driving and Vehicle Licensing Authority.
70 years.
a
with a cardiac arrhythmia and a patient with a
pacemaker. The clinical histories provided for the
patients with dementia are shown in Table 2.Three or
four options were given in each instance which tested
both knowledge of the Driving Vehicle Licensing
Authority (DVLA) regulations and interpretation of
the law. The General Medical Council has issued
specific advice about the circumstances in which
disclosure of information about a patient may be
made to the DVLA [8].
Results
A total of 418 replies were obtained, giving a 59%
response rate. Of this 418, 275 (67%) correctly
indicated that patients aged 70 had a responsibility to
inform the DVLA. Surprisingly, 143 geriatricians (33%)
were unaware of this (Table 1).
Three hundred and fifteen respondents (75%)
correctly stated that responsibility for informing the
DVLA about a medical condition usually lay with the
patient. However, if the patient was incapable of
understanding medical advice, 83% of geriatricians
(346/418) would have legitimately breached patient
confidentiality and informed the DVLA about their
concerns. However, 46 doctors (11%) would not have
informed the DVLA and 26 (6%) did not answer this
question.
Most geriatricians (367; 88%) stated that their role
was one of providing advice and information rather
than enforcing DVLA regulations.
Table 2 presents the responses of the geriatricians
54
surveyed to patients with ‘mild’ dementia and with
more ‘severe’ dementia. In the case of mild dementia,
although most (207; 49%) opted for annual review, 37%
(153/418) would have suggested giving up driving.
This is contrary to current opinion, and would have
resulted in unnecessary driving restriction. Responses
to the difficult case of the individual with severe
dementia who persists in driving raises the issue of
where responsibilities lie. The most common answer
was to convey to the general practitioner that advice
not to drive has been given. The reluctance of
geriatricians to inform the DVLA is reflected in only
20% of responders (82) expressing a willingness to
breach confidentiality in patients with severe dementia. It is apparent that doctors would only breach
confidentiality as a last resort.
Table 3 shows the responses to patients with
cardiovascular and Parkinson’s disease. Of particular
interest is that 214 respondents would have made a
clinical decision to permit the patient with nonsustained ventricular tachycardia to continue to drive.
This advice would be contrary to recommendations by
the DVLA, which are that the driving status of such
patients should be assessed by the DVLA.
The presence of a fully functioning pacemaker is not
a contra-indication to driving, yet 58 geriatricians (14%)
were uncertain whether patients with a pacemaker
should drive a car.
Discussion
In some parts of the world, there are stringent
Driving in elderly patients
Table 2. Responses of geriatricians to patients with ‘mild’ dementia and with more ‘severe’ dementia
Case history
Response
........................................................................................................................................................................................................................
1: ‘Mild’ dementia
A 70-year-old man attends your clinic with his wife. She reports that he has had increasing problems with his memory and
that he is not quite as sharp when they are playing bridge. In addition, she notices his concentration wavers when they are
at the theatre. He drives his car with his wife present and manages perfectly well with her assistance only requiring her to
find the car after he has parked it in unfamiliar locations.
Full assessment including a psychiatric and psychological assessment together with a computed tomography scan of the
brain, reveal that the man is suffering from early Alzheimer’s disease.
He retains insight and is keen to continue to drive.
Would you?
(a)
(b)
(c)
(d)
(e)
Suggest he give up driving
Have his driving assessed on an annual basis
Recommend that he should continue to drive as before
Leave the decision to the patient
Don’t know
37% (153/418)
49% (207/418)
2% (7/418)
2% (9/418)
10% (42/418)
2: ‘Severe’ dementia
A 72-year-old man is admitted to your ward with an acute confusional state. He is treated for a urinary tract infection and
undergoes computed tomography scan of head which reveals marked degenerative changes consistent with the clinical
diagnosis of dementia. His acute confusional state settles and he is discharged home where he has full family support.
He is seen at the day hospital where it is discovered that he is still driving despite the advice from his family and general
practitioner. You advise him strongly that he should give up driving but he refuses.
Do you?
(a) Advise his general practitioner you have strongly suggested he give up driving
(b) Breach patient confidentiality and inform the DVLA
(c) Document clearly in the medical notes that you have informed him to give up driving and take no further action
(d) Don’t know
(e) Both a and c
27% (113/418)
20% (82/418)
18% (77/418)
18% (77/418)
17% (65/418)
DVLA, Driving and Vehicle Licensing Authority.
guidelines for elderly patients who wish to continue
driving motor vehicles. For example in Finland [9],
after the age of 70 years, people who wish to continue
to drive must pass a medical review and apply for a
new licence. In the UK the guidelines are less
demanding. Under section 94 of the Road Traffic Act
1988, it is the responsibility of the licence holder to
notify DVLA of any medical condition which may affect
his or her fitness to drive [10]. It is, however, part of a
doctor’s duty of care to know the standards of fitness to
drive and to advise patients who become unfit that
they must stop driving and notify the DVLA [11]. It is
therefore surprising that 33% of consultants were
unaware that patients have a responsibility to inform
the DVLA when they reach 70 years of age, if they plan
to continue to drive. Geriatricians must be aware of the
legal requirements for driving, as elderly drivers under
their care may have potentially dangerous medical
conditions. The main responsibility of medical practitioners is to provide patients with appropriate
information and advice on driving. Doctors could be
held legally responsible if a patient under their care,
with an important medical condition, were to be
involved in a road traffic accident.
Most doctors surveyed (75%) appreciated that
overall responsibility for informing the DVLA about
driving matters lies with the patient. In the initial set of
questions, 83% of respondents reported that they
Table 3. Advice geriatricians would offer to patients with cardiac disease and Parkinson’s disease
No. (and %) of geriatricians, by action chosen
..............................................................................................................................................
Case history
Inform DVLA
Permit to drive
Advise to give up driving
Don’t know
........................................................................................................................................................................................................................
3: Asymptomatic ventricular tachycardia
4: Cardiac pacemaker (otherwise well)
5: Poorly controlled Parkinson’s disease
161 (38%)
114 (27%)
220 (53%)
214 (51%)
246 (59%)
43 (10%)
7 (2%)
2 (1%)
88 (21%)
36 ( 9%)
56 (13%)
67 (16%)
DVLA, Driving and Vehicle Licensing Authority.
55
N. D. Gillespie et al.
would breach patient confidentiality if required. In the
case of the patient with the more severe dementia who
refused to give up driving, some doctors would have
failed to inform the DVLA immediately (62%, 255/418).
Instead, they would have documented the case clearly
in the case notes and left the ultimate responsibility
with the patient’s general practitioner. However, it is
likely from the comments of the respondents that
doctors would only inform the DVLA against a patient’s
wishes as a last resort following exhaustive efforts by
themselves, the general practitioner and the patient’s
family in an attempt to persuade them to give up driving.
The results of our study demonstrate that over onethird of patients with ‘mild’ dementia would have been
encouraged to give up driving. Clearly this is a clinical
decision but more widespread knowledge of recent
studies may facilitate the continued driving of some
patients under supervised conditions [12].
Objective methods of assessing patients’ ability to
drive are needed. Potentially useful ways of assessing
competence to drive include multidisciplinary assessment, neuropsychological testing, visual assessment
and formal on-road testing. In one study [13] an
assessment of activities of daily living was a useful
predictor of competence behind the wheel.
One problem is the paucity of facilities for testing
on-road competence in the UK. Memory clinics [14]
have been set up in the last 10 years and these may
evolve a role in advising elderly patients with memory
disorders on whether they should drive.
Patients with Parkinson’s disease may have particular difficulties when driving [6]. For periods of ‘on–
off’ phenomenon, it would be sensible to recommend
cessation of driving. However, the situation is less clear
in patients with milder Parkinson’s disease as it is
always difficult to predict when the patient might
deteriorate. This is reflected in the responses which
demonstrate that 220 cases (53%) would have been
referred to the DVLA for assessment.
With regard to patients with cardiac pacemakers, it
is safe for them to drive as long as the pacemaker is
functioning satisfactorily. The reliability of permanent
cardiac pacemakers is now established. Patients with a
tachy-arryhthmia should only be issued with a licence
for a short period subject to regular review. The DVLA
regulations stipulate that driving must cease with any
arrhythmia which may distract the driver’s attention or
render him or her liable to sudden impairment of
cerebral function. As a result, many of the respondents
would have incorrectly reassured a patient with
symptomatic ventricular tachycardia. In such circumstances where doubt exists, it is prudent to discuss the
situation with the DVLA directly (without naming the
patient) and seek the advice of a cardiologist. A copy of
the DVLA’s fitness-to-drive book [15] should perhaps
be kept in the clinic as it is unrealistic to expect doctors
to have detailed knowledge about each condition that
might affect driving.
56
In conclusion, this postal survey of British geriatricians highlights a wide range of opinions and views
on elderly drivers. Geriatricians and other doctors
should be aware not only of the regulations but also the
clinical situations where the issue of driving should be
raised. Better education should improve awareness of
both when elderly drivers can safely continue to use
the road and when underlying medical problems
should prompt encouragement to seek other means
of transport.
Acknowledgements
The authors would like to thank the secretarial and
nursing staff in the Section of Ageing and Health and in
particular A. Makarewicz for assistance with the
manuscript. We would also like to thank Chris Lien
for his assistance with data analysis and Paul Thompson
for suggestions.
Key points
• 67% of British geriatricians were aware of the legal
responsibility for patients to re-apply for their
driving licence once they reached the age of 70.
• 75% of respondents stated that the overall responsibility for informing the Driving and Vehicle
Licensing Authority was with the patient.
• In patients with severe dementia, 83% of geriatricians would have breached patient confidentiality
and informed the DVLA.
• Many geriatricians (51%) would have incorrectly
reassured a patient with asymptomatic ventricular
tachycardia that they could drive legally.
• There was a wide variation in knowledge of driving
regulations amongst responding geriatricians.
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Received 6 March 1998; accepted 19 March 1998
57
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