Driving and the elderly
What is the ophthalmologist's role in certifying older patients for driving?
The full details are unclear, but on January 17, 2019, Prince Philip, Duke of Edinburgh was involved in a road traffic accident near Queen Elizabeth II’s private home, the Sandringham estate in Norfolk, England.
According to a report from the BBC, the 97-year-old lost control of the Land Rover Range Rover he was driving and made contact with another car carrying two women and a baby. The driver of the other car was unscathed, as was the child, but the adult passenger broke her wrist in the accident. A bystander reported hearing that the Duke told police he had been dazzled by the sun.
While most of the headlines focused on the fact of Prince Philip’s position and the well-being of the injured woman, the incident also opened up a conversation about driving and the elderly.
What is the protocol for older drivers? While specifics vary in different jurisdictions, roughly similar rules abound. In both the United Kingdom and Ireland, drivers older than 70 are required to renew their licence every one-to-three years. In the UK, drivers must meet minimum eyesight requirements, which are as follows:
You must be able to read (with glasses or contact lenses, if necessary) a car number plate made after 1 September 2001 from 20 metres.
You must also meet the minimum eyesight standard for driving by having a visual acuity of at least decimal 0.5 (6/12) measured on the Snellen scale (with glasses or contact lenses, if necessary) using both eyes together or, if you have sight in one eye only, in that eye.
In Ireland, however, drivers older than 70 require a certification of fitness to drive by their doctor.
“This includes a cardiac and neurological and cognitive assessment as well as vision and hearing,” says Dr Tony Cox, Medical Director of the Irish College of General Practitioners. “Assessment of their mobility and independence is also undertaken. It’s a thorough enough assessment.”
A doctor can certify for one or three years, and can add restrictions to person’s range and time of driving.
Arthur Cummings MD describes this assessment: “It needs to be mentioned whether you first of all pass the required 6/12 with spectacles and if you don’t wear spectacles, whether you pass the 6/12 without spectacles. The license then states whether you need to wear spectacles or not.”
Mr Cummings, Consultant Ophthalmic Surgeon and Medical Director of the Wellington Eye Clinic and Head of the Department of Ophthalmology Beacon Hospital, Dublin, continues: “The second requirement is doing a binocular visual field test to ensure that the visual field is wide enough and the current requirement is 150°.”
Speaking to EuroTimes in 2014, Louis Kartsonis MD, a general ophthalmologist in San Diego, California, US, described a scenario where a patient presented with high visual acuity but her family informed him that she was displaying early signs of Alzheimer’s.
“You have two ways to go with a case like this,” said Dr Kartsonis. “One, you could say my job as an ophthalmologist is vision care, and my responsibility stops with evaluating the status of vision. But we have to recognise a larger picture, particularly in a case where driving accidents have already occurred.”
In California, a doctor can file a report with the Department of Motor Vehicles questioning the patient’s fitness to drive. The patient then receives a letter informing them that their licence has been suspended and requesting they perform a hearing, vision, written and driving tests.
Concerned doctors – GPs or ophthalmologists – can take simple steps to test patients’ cognitive functions. These include trail making, where the patient is asked to draw lines connecting circled letters and numbers in different sequences, and the clock drawing test.
In this test the patient is asked to draw a clock face, drawing in the 12 hours and then drawing in the hands to a specific time. If the patient is unable to complete the task it is a clear sign of cognitive impairment.
While these are rudimentary tests and should not be used in isolation, they may help to point in the direction of a diagnosis.
Ultimately, the directions are clear. However, the remaining unknown is the quality of the relationship between the patient and GP, which can be built up over many years and can be shattered in moments.
With patients referred to him by GPs, the issue can go one of two ways, says Mr Cummings: “Many times the issue is due to a cataract and we can resolve it with surgery and sometimes unfortunately it is due to something like advanced glaucoma, or age-related macular degeneration and then the news is less good.”
It may also fall to the patient’s family to step in. The ability to drive can be someone’s lifeline, a symbol and manifestation of their independence. This will not be given up lightly. Patient safety, however, and that of other road users, is paramount.