I got a phone call the other day from my old pal Leo. He hemmed and hawed for a few moments before admitting that he needed a favor: He was out of food and hoped I could give him a ride to the grocery store. “I’ve got nothing to eat, Boss,” he lamented.
My octogenarian comrade gave up his car keys a few years ago as Parkinson’s began taking its toll, and he’s been relying on his vast network of friends to get from point A to point B ever since. On this particular occasion his promised ride had canceled, forcing him to recalibrate on an empty stomach. It’s not the first time I’ve received the SOS.
I’ve never been quite sure how Leo managed to assemble his personal rideshare program, but I’m relieved that he’s no longer behind the wheel. Those final years sitting in the passenger seat of his ancient Buick as he meandered along busy city streets always left me a little faint-hearted — and concerned about his welfare. He admitted at one point that he stopped driving because he worried about getting lost, but I worried about the collision waiting for him around the next corner.
It’s a concern that routinely weighs on family and friends of the more than 50 million American seniors navigating our streets and freeways these days. As Judith Graham reports in KFF Health News, motor vehicle deaths among the Medicare set rose by 34 percent between 2012 and 2021; more than 266,000 senior drivers were injured in crashes in 2021.
Those realities have sparked an interest in creating a process to establish some guardrails for elderly drivers confronting their own limitations. Modeled loosely after the popular healthcare directives that older adults create to declare their treatment preferences should they find themselves unable to clearly state their case when decisions need to be made, an advance directive for driving spells out the conditions under which a senior will agree to no longer get behind the wheel.
For Lewis Morgenstern, 59, the directive will take effect when he turns 65. “I recognize that I might not be able to make the best decision about driving at a certain point, and I want to make it clear I trust my children to take over that responsibility,” he tells Graham.
Morgenstern, MD, a professor of neurology, neurosurgery, and emergency medicine at the University of Michigan, is more conversant on this topic than most. In a 2023 article he coauthored in the Journal of the American Geriatrics Society, he cited research showing that 61 percent of cognitively impaired seniors are still on the road, despite concerns from their caregivers.
Versions of these directives range from simply naming someone who will discuss with the elderly driver whether it’s time to give up the car keys to spelling out various alternative transportation options and committing friends or family to provide rides when necessary. One type of directive focuses specifically on drivers displaying symptoms of dementia, asking them to acknowledge their limitations and support any efforts undertaken to keep them off the road.
These directives may help families and caregivers better plan for the point at which their loved one is no longer able to safely navigate traffic, notes Elin Schold Davis, OTRL, former coordinator of the Older Driver Initiative at the American Occupational Therapy Association.
“We should all be planning for our changing transportation needs in our 70s, 80s, and 90s, she says. “The hard part is that driving is associated with independence, and this is such an emotional issue. But the more people look ahead, the more choice and control they have.”
To determine whether and when someone is no longer able to safely navigate traffic, however, is a dicey process. In a recent JAMA editorial, neurologist Kirk Daffner, MD, and neuropsychologist Margaret O’Connor, PhD, argue that few neurologists or general practitioners are equipped to evaluate the cognitive abilities and driving skills of seniors because common cognitive screening tests do not necessarily predict a patient’s ability to drive safely.
“They must adjudicate whether patients are unfit to drive without having the most relevant information, which is direct observation of driving performance,” they write.
Only occupational therapists who specialize in evaluating the cognitive abilities and driving skills of elderly drivers can serve as the kind of “objective third party” that Daffner and O’Connor believe can “reduce the burden on patient-family and patient-physician relationships that can be strained by decisions about driving competence.”
But such therapeutic services can be pricey, putting them out of reach for many seniors. That’s why Daffner and O’Connor contend that Medicare should offer coverage. While federal officials may argue that such evaluations lack the “medically necessary” threshold governing many coverage decisions, the authors argue the risk of injuries from driving are analogous to the risk of falling.
And, they add, you could make the case that it’s a public health imperative. “Coverage of driving assessments differ in one crucial way — impaired drivers pose safety risks for not only themselves but also the public at large.”
Such a change would require congressional approval, so we’re not likely to see much movement in that direction any time soon. All of which may argue for a wider dissemination of information about advance directives for driving. Not everyone is as willing as my pal Leo to give up their car keys, after all. And even fewer can be assured that when they reach out for a ride someone will answer the phone and pick them up.
