MKSAP Quiz: Evaluation after multiple motor vehicle collisions
An 82-year-old woman is evaluated after a motor vehicle collision. She has had three minor motor vehicle collisions in the past 2 years. Her family has noticed mild memory lapses in the past 6 months. Following a physical and ophthalmic exam and Mini-Cog test, what is the most appropriate management?
An 82-year-old woman is evaluated after a motor vehicle collision. She has had three minor motor vehicle collisions in the past 2 years. Her family has noticed mild memory lapses in the past 6 months. Her only medical problem is depression, which is treated effectively with sertraline.
On physical examination, vital signs are normal. Ophthalmic examination reveals bilateral minimal opacity of the lenses consistent with early cataracts. Visual acuity is 20/40 bilaterally. The Mini-Cog test shows inability to recall three words.
Which of the following is the most appropriate management?
A. Discontinue sertraline
B. Recommend she retire from driving
C. Refer for cataract removal
D. Restrict driving to within a 5-mile radius of home
MKSAP Answer and Critique
The correct answer is B. Recommend she retire from driving. This content is available to MKSAP subscribers as Question 43 in the General Internal Medicine 1 section. More information about MKSAP is available online.
The most appropriate management is to recommend that this older patient with several previous motor vehicle collisions (MVCs) and cognitive impairment retire from driving (Option B). Drivers older than 65 years are associated with more traffic fatalities than any other group of drivers older than 25 years. Older drivers are at risk for accumulating deficits in multiple areas that affect driving safety, including vision, cognition, and mobility. However, driving is a highly valued instrumental activity of daily living, and cessation of driving is associated with social isolation and depression. The decision to discontinue driving is thus a complex and somewhat subjective assessment that often requires partnering between the patient, family, and clinician. If modifiable risk factors for driving safety are present, interventions to address those risk factors with subsequent reassessment may be an appropriate strategy. In this case, the patient has an abnormal result on the Mini-Cog test. The Mini-Cog is sensitive (76%-100%) but not highly specific (54%-85%) in the diagnosis of dementia. On the basis of this patient's history of MVCs and cognitive impairment, a recommendation to retire from driving is appropriate. This recommendation should be accompanied by a discussion of future transportation, including resources that can be provided by the family and a referral to community resources that would allow her to live independently and continue participating in social activities that are important to her.
Discontinuation of centrally acting medications can improve driving safety in older adults. Sertraline has been effective in treating this patient's depression, however, so discontinuation (Option A) would be inappropriate. Undertreated or untreated depression is also a risk factor associated with MVCs in older adults.
The presence of cataracts without significant impact on visual acuity would not necessarily be an indication for cataract removal (Option C). Visual acuity between 20/40 and 20/70 is not associated with increased MVC risk.
Many older drivers self-restrict to driving only in areas with which they are familiar or during daytime hours. This patient has demonstrated unsafe driving on the basis of multiple MVCs. Combined with cognitive impairment, this makes her driving unsafe even with restrictions (Option D).
Key Point
- The decision to advise an older driver to retire from driving is qualitative, complex, and largely dependent on clinician judgment; the evaluation should consider the known risk factors and underlying medical conditions.