Resources for assessing and counseling older drivers are available to guide clinicians in difficult conversations with elderly patients about whether it is safe for them to continue driving. But few clinicians have any idea what to tell younger drivers who have suffered a critical illness.
After landing in the ICU with a severe illness, as many as 60% of adults develop long-term problems with cognition, making pain pills mental health, or physical function, a group of symptoms known as post-intensive care syndrome (PICS). Yet no guidelines exist for fitness to drive for critical care survivors.
Dr Timothy Girard
“It’s sort of the Wild West,” said Timothy Girard, MD, MSCI, an associate professor of critical care medicine at the University of Pittsburgh School of Medicine. “Patients are left on their own to figure it out, or clinicians are left on a case-by-case basis to try to sort this out.”
Dr Kelly Potter
A research letter published this week in JAMA Internal Medicine by Girard and first author Kelly Potter, PhD, RN, CNE, a postdoctoral researcher at the University of Pittsburgh, illustrates the need for better assessment tools for PICS patients.
The group followed up 126 patients (median age, 58 years) 1 month after discharge from an ICU stay lasting at least 4 days for sepsis, respiratory failure, or delirium. Patients were asked about driving status before and after the illness. Research staff completed assessments using standardized instruments to measure frailty, ability to conduct activities of daily living, anxiety, depression, posttraumatic stress disorder, and cognition.
The researchers found few differences at baseline between those who had resumed driving and those who had not in terms of age, gender, education, preexisting chronic medical conditions, and assessments of frailty.
But few patients felt comfortable getting back on the road again: at the 1-month follow-up point, only 16 (13%) of 126 patients had resumed driving. Not surprisingly, “the patients who had resumed driving had better physical function and better cognition than those who had not resumed driving,” Potter told Medscape Medical News,
Although the group back behind the wheel scored higher on average for several domains, half of those driving received low enough scores on one instrument ― the Montreal Cognition Assessment (MoCA) ― to trigger alarms. Studies involving older drivers suggest that low scores on the MoCA generally predict impaired driving skills. Potter said the scores definitely “raise some questions about their safety on the road.”
Girard and Potter said the new findings shine a headlamp on the challenges PICS patients face in resuming driving and on the need for screening tools to use with patients who have suffered critical illnesses.
Linda Hill, MD, MPH, the director for the Training Research and Education for Driving Safety at UC San Diego, said she was not surprised by the results. Hill led a study that involved screening hospitalized patients who were older than 65 years for driving fitness. The investigators found many with unrecognized cognitive problems. “There were a lot of people with cognitive impairment, but there was nothing on their charts,” she said.
Hill has worked on driver safety since 2005 and served on the advisory panel for the Clinician’s Guide to Assessing and Counseling Older Drivers. She said a good starting point would be to assess PICS patients “whether they’re from the ICU or just from the community and you’re seeing them in your office.” Key screening domains, she added, should include “vision, frailty, cognitive impairment, the medications that they’re on, and then other medical conditions that could lead to lapse of consciousness.”
The study was supported in part by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health (Potter). Girard has received grants from Ceribell Inc and personal fees from Lungpacer Medical Inc and Haisco Pharmaceutical Group Co Ltd outside the submitted work. Potter and Hill have disclosed no relevant financial relationships.
JAMA Intern Med. Published online March 27, 2023. Full text
Ann Thomas is a pediatrician and epidemiologist based in Portland, Oregan.
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