Prevalence of Potentially Inappropriate Medication use in older drivers

Background

Potentially Inappropriate Medication (PIM) use has been studied in a variety of older adult populations across the world. We sought to examine the prevalence and correlates of PIM use in older drivers.

Methods

We applied the American Geriatrics Society 2015 Beers Criteria to baseline data collected from the “brown-bag” review of medications for participants of the Longitudinal Research on Aging Drivers (LongROAD) study to examine the prevalence and correlates of PIM use in a geographically diverse, community-dwelling sample of older drivers (n = 2949). Proportions of participants who used one or more PIMs according to the American Geriatrics Society 2015 Beers Criteria, and estimated odds ratios (ORs) and 95% confidence intervals (CIs) of PIM use associated with participant characteristics were calculated.

Results

Overall, 18.5% of the older drivers studied used one or more PIM. The most commonly used therapeutic category of PIM was benzodiazepines (accounting for 16.6% of the total PIMs identified), followed by nonbenzodiazepine hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%). Compared to older drivers on four or fewer medications, the adjusted ORs of PIM use were 2.43 (95% CI 1.68–3.51) for those on 5–7 medications, 4.19 (95% CI 2.95–5.93) for those on 8–11 medications, and 8.01 (95% CI 5.71–11.23) for those on ≥12 medications. Older drivers who were female, white, or living in urban areas were at significantly heightened risk of PIM use.

Conclusion

About one in five older drivers uses PIMs. Commonly used PIMs are medications known to impair driving ability and increase crash risk. Implementation of evidence-based interventions to reduce PIM use in older drivers may confer both health and safety benefits.

Trial registration

Not applicable.

Relationship Between Physical Activity and Motor Vehicle Crashes Among Older Adult Drivers

Background: There are approximately 42 million licensed drivers aged 65 years or older in the United States, who face unique age-related risks while driving. While physical activity affects several chronic conditions thought to be associated with motor vehicle crashes (MVCs), it is unclear if increased physical activity leads to fewer MVCs. This study explores whether self-reported vigorous and moderate physical activity is associated with MVCs in the previous year. Methods: Using cross-sectional data from the LongROAD study, a large multisite prospective cohort study of 2990 older adult drivers, we examined variables related to physical activity and performed a multivariate regression analysis to examine the association of physical activity health behaviors with self-reported MVCs. Results: Overall, 41.2% of participants reported vigorous and 69.6% of participants reported moderate exercise at least once per week. Eleven percent of participants reported at least 1 MVC in the previous year. Neither vigorous nor moderate physical activity was significantly associated with self-reported MVCs in the previous year. Select variables that were significantly associated with self-reported MVC included self-reported unsafe driving practices (odds ratio [OR] 1.55, confidence interval [CI] 1.05-2.29), and fall in the past 12 months (OR 1.46, CI 1.14-1.85). Conclusions: We were unable to detect a significant association between self-reported physical activity and MVCs in the past year among this group of older drivers. Use of objective measures of activity may better clarify this relationship.

Patterns of Self-Reported Driving While Intoxicated Among Older Adults

Objective: This study examines the prevalence of self-reported driving while intoxicated (DWI) among drivers aged 65 and older. Method: This cross-sectional study was based on baseline data from the AAA Longitudinal Research on Aging Drivers (LongROAD) study, a multisite prospective cohort study of 2,990 older adult drivers. Alcohol-related variables from the baseline questionnaire were examined in relation to demographics, health status, and driving behaviors. A logistic regression model assessed variables associated with DWI. Results: Of the 2,990 participants, 72.7% reported consuming alcohol, 15.0% reported high-risk drinking, and 3.3% reported DWI. High-risk drinking (OR = 12.01) and risky driving behaviors (OR = 13.34) were significantly associated with at least occasional DWI. Avoidance of hazardous driving conditions (OR = 0.71) and higher level of comfort during challenging driving scenarios (OR = 0.65) were less likely to be associated with DWI. Conclusion: A large number of older adults engage in high-risk drinking and DWI. Public health education and DWI-related interventions should include older adults.

Preventing Firearm-Related Death and Injury

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

"Hey, let me hold your guns for a while": A qualitative study of messaging for firearm suicide prevention

A recommended component of suicide prevention is encouraging at-risk individuals to voluntarily and temporarily reduce access to firearms and other lethal methods. Yet delivering counseling on the topic can be difficult, given the political sensitivity of firearm discussions. To support such counseling, we sought to identify recommended framing and content of messages about reducing firearm access for suicide prevention. Through qualitative interviews with firearm owners and enthusiasts, we identified key points for use in framing (identity as a gun owner, trust, voluntary and temporary storage, and context and motivation) and specific content (preference for "firearm" over "gun," and legal issues such as background checks for transfers). These findings build on prior work and should enhance efforts to develop and deliver effective, acceptable counseling and-ultimately-prevent firearm suicide.

Importance of Driving and Potential Impact of Driving Cessation for Rural and Urban Older Adults

PURPOSE

Analyses compared older drivers from urban, suburban, and rural areas on perceived importance of continuing to drive and potential impact that driving cessation would have on what they want and need to do.

METHODS

The AAA LongROAD Study is a prospective study of driving behaviors, patterns, and outcomes of older adults. A cohort of 2,990 women and men 65-79 years of age was recruited during 2015-2017 from health systems or primary care practices near 5 study sites in different parts of the United States. Participants were classified as living in urban, surburban, or rural areas and were asked to rate the importance of driving and potential impact of driving cessation. Logistic regression models adjusted for sociodemographic and driving-related characteristics.

FINDINGS

The percentages of older drivers rating driving as "completely important" were 76.9%, 79.0%, and 83.8% for urban, suburban, and rural drivers, respectively (P = .009). The rural drivers were also most likely to indicate driving cessation would have a high impact on what they want or need to do (P < .001). After adjustment for sociodemographic and driving-related characteristics, there was a 2-fold difference for rural versus urban older drivers in odds that driving cessation would have a high impact on what they need to do (OR = 2.03; 95% CI: 1.60-2.58).

CONCLUSIONS

Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful. Strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults.

Gun Retailers' Willingness to Provide Gun Storage for Suicide Prevention

Objectives: We examined factors grounded in the theory of planned behavior that influence gun retailers' willingness to provide temporary, voluntary firearm storage for suicide prevention. Methods: We conducted a cross-sectional survey of gun retailers in the US mountain west. Analyses included descriptive statistics and ordered logistic regression. Results: Ninety-five gun retailers responded to the survey (25% response rate) and 67.6% (95% CI: 59.6, 75.6) stated that they would be very or somewhat likely to provide temporary gun storage. Firearm retailers who agreed with the statements: "Our store can be an important part of the effort to improve gun safety in my community" (OR: 1.86, 95% CI: 1.1, 3.14) and that offering storage provided "The chance to be seen as a positive member of the community" (OR: 1.49, 95% CI: 1.00, 2.22) were more likely to state that they would be willing to provide storage. Conclusions: Firearm retailers are potentially important storage partners for means safety and suicide prevention efforts. Additional research and practice innovations are needed to assess gun retailers' willingness to provide gun storage and partner on suicide prevention efforts in other geographic regions.

Law Enforcement Agencies' Perceptions of the Benefits of and Barriers to Temporary Firearm Storage to Prevent Suicide

OBJECTIVES

To examine the perceived benefits of and barriers to law enforcement agencies providing increased access to voluntary and temporary firearm storage.

METHODS

We surveyed 448 police chiefs and sheriffs in 8 US Mountain West states about firearm storage practices, benefits of and barriers to storage, and related attitudes and beliefs. Data collection occurred during the spring and summer of 2016.

RESULTS

Nearly three quarters of agencies reported that they are already providing storage and perceive relatively few barriers in doing so. Agency characteristics were not associated with current provision of firearm storage. Among the barriers identified included state laws, limited space, training needs, and community perceptions. Benefits of storage included being perceived positively by the community and supporting health care workers.

CONCLUSIONS

Engaging with law enforcement agencies in suicide prevention efforts and addressing their perceived barriers to providing temporary firearm storage have promise as part of a comprehensive suicide prevention approach.

Self-reported health conditions and related driving reduction in older drivers

We surveyed self-reported lifetime health conditions (using National Health and Aging Trends Study questions) and related driving reduction in a large multi-site older driver cohort (n = 2990) from the AAA Longitudinal Research on Aging Drivers (LongROAD) Study's baseline assessment. Those reporting reduced driving (n = 337) largely attributed reduction to musculoskeletal (29%), neurologic (13%), and ophthalmologic (10%) conditions. Women reported health condition-related driving reduction more often than men (14% versus 8%, p<.001). Mobility affects well-being; health professionals should consider that health conditions may cause older adults to reduce driving. Gender differences deserve attention in future research and education efforts.

Social Disconnection Among Older Adults Receiving Care in the Emergency Department

INTRODUCTION

Social disconnection is a public health problem in older adults, as it can lead to decreased quality of life for this population. This study describes the prevalence of social disconnection and patient interest in social resources to address social disconnection among older adults receiving emergency department (ED) care.

METHODS

We conducted a cross-sectional survey of community-dwelling older adults (≥65 years) receiving care at two U.S. EDs. We described participant characteristics (demographic, social, and health variables), social disconnection prevalence, and desire for social resources using percentages and 95% confidence intervals. Then, we performed Chi Square tests and logistic regression to determine factors associated with positive screens for social disconnection.

RESULTS

Of 289 participants, 51% were female and the median age was 72 (interquartile range: 69-78). Most (76%) engaged with the community regularly, and 68% reported driving. Regarding social disconnection, a substantial minority of participants reported feeling as if they were burdensome to others (37%); as if they didn't belong (27%); or that people would be better off if they were gone (15%); 52% reported at least one of these. In separate regression analyses, the perceptions of being a burden or better off if gone were each significantly associated with needing help with routine tasks (odds ratio [OR] [5.87, 5.90]); perceived burden was associated with hospitalization in the prior month (OR [2.09]); and low belonging was associated with not engaging in the community regularly (OR [2.50]), not seeing family regularly (OR [3.82]), and difficulty affording food (OR [2.50]). Regarding potential ED referrals, most participants were interested in transportation options (68%), food assistance (58%), and mental health resources (55%). Participants experiencing difficulties affording food were interested in food and housing assistance (p=.03; p=.01).

CONCLUSION

Over half of this sample of older ED patients reported feeling socially disconnected. Social and functional health problems are often related and both must be addressed to optimize older ED patient quality of life. Future research should consider the impact of social disconnection on older adults discharged from the ED and work to develop ED services that could refer this population to programs that may decrease social disconnection.

'Lock to Live': development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide

OBJECTIVES

We sought to (1) clarify decision needs among suicidal adults with home firearm access; (2) identify accurate, unbiased and acceptable approaches for content and messaging; and (3) develop a tablet-delivered decision aid for firearm storage options.

METHODS

Following international standards, we used stakeholder interviews to develop a decision aid for the decision, 'what option(s) to choose to reduce home access to firearms for an adult at risk of suicide'. Participants were adults with personal or family history of suicidal ideation or behaviours, firearm ownership or employment in a firearm range or store, involvement in suicide prevention field, or work as emergency department or other healthcare provider.

RESULTS

Through 64 interviews, we created the 'Lock to Live' decision aid, which includes (1) introduction specifying the decision, (2) clarification of preferences and logistics, (3) table of storage options and (4) summary with specific next steps. The final tool had high user acceptability.

CONCLUSIONS

Should the 'Lock to Live' decision aid prove useful in a pilot feasibility trial and subsequent testing, it could enhance lethal means counselling and help prevent firearm suicide.

Emergency Department patients with suicide risk: Differences in care by acute alcohol use

OBJECTIVE

To compare Emergency Department (ED) care of suicidal patients with and without documented acute alcohol use.

METHODS

Retrospective chart review of randomly sampled patient visits (n = 800; January 2014 to December 2015) at an urban ED with universal screening for suicide risk. Eligible visits were by adults (18+ years) who screened positive for suicide risk at the ED visit (i.e., suicidal ideation in past two weeks or suicide attempt in past six months). Analyses compared those with and without documentation of acute alcohol use.

RESULTS

Among these patients with suicide risk, 19% had documented acute alcohol use (versus 43% with no use and 38% without documentation); individuals with acute alcohol use were more often male and aged 35-59 years. Overall, 62% were evaluated by a mental health professional in the ED. Individuals with acute alcohol use were significantly less likely (vs those without use) to be evaluated by a mental health professional in the ED (odds ratio 0.49, 95%CI 0.28-0.87) after adjustment for age, recent suicide ideation, current suicide plan, self-harm as a chief complaint, contact with family, and ED disposition.

CONCLUSIONS

Although alcohol use can increase suicide risk, ED patients with acute use appear to receive less thorough suicide risk assessments.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders

INTRODUCTION

For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling.

METHODS

We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse.

RESULTS

From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%).

DISCUSSION

Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Predictors of Readiness for Mobility Transition in Older Drivers

We administered the Assessment of Readiness for Mobility Transition (ARMT) to 301 older drivers and compared total scores with participant characteristics. Overall, 18% of participants were not attitudinally ready for mobility transition, while 19% were very ready. Notably, participants with hospitalizations in the past year were either very ready for mobility transition (20% vs 14% without hospitalizations) or not ready at all (30% vs 17%). Significant health events may polarize reactions towards mobility transition. Individualizing communication about driving cessation readiness could help address such differing views. To further consider its effectiveness, ARMT could be utilized in mobility transition counseling interventions.

Prospective Validation of a Screening Tool to Identify Older Adults in Need of a Driving Evaluation

OBJECTIVES

To prospectively validate and refine the 5-item "CRASH" screening tool for identifying older drivers needing a behind-the-wheel (BTW) test.

DESIGN

Prospective observational study.

SETTING

Geriatric and internal medicine primary care clinics affiliated with a tertiary care hospital and a local BTW program.

PARTICIPANTS

Cognitively intact drivers aged 65 and older (N = 315).

MEASUREMENTS

Participants completed baseline questionnaire (including CRASH tool) and assessments and BTW test (evaluator blinded to questionnaire results) and participated in 1-month telephone follow-up. Analysis included descriptive statistics and examination of predictive ability of the CRASH tool to discriminate normal (pass) from abnormal (conditional pass or fail) on the BTW test, with logistic regression and CART techniques for tool refinement.

RESULTS

Two hundred sixty-six participants (84%) had a BTW test; of these, 17% had a normal rating and 83% an abnormal rating. Forty-five percent of those with an abnormal score were advised to limit driving under particular conditions. Neither the CRASH tool nor its individual component variables were significantly associated with the summary BTW score; in refined models with other variables, the best-performing tool had approximately 67% sensitivity and specificity for an abnormal BTW score. Most participants found the BTW test useful and were willing to pay a median of $50. At 1-month follow-up, no participants had stopped driving.

CONCLUSION

The CRASH screening tool cannot be recommended for use in clinical practice. Findings on older adults' perceived utility of the BTW test and the stability of driving patterns at 1-month follow-up could be useful for future research studies and for design of older driver programs.

How Should Physicians Make Decisions about Mandatory Reporting When a Patient Might Become Violent?

Mandatory reporting of persons believed to be at imminent risk for committing violence or attempting suicide can pose an ethical dilemma for physicians, who might find themselves struggling to balance various conflicting interests. Legal statutes dictate general scenarios that require mandatory reporting to supersede confidentiality requirements, but physicians must use clinical judgment to determine whether and when a particular case meets the requirement. In situations in which it is not clear whether reporting is legally required, the situation should be analyzed for its benefit to the patient and to public safety. Access to firearms can complicate these situations, as firearms are a well-established risk factor for violence and suicide yet also a sensitive topic about which physicians and patients might have strong personal beliefs.

Associations Between Falls and Driving Outcomes in Older Adults: Systematic Review and Meta-Analysis

OBJECTIVES

To examine associations between falls and subsequent motor vehicle crashes (MVCs), crash-related injuries, driving performance, and driving behavior.

DESIGN

Systematic review and metaanalysis.

PARTICIPANTS

Observational studies including drivers aged 55 and older or with a mean age of 65 and older.

MEASUREMENTS

Two authors independently extracted study and participant characteristics, exposures, and outcomes and assessed risk of bias. Pooled risk estimates for MVCs and MVC-related injuries were calculated using random-effects models. Other results were synthesized narratively.

RESULTS

From 3,286 potentially eligible records, 15 studies (N = 27-17,349 subjects) met inclusion criteria. Risk of bias was low to moderate, except for cross-sectional studies (n = 3), which all had a high potential for bias. A fall history was associated with a significantly greater risk of subsequent MVC (summary risk estimate = 1.40, 95% confidence interval (CI) = 1.20-1.63; I2  = 28%, N = 5 studies). One study found a significantly greater risk of MVC-related hospitalizations and deaths after a fall (hazard ratio = 3.12, 95% CI = 1.71-5.69). Evidence was inconclusive regarding an association between falls and driving cessation and showed no association between falls and driving performance or behavior.

CONCLUSION

Falls in older adults appear to be a risk marker for subsequent MVCs and MVC-related injury. Given the nature of the evidence, which is limited to observational studies, the identified associations may also result at least partly from confounding or bias. Further research is needed to clarify the mechanisms linking falls to crash risk and to develop effective interventions to ensure driving safety in older adults with a history of falls.

Longitudinal Research on Aging Drivers (LongROAD): study design and methods

BACKGROUND

As an important indicator of mobility, driving confers a host of social and health benefits to older adults. Despite the importance of safe mobility as the population ages, longitudinal data are lacking about the natural history and determinants of driving safety in older adults.

METHODS

The Longitudinal Research on Aging Drivers (LongROAD) project is a multisite prospective cohort study designed to generate empirical data for understanding the role of medical, behavioral, environmental and technological factors in driving safety during the process of aging.

RESULTS

A total of 2990 active drivers aged 65-79 years at baseline have been recruited through primary care clinics or health care systems in five study sites located in California, Colorado, Maryland, Michigan, and New York. Consented participants were assessed at baseline with standardized research protocols and instruments, including vehicle inspection, functional performance tests, and "brown-bag review" of medications. The primary vehicle of each participant was instrumented with a small data collection device that records detailed driving data whenever the vehicle is operating and detects when a participant is driving. Annual follow-up is being conducted for up to three years with a telephone questionnaire at 12 and 36 months and in-person assessment at 24 months. Medical records are reviewed annually to collect information on clinical diagnoses and healthcare utilization. Driving records, including crashes and violations, are collected annually from state motor vehicle departments. Pilot testing was conducted on 56 volunteers during March-May 2015. Recruitment and enrollment were completed between July 2015 and March 2017.

CONCLUSIONS

Results of the LongROAD project will generate much-needed evidence for formulating public policy and developing intervention programs to maintain safe mobility while ensuring well-being for older adults.