INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 10: 15-17 (1995)

DEPRESSION AND DRIVING IN THE ELDERLY JUDY RUBINSZTEIN* AND CLAIRE ALISON LAWTON?

*Senior House OBcer in Psychiatry, ?Consultant Psychiatrist for the Elderly, Fulbourn Hospitul, Cambridge, UK

SUMMARY

Elderly, depressed patients have particular problems which may hamper their ability to drive a motor car safely. Attention and psychomotor functioning are important for safe driving. These factors are commonly impaired in depression. In addition, age-related decreases in these functions have been shown. The elderly often have other disabilities which may hamper driving, for example poor vision and reduced strength. All these factors may be cumulative and need to be considered by the doctor advising an elderly depressed patient on their ability to drive. These issues are highlighted in this article using two case histories of elderly patients involved in motor car crashes who were depressed.

KEY WORDS-Depression, affective disorder, aged, automobile driving.

Advice to elderly patients on their fitness to drive has recently been the subject of discussion in the literature (Retchin and Anapolle, 1993). Medical and psychiatric disorders, for example cardiovascu- lar disease, seizure disorder, diabetes (Hansotia, 1993) and dementia (Friedland et af., 1988; Gilley et al., 1991; O’Neill et al., 1992) have received parti- cular attention. Little, however, has been written about the effect of mood change, particularly depression, on driving skills in the elderly. There are more drivers today than ever before, with a proportional increase in the number of elderly drivers. Depressive symptoms occur in approxi- mately 15% of people over 65 living in the com- munity (Addonizio and Alexopoulos, 1993).

In this article we describe two patients admitted recently to our acute geriatric psychiatry ward with major depressive disorder, both of whom had motor car crashes in the few days prior to admis- sion. We go on to discuss some of the areas in this unresearched field which may merit further investigation.

CASE 1

An 81-year-old married man was admitted as an emergency, following a failed suicide attempt. Pre-

Address for correspondence: Dr J. S . Rubinsztein, Fulbourn Hospital, Cambridge CBI 5EF, UK. Tel: 0223 21889. Fax: 0223 218992.

cipitants for his current depressive disorder were: the death of a brother, to whom he was close, from cancer 2 years previously and the death of his son from cancer 3 months previously. He had an acci- dental car crash 4 days prior to admission in which his car had been ‘written off. He had accepted lia- bility and admitted to having ‘lost his concentration while driving’. Case 1 had biological features of depression with a particularly striking pattern of diurnal variation as well as reduced attention and concentration. He fulfilled the DSM-111-R and ICD 10 criteria for major depressive episode and scored 26/30 on mini mental state examination (Folstein et al., 1975). He had no past psychiatric history and he was not taking an antidepressant on admis- sion. He responded well to lofepramine and was discharged after 2 months in hospital. On discharge he scored 29/30 on mini-mental state examination. He decided voluntarily to stop driving.

CASE 2

A 77-year-old man was admitted to a medical ward after an infective exacerbation of chronic obstruc- tive airways disease. During his recovery in the medical ward he was found to be severely depressed with psychomotor retardation. His wife had died 3 months before. The patient had nursed her for 7 years following a severe cerebrovascular accident. A few days prior to admission to the medical ward he had a motor crash in which his car had been

CCC 0885-6230/95/010015--03 0 1995 by John Wiley & Sons, Ltd.

Received 23 March 1994 Accepted I0 June I994

16 J. RUBINSZTEIN AND C. A. LAWTON

‘written off. He had accepted liability for the acci- dent. He fulfilled DSM-111-R and ICD 10 criteria for major depressive disorder and showed marked psychomotor retardation. It was difficult to con- verse with him because of his severe emphysema and current mental state. A full mini mental score was never completed because of this, but he was fully orientated with good recall of recent and past events. He had no past psychiatric history and he was not taking an antidepressant when admitted. There was no evidence of sleep apnoea. Lofepra- mine was commenced on the medical ward. After his medical condition was considered stable, he was transferred to the acute old age psychiatry ward. He showed some improvement on lofepramine after 2 weeks but required transfer back to the medical ward after developing a pneumothorax. This was treated but he died a week later in the medical ward after a second pneumothorax.

Both of these patients had impaired attention and concentration and psychomotor retardation and these factors may have contributed towards their car crashes. Although depression was only diagnosed in these cases after the car crashes, rela- tives confirmed that both patients had been depressed before the event. This is an important point as the psychiatric consequences of road traf- fic accidents are well recognized (Mayou, 1992).

We felt a number of factors contributed towards their ability to drive which are shared by many patients. Even in the non-depressed elderly, there is frequently some psychomotor slowing as a conse- quence of ageing. The reason for this is not clear and is probably due to a combination of peripheral and central processes (Retchin and Anapolle, 1993). Age-related decreases in reaction time, divided attention (performing two or more simul- taneous tasks) and selective attention (filtering out unrelated tasks) have been shown in a laboratory setting (Marottoli and Drickamer, 1993). Driving is considered a good example of a divided attention task, for example with increased traffic density or at driving intersections where divided attention is important (Parasuraman and Nestor, 1993).

When people are depressed, attention and con- centration as well as psychomotor functioning are known to be affected and are an integral part of the diagnosis. In the elderly patient where there are also age-related decreases in these functions, the effect is likely to be cumulative. Vision and strength (unimpaired in our patients) are also important for driving (Retchin and Anapolle, 1993).

After controlling for miles driven, older drivers do have higher crash rates per mile driven than any other age group, except for those under the age of 24 (Retchin and Anapolle, 1993). Even after adjusting per mile, however, the increased risk does not begin until the age of 70. It rises rapidly after the age of 80. There is no work on whether this increased risk is significantly higher in the depressed elderly.

Neither of our patients was treated prior to admission, but antidepressants are frequently pres- cribed to depressed outpatients. Antidepressant medication, particularly the more sedating tri- cyclics, for example amitriptyline, imipramine and doxepin, has been shown after a single dose to impair psychomotor function, attention and con- centration and motor coordination (Ray et al., 1993). Ray et a[. (1992) found in elderly drivers that current use of tricyclic antidepressants resulted in a more than doubled risk of involvement in in- jurious car crashes. Caution needs to be exercised before allowing patients on certain antidepressants to drive. Lofepramine has been shown to have neg- ligible effects on psychomotor function as mea- sured by car handling tasks (Hindmarsh, 1988). Serotonin specific reuptake inhibitors would also have been an appropriate choice.

Guidance for medical practitioners in the United Kingdom comes from the Driving Vehicle Licens- ing Agency (1993). They suggest that in psychosis and schizoaffective disorders, patients requiring hospital admission should not drive for 6 1 2 months after an acute episode. Patients with neuro- sis need not be notified and driving need not cease. Depression is mentioned as an example of a neuro- sis and manic depressive disorder is mentioned under psychosis. Non-psychotic depression, as categorized in ICD 10 under mood disorders, is not classified as a separate category. No recommen- dations for driving practice are given for patients who have been acutely psychotic and managed as outpatients.

Our two patients are extreme examples of the possible effect of depression on driving ability. The depressed elderly patient is probably at greater risk of involvement in a motor crash because of changes associated with depression, as described above, together with the added effect of age-related changes. Further controlled studies are needed to elucidate the effects of depression in the elderly driver. In the meantime, and perhaps even more importantly, clinicians need to be aware that many of their older patients drive and that depression

DEPRESSION AND DRIVING IN THE ELDERLY 17

needs to be considered in the overall assessment of fitness to drive.

REFERENCES

Addonizio, G. and Alexopoulos, G. S. (1993) Affective disorders in the elderly. Int. J . Geriatr. Psychiat. 8, 4147.

Driving Vehicle Licensing Agency (1993) At a Glance Guide to the Current Medical Standards of Fitness to Drive. DVLA, Swansea.

Folstein, M. F., Folstein, S. E. and McHugh, P. R., (1975) Mini Mental State: A practical method forgrad- ing the cognitive state of patients for the clinician. J . Psychiatr. Res. 12, 189-198.

Friedland, R. P., Koss, E., Kumar, A., Gaine, S., Metzler, D., Haxby, J. V. and Moore, A. (1988) Motor vehicle crashes in dementia of the Alzheimer type. Ann. Neurol. 24, 782-786.

Gilley, D. W., Wilson, R. S., Bennett, D. A,, Stebbins, G. T., Bernard, B. A., Whalen, M. E. and Fox, M. D. (1991) Cessation of driving and unsafe motor vehicle operation by dementia patients. Arch. Intern. Med. 151,941-946.

Hansotia, P. (1 993) Seizure disorders, diabetes mellitus, and cerebrovascular disease: Consideration for older drivers. Clin. Geriatr. Med. 9, 323-339.

Hindmarsh, 1. (1 988) The psychopharmacological approach: Effects of psychotropic drugs on car hand- ling. Znt. Clin. Psychopharm. 3, Suppl. I, 73-79.

Marottoli, R. A. and Drickamer, M. A. (1993) Psycho- motor mobility and the elderly driver. Clin. Geriatr. Med. 9,403-4 12.

Mayou, R. (1992) Psychiatric aspects of road traffic acci- dents. Int. Rev. Psych. 4,45-54.

O'Neill, D., Neubauer, K., Boyle, M., Gerrard, J., Sur- mon, D. and Wilcock, G . K. (1992) Dementia and driving. J. Roy. Soc. Med. 85, 199-202.

Parasuraman, R. and Nestor, P. (1993) Attention and driving assessment in elderly individuals with dementia. Clin. Geriatr. Med. 9, 377-387.

Ray, W. A., Fought, R. L. and Decker, H. D. (1992) Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers. Am. J . Epidemiol. 136,873-883.

Ray, W. A., Thapa, P. B. and Shorr, R. I. (1993) Medica- tions and the older driver. Clin. Geriatr. Med. 9, 41 3- 438.

Retchin, S. M. and Anapolle, J . (1993) An overview of the older driver. Clin. Geriatr. Med. 9, 279-296.