Author	Affiliation
Shahram Lotfipour, MD, MPH	University of California Irvine, Department of Emergency Medicine, Irvine, California
Victor Cisneros, BS	University of California Irvine, Department of Emergency Medicine, Irvine, California
Bharath Chakravarthy, MD, MPH	University of California Irvine, Department of Emergency Medicine, Irvine, California

“TRAUMA CODE NOW” sounds overhead throughout the emergency department (ED). The emergency physician (EP), the resident, and the trauma team begin to gown, glove, and prepare for patient arrival. On arrival the patient is moved from the stretcher to a hospital bed, and a methodical process ensues. The paramedics begin to report their findings as the team is assessing the pale, 79-year-old female, who lies covered with blood under a white sheet. Both arms appear deformed, and there is shattered glass strewn in her hair and lacerations along her orbits and nose. After assessment, it was determined that the patient had a possible polypharmacy side effect that impaired her vision and driving abilities, causing her to collide with the center divider at 65mph. As the geriatric population increases, these types of events will become a more recurrent image in EDs.1,2 From 2001 to 2009 there was a 79% increase in older adult visits to EDs in the western United States, thus making it one of the fastest growing demographics.3

According to the Centers for Disease Control, in 2009 there were 33 million licensed drivers 65 years and older in the U.S. This represents a 23 percent increase from 1999, a number that is predicted to double by 2030.1,4 An increase in the number of older drivers will result in increasing ED visits as a result of older-adult motor vehicle collisions (MVC).1,4 According to Vogel et al., the MVC-related ED visit rates for older adults are lower per capita than for younger adults, yet older-adult MVCs require more resources, such as additional diagnostic imaging. There is also a trend toward increased odds of admission. Furthermore, they conclude that allocation of healthcare resources in the ED is important for implementation of appropriate diagnostic and treatment protocols for optimized care of this growing older-adult patient population.1

Many government and private agencies have concentrated their efforts on understanding and reducing the risk associated with MVC in older drivers.5 However, very few have focused on implementing more appropriate resources for older-adult MVCs.6–11 Not enough research currently exists to show the significance of addressing the specific needs of older-adult trauma patients and whether this will lead to better outcomes.9,12,13 According to Mangram et al, older-adult patients with specialized treatment resources have a decrease in all the following areas: average ED length of stay (LOS), average ED to operating room time, average surgical intensive care unit LOS, average hospital LOS, and a decrease in mortality rate.9,12

Driving is important for older adults because it helps them remain mobile and independent, but as adult drivers increase in age, this also represents an increased risk of being injured or killed in a MVC.4,14–15In older patients the presence of multiple comorbidities, age-related decline in vision and cognitive functioning, such as ability to remember and reason, as well as other physical changes, can affect older adults’ driving ability and increase their susceptibility to injury.2,4,8,11,16–19 These factors can make it difficult for a healthcare provider to recognize the “red flags” that indicate an older driver should no longer be driving. Therefore, it is important to continue training EPs and other healthcare providers to treat the increasing older-patient population, but it is also imperative that we increase our injury prevention and screening methodology. The American College of Emergency Physicians (ACEP) believes that EPs have the responsibility to affect the health of the public by leading the integration of injury prevention and control into their practices as they interact in different practice settings.20 One way we can lead this effort is to increase injury prevention education in emergency medicine residents, medical students, and healthcare providers.20–24 ACEP has a list of recommendations that includes education in medical schools and hospitals to encourage the development of evidence-based injury prevention education and its inclusion into routine clinical practice to identify patients at risk for injury.20 ACEP also recommends educating the public, policy makers, and community leaders about injury prevention and screening methods.

Education can be essential in preventing older-adult MVCs.24,25 The CDC has established several steps that older adults can take to stay safe on the road. These recommendations include: consulting their physician or pharmacist to review medicine side effects and interactions that can inhibit driving abilities; regular visual function testing;26 finding the safest route with well-lit streets; and exercising regularly to increase strength and flexibility.4 Unfortunately, many of the screening and assessment tools of fitness-to-drive of older persons have not been validated or do not exist in an evidence-based methodology.27–28 This leaves EPs to rely more on subjective impression then on objective methods.28Therefore, more research is needed in this area to help develop clinical measures and practical tools that can be used in EDs to objectively assess fitness-to-drive.27,28

Many of the recommendations might not reach our patients in time if clinicians and older drivers wait to discuss prevention mechanisms for safer driving until there are specific “red flags,”29 such as being a MVC victim, which at times can be too late – as in our 79-year-old female patient. Recent studies have shown that older drivers are open to discussing their driving plans with physicians, support the idea of mandatory age-based testing, and are more likely to follow recommendations from physicians or family members.30–31 Older drivers who are asked to take a driving test at the Department of Motor Vehicle (DMV) often do not meet the DMV’s minimum vision requirement or have been referred because of a physical or mental condition or lack of driving skills.32 Many times law enforcement officers, relatives, friends, and physicians refer older drivers to the DMV to check driving abilities.32 This supports the important role an EP can play when assessing the driving abilities of older drivers.30 It is important that EPs, as care providers of this population, partner with different agencies and community leaders to increase awareness of the specific needs and resources of this growing older adult population in efforts to prevent the increase of older-adult MVC victims.

Footnotes

Address for Correspondence: Shahram Lotfipour, MD, MPH, Center for Trauma and Injury Prevention Research, Department of Emergency Medicine, 101 The City Drive, Rte 128-01, Orange, CA 92868. Email: shl@uci.edu. 11 / 2013; 14:582 – 584

Submission history: Revision received July 13, 2013; Submitted July 27, 2013; Accepted July 31, 2013

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

REFERENCES

1. Vogel J, Ginde A, Lowenstein S Emergency Department Visits by Older Adults for Motor Vehicle Collisions: A Five-year national study. West J Emerg Med. 2013; 2:122-130

2. Chakravarthy B, Shah S, Lotfipour S Prescription drug monitoring programs and other interventions to combat prescription opioid abuse. West J Emerg Med. 2012; 13:422-425

3. Pines J, Mullins P, Cooper J National Trends in Emergency Department Use, Care Patterns, and Quality of Care of Older Adults in the United States. Geriatric Soc. 2013; 61:12-17

4. Injury Prevention & Control: Motor Vehicle Safety (2013). . ;

5. Grotsky T, Lotfipour S The dilemma of increasing media scrutiny on older-adult driving fitness. Cal J Emerg Med. 2006; 7:34-36

6. Mansuri O, Hoonpongsimanont W, Vaca F The crisis in emergency and trauma care in California and the United States. Cal J Emerg Med. 2006; 7:81-86

7. Lotfipour S, Howard J, Roumani S Increased detection of alcohol consumption and at-risk drinking with computerized alcohol screening. J Emerg Med. 2013; 44:861-866

8. Kennelly SP, Morely D, Coughlan T Knowledge, skills and attitudes of doctors towards assessing cognition in older patients in the emergency department. Postgrad Med J. 2013; 89:137-141

9. Mangram AJ, Mitchell CD, Shifflette VK Geriatric trauma service: a one-year experience. J Trauma Acute Care Surg. 2012; 72:119-122

10. Lotfipour S, Cisneros V, Anderson CL Assessment of alcohol use among Spanish-speaking patients. Subst Abus. 2013; 34:155-161

11. Lotfipour S, Sayegh R, Chakravarthy B Fatality and Injury Severity of Older Adult Motor Vehicle Collisions in Orange County, California, 1998–2007. West J Emerg Med. 2013; 14:63-68

12. Bonne S, Schuerer DJ Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clin Geriatr Med. 2013; 29:137-150

13. McCoy CE, Chakravarthy B, Lotfipour S Guidelines for Field Triage of Injured Patients: In conjunction with Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention. West J Emerg Med. 2013; 14:69-76

14. Lotfipour S, Kaku SK, Vaca FE Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009; 10:19

15. Why Are Older Drivers at Risk?. . 2013;

16. Samaras N, Chevalley T, Samaras D Older Patients in the Emergency Department: A Review. Ann Emerg Med. 2010; 56:261-269

17. Ewing T, Barrios C, Lau C Predictors of hazardous drinking behavior in 1,340 adult trauma patients: a computerized alcohol screening and intervention study. J Am Coll Surg. 2012; 215:489-495

18. Lotfipour S, Mortazavi R, Chakaravarthy B Commentary: Alcohol and motor vehicle-related crashes—driver attitudes need further intervention. Ann Emerg Med. 2011; 57:406-408

19. Chu I, Vaca F, Stratton S Geriatric trauma care: challenges facing emergency medical services. Cal J Emerg Med. 2007; 8:51-55

20. Role of the Emergency Physician in Injury Prevention and Control for Adult and Pediatric Patients. . 2013;

21. Wilding L, O’Brien JA, Pagliarello G Survey of current injury prevention practices by registered nurses in the emergency department. J Emerg Nurs. 2008; 34:106-111

22. Betz M, Li G Injury prevention and control. Emerg Med Clin North Am. 2007; 25:901-914

23. McDonald EM, MacKenize EJ, Teitelbaum SD Injury prevention activities in the U.S. trauma centers: are we doing enough?. Injury. 2007; 38:538-547

24. Yoshii I, Sayegh R, Lotfipour S Need for injury-prevention education in medical school curriculum. West J. Emerg Med. 2010; 11:40-43

25. Anderson KL, Patel CV, Vaca F Traffic law knowledge disparity between Hispanics and non-Hispanic whites in California. J Emerg Med. 2011; 40:687-695

26. Lotfipour S, Patel BH, Grotsky TA Comparison of the visual function index to the Snellen Visual Acuity Test in predicting older adult self-restricted driving. Traffic Inj Prev. 2010; 11:503-507

27. Betz ME, Fisher J The Trail-making Test B and driver screening in the emergency department. Traffic Inj Prev. 2009; 10:415-420

28. Molnar FJ, Marshall SC, Man-Son-Hing M Acceptability and concurrent validity of measures to predict older driver involvement in motor vehicle crashes: An Emergency Department Pilot case control study. Accid Anal Prev. 2007; 39:1056-1063

29. Betz M, Jones J, Petroff E “I Wish we could Normalize Driving Health:” A Qualitative Study of Clinician Discussions with Older Drivers. J Gen Intern Med. 2013;

30. Betz ME, Lowenstein SR, Schwartz R Older adults opinion of “Advance driving directives.”. J Prim Care Community Health. 2013; 14:14-27

31. Bestz ME, Schwartz R, Valley M Older adult opinions about driving cessation: a role for advanced driving directives. J Prim Care Community Health. 2012; 3:150-154

32. Senior Driver: Driving Tests. . 2013;