- Email: [email protected]
Senior driving under the influence
Accepted Manuscript Title: Senior Driving Under the Influence Authors: Benjamin Kirsch, Christoph G. Birngruber, Reinhard Dettmeyer PII: DOI: Reference:
S0379-0738(17)30173-1 http://dx.doi.org/doi:10.1016/j.forsciint.2017.05.002 FSI 8840
To appear in:
FSI
Received date: Revised date: Accepted date:
31-1-2017 29-3-2017 2-5-2017
Please cite this article as: Benjamin Kirsch, Christoph G.Birngruber, Reinhard Dettmeyer, Senior Driving Under the Influence, Forensic Science Internationalhttp://dx.doi.org/10.1016/j.forsciint.2017.05.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Senior Driving Under the Influence A five-year retrospective study of alcoholized road-users aged 70 and over
Authors: Benjamin Kirsch Dr. med. Christoph G. Birngruber Prof. Dr. med. Dr. jur. Reinhard Dettmeyer
Corresponding Author: Dr. med. Christoph G. Birngruber Institute of Legal Medicine at Justus-Liebig-University Frankfurter Straße 58 35392 Giessen Germany E-mail: [email protected]
Highlights
404 cases of seniors driving under the influence of alcohol were analyzed. 72% of the alcoholized seniors participated in road traffic as car drivers. In 48.5% of the cases, drunk driving was associated with an accident. Medication intake was affirmed in 60% of the cases, pre-existing illness in 54.5%. Medical examination should be adapted to polypharmacy and multimorbidity.
Abstract The demographic development in Germany shows a steady increase to senior citizens. The driving suitability of older road-users is of large social and political concern, because awareness and reactivity can be influenced by age-related diseases and potential medication, particularly in combination with the consumption of alcohol. This study provides an overview of senior road-users under the influence of alcohol. Therefore, 404 cases of drunken-driving by road-users aged 70 and over within the purview of the Institute of Legal Medicine at Justus-Liebig-University, Giessen, from the years 2009 to 2013 were evaluated in retrospect. The vast majority of the drivers were male (88.4% of the cases). Distribution of the blood alcohol concentrations were almost equally in male and female drivers with 62.8% of all cases showing a blood alcohol concentration (BAC) of more than 1.1‰ and 10.9% a BAC of more than 2.0‰. In 48.5% of the cases, drunk driving was
associated with an accident. 54.5% of the drivers stated suffering from at least one disease and 60% admitted a regular medication or an intake prior to the incident. Moreover, the collected data includes aspects such as the kind of traffic participation as well as neurological and physiological deficits of the road-users. If accidents were caused by drunk driving, the external circumstances and consequences of these accidents were analyzed, too. The evaluation revealed, that the standard medical examination protocol proved to be improbable to cover polypharmacy and multimorbidity of older alcoholized drivers. So, an evaluation and adaptation of the common medical examination protocol must be considered.
Keywords Alcohol, traffic, senior, driving suitability, medical examination
1. Introduction In recent years, demographic trends in the Federal Republic of Germany led to a steady increase in the proportion of seniors among the population. According to the Federal Statistical Office, in 2013 16% of the German citizens were aged 70 years or older. Looking at current calculations, this share is expected to increase to 20% by the year 2030 [1]; therefore, also the share of the older road-users is steadily growing. In this respect, there is a large public interest in the driving suitability of elderly people, since perception and responsiveness can be influenced by an agerelated increase of morbidity. In 2007 the Higher Regional Court of Celle, Germany, decided, that the high age of a road-user alone, even in connection with major driving errors, does not justify the conclusion of physical deficiencies affecting driving safety [2]. Pottgießer et al. concluded similarly in 2012, when they said, that not the age alone but the individual combination of age-related, physical restrictions and possibly existing medication has evident influence on the driving safety [3]. However, if the driving fitness is affected by any kind of disease, such as unstable cardio-vascular disorders or diabetes, German law demands a reevaluation of the driving suitability [4]. Kaiser discussed the requirements for road safety programs for senior drivers in 2003. He proclaimed, there was a complex interaction of degenerative processes on one hand and compensation mechanisms, learned through years of experience, on the other hand. So, the need for assistance and problem management must be determined for each elderly traffic participant individually [5]. In 2016, Germann et al. compared different compensation strategies of elderly road-users. They concluded, that an individual amount of self-awareness helps to identify subjective limitations of driving skills. Similar to the reports mentioned above, high age alone was not considered a risk [6]. Currently developed driver assistance systems can possibly be adapted specifically to the needs and deficits of the elderly drivers [7]. As Rudisill et
al. discussed in 2016, the influence of alcohol on driving ability deserves a higher attention in the age group of the elderly, considering the influence of physical constitution and possibly existing medication on alcohol tolerance [8]. Alcohol consumption in higher ages is not a rare phenomenon as Du et al. showed in 2008, when they analyzed a collective of 1605 elderly German adults and showed a last week prevalence of 47.3% for alcohol consumption as well as 15.1% for risky drinking behavior [9]. So, a possible combination of high age and alcohol seems to be a risk to traffic safety, that should not be underestimated. Since data on that matter is scarcely to be found in literature, this work provides an overview of alcoholized elderly road-users, their impairments, and the consequences of drunken driving in high age. Additionally, we evaluate the current medical examination and check, if it captures the impairments of senior drunken drivers sufficiently.
2. Material and methods In the years 2009 - 2013, 26,395 blood alcohol tests had been analyzed at the Institute of Legal Medicine at Justus-Liebig-University, Giessen. Retrospectively, the data on blood alcohol tests of persons aged > 70 years were looked up in the digital archive of the institute using Microsoft Access®. Beforehand, study design and data collection were approved by the ethics committee of the medical faculty at JustusLiebig-University. Following the acquisition, the data was anonymized for further analysis, making it impossible to trace back information to a certain person. In 404 of these cases, blood alcohol tests were conducted in a drunkenness-associated event in road traffic. In addition to that, police reports and medical examination protocols of this collective were evaluated to gain insight into the circumstances of the drunkenness and the condition of the alcoholic user. Moreover, an insight into the corresponding files of the respective public prosecutor’s office took place. These files provided information about the legal consequences as well as the nature and implications of traffic accidents. The analysis of the data and the graphics shown in this article were created with Microsoft Excel®.
3. Results In the analyzed collective, the gender comparison shows a clearly unequal weighting with 47 female versus 357 male traffic participants in the age of 70 and over. Men and women, however, distribute similar by blood alcohol concentrations (BAC) (Fig. 1). 25.5% of the women and 27.7% of the men show a BAC of between 0.5 and 1.1‰, which would be a legal offence according to § 24a of the German Road Traffic Law (StVG), provided, that no additional change of behavior had occurred. Whereas 70.2% of the women and 61.9% of the men showed a BAC above the 1.1‰ limit at
the time of blood collection. Post-offence drinking aside, this level of BAC complies with the criminal offence mentioned in § 316 of the German Penal Code (StGB) [10]. The investigated cases were divided into 171 traffic offenses, 196 traffic accidents and 37 contraventions. Drunken driving was associated with an accident in 48.5% of the cases. In the 404 cases, 375 police reports and medical examination protocols were available for further research at the time of data collection.
A detailed look at the distribution of the BAC by the road-users’ age at the time of the blood sampling shows, that most of the examined individuals aged 70-74 had a BAC of between 1.40‰ and 1.69‰. The peak of the 75-79 age group can be located at between 1.10‰ and 1.39‰, while the persons aged 80 and over seem evenly spread in the per thousand range below 2,0‰ (Fig. 2). The evaluation of the medical examination protocols showed, that during the motor coordination tests, 144 disorders in tandem gait and 164 failed sudden turn-arounds were documented. Dysmetria could be diagnosed in 144 cases with the finger-tofinger-test and in 124 cases with the finger-to-nose-test. 89 Persons showed a coarse post rotatory nystagmus lasting at least five seconds. This nystagmus test was not performed in 57% of the examinations, while it was stated explicitly in 61 of these cases, that the reason for not performing this test was a high risk of falling due to an impaired motor system. According to the respective examiner, said impairment based on a gait disorder suspected to be age-related (Fig. 3). A further aspect of the medical examination protocol was the question regarding a regular medication intake. 60% of the examined persons admitted a regular medication or at least a single intake prior to the time, the blood sample was taken. 27% declined taking any medication and 13% denied a statement. 220 examined persons declared suffering from at least one acute, chronic, or preexisting disease. A detailed look at the distribution of the different diseases shows, that most of them were illnesses affecting the cardio-vascular system like arterial hypertension or coronary artery disease followed by metabolic disorders such as diabetes or dyslipidemia. Degenerative musculoskeletal disorders such as osteoarthritis were stated in 32 cases. 25 of the stated diseases affected the central nervous system or the sensory perception. Moreover, a total of 16 road-users admitted suffering from a psychiatric disorder, with eleven persons having a drinking problem, three suffering from depression, and two suffering from dementia (Fig. 4). Looking at the gender distribution, 71% of the women in comparison to 59% of the men affirmed a medication. As shown, the extent of the documentation of medication and pre-existing diseases depends on the examining physician, as well as on, the compliance of the investigated person. Thus, in some cases, imprecise descriptions
are found, such as ‘blood pressure medication’ or ‘heart pill’, so neither the active substance nor the exact dose can be deduced. With a share of 72% most of the seniors participated in road traffic as car drivers. 8% went by motorcycle, while vehicles such as trucks, tractors or bicycles were used in single cases only. The respective prosecutor’s office provided insight into 133 accident offence files of the 196 accidents mentioned above. These files include more detailed observations of the accident, like light conditions, location of the accident, accident category and type of accident. The analyses of the police reports as part of the legal proceeding show, that 64 accidents happened in darkness, 58 in daylight, and 10 in twilight. In addition to the light conditions, these reports provide information about the accident’s location. About 108 accidents took place in urban territory, whereas 25 happened outside of any city limits. As demonstrated in Fig. 5, the distribution of the different types of traffic accidents shows, that 47% of the accidents were driving accidents, in which the driver lost control over his vehicle. In 17% the accident involved one stationary vehicle. Rearend or head-on collisions happened in 9% of the cases, while 5% of the accidents were caused by a vehicle turning into a road or crossing it. With a share of 4% a vehicle collided while turning off the road. An amount of 19% was not further categorized by the respective policeman. The different accident categories distribute as follows: in 66 cases, the material damage caused by the accident left the damaged vehicle still functioning, while in 21 cases the material damage was more severe and least one vehicle had to be towed from the scene of the accident. In 32 accidents, at least one participant suffered a slight injury. Severe injuries were inflicted in 14 cases, which required an intense clinical treatment for at least 24 hours. A fatal outcome was not reported in the analyzed collective (Fig. 6).
4. Discussion A more detailed analysis of the factors contributing to the drunkenness as a basis for a risk assessment of traffic participation in the elderly age seems necessary. The results presented above can be summarized as follows: The group examined in this study showed a gender-specific male dominated data situation with a male share of 88.4%. The tendency of the mean BAC decreases with increasing age. The overwhelming majority of 72% took part in road traffic as car drivers. In addition to the alcohol consumption 60% of the examined persons admitted a medication intake prior to the blood collection. The introduction of an age-adjusted protocol for the
medical examination during the blood collection should be considered, to obtain a structured overview of the medication and the morbidity of the drunk driver. An adaptation of the individual tests is also necessary, for in 16.2% of the cases an examination of the motor system could not be carried out or was not evaluated by the examiner, as there was a gait and / or stability failure which was regarded as agerelated and could not be attributed to either the alcoholization or the general condition of the examined person. When carried out, the tests revealed in 38.4% of the cases a failing tandem gait and in 43.7% a failed sudden turn-around. As other publications show, dizziness and associated gait disorders are no rare phenomena in the higher age. A report by Jahn et al. (2015) stated, that nearly 30% of the seniors suffered from vertigo at such an extent, that they felt restrictions in everyday life. The etiology of this vertigo was described as a combination of different aged-related processes [11]. Often it was caused by neurological malfunctions such as bilateral vestibulopathy, polyneuropathy, reduction of visus or benign paroxysmal positional vertigo. Furthermore, other diseases of the central nervous system like cerebellar ataxia or normal pressure hydrocephalus are possible triggers for dizziness. Also, dementia or psychiatric illnesses like anxiety disorders must be considered relevant. It seems rather difficult to differentiate between the influence of alcohol and a preexisting disease as the cause for a balance disorder when examining an alcoholized senior. Therefore, for the physician conducting the examination it is eminent to capture the various abnormalities as detailed as possible. Physical or mental impairments can aggravate the effect of alcohol or even imitate it. It is conceivable that such impairments caused driving failures in the first place. At this point the driving suitability in general is in doubt. In order to distinguish between the effects of alcohol and morbidity, we presume to conduct a second examination on the driver, this time in a sober condition. Additionally, mandatory driving suitability evaluations related to age or certain diseases can be established as a precautionary measure. Although here only two persons actually admitted suffering from dementia, literature shows, that this disease must be taken into consideration, if elderly drivers show signs of conspicuous behavior. Various researches show, that different forms of dementia have a significant influence on the handling of a vehicle, depending on the severity of the particular form. At an early stadium of the disease an impairment of the driving suitability is not mandatory [12, 13, 14]. Seeger postulated in 2015, that each year more than 16,000 new cases of dementia occur among road-users in Switzerland, a country with an infrastructure and demographic development similar to those of Germany [15]. Of course, a detailed dementia test is too extensive to perform in the context of a blood collection for the BAC determination. And, due to the influence of alcohol its significance would be doubtful. But in individual cases a thorough recording of any neurocognitive deficit or behavioral abnormality could lead the way to diagnose dementia. Analyzing the different items of the medical examination protocol showed us, that the evaluation of the eyesight is not part of the protocol. In 2012 the German Ophthalmologic Society demanded a regular ophthalmologic checkup for road users
aged 50 and over. Millions of German citizens suffer from cataract, macular degeneration or glaucoma. Due to the subtle character of these diseases’ progressions, they become symptomatic not until a considerable decline of the visual field [16]. In 2014 Desapriva et al. considered vision to be one of the key domains required for safe driving [17]. Bearing this in mind, it seems only logical to conduct regular evaluations of the eyesight of elderly road users. Also, an ophthalmologic test should be implemented into the medical examination at the time of the blood collection. Surprisingly, only 60% of the examined persons affirmed a medication intake in the 24 hours prior to the blood collection. Looking at the results of a study carried out by the German Robert-Koch-Institute in 2013 this share seems much too small. In this study 96.7% of the women and 92.6% of the men between 65 and 79 years of age took a medication or a nutritional supplement at least once a week [18]. The fact, that the examination protocol features just one single line to document the medication, seems insufficient considering the common polypharmacy in the elderly. Consequently, the sometimes confusing documentation of more than one preparation is prone to failure. In a report about drug abuse in high age Glaeske (2012) explained, that polypharmacy in the elderly increases the risk for adverse drug reactions (ADR) to occur. Especially drugs targeting structures in the central nervous system pose a risk [19]. Over the last decades, miscellaneous international groups of experts published lists of potentially inappropriate medications (PIMs) with the ambition to reduce the prescription of these active substances in the elderly [20, 21, 22]. The current layout of the examination protocol cannot cover the complex nature of such a multimedication and therefore proves to be inappropriate for the age group of the elderly.
5. Conclusions The high number of 404 cases of senior drunken drivers in our purview as well as the insufficient layout of the existing examination protocol showed us, that the combination of high age and alcohol in road traffic is clearly underestimated. We presume an adaptation of the examination protocol, that can assess the various particulars of multimorbidity and polypharmacy in the elderly. In the case of an alcoholized, aged person, a detailed and clear medical history is essential, to comprehensively record the causes of existing impairments. It is eminent to conduct further analyses of this age group and in addition comparisons to younger road users to evaluate and improve the risk assessment for elderly participation in road traffic. The collective analyzed here represents the rural area of the northern and middle parts of Hesse [23]. In 2009 Wilke et al. already carried out an evaluation of examination protocols of road-users aged > 60 years in the urban area of Hamburg [24]. Considering the future demographic development in the Federal Republic of Germany, this issue should not be underestimated.
References [1] Federal Statistical Office Germany, Population Projection, https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung/Bevoelker ungsvorausberechnung/Tabellen/AltersgruppenBis2060.html, 2013 (accessed: 24.01.2017). [2] Decision of the Higher Regional Court (OLG) of Celle, Germany, 07.08.2007, file number: 32 Ss 113/07. [3] S. Pottgießer, U. Kleinemas, K. Dohmes, L. Spiegel, M. Schädlich, G. Rudinger, Profiles of elderly drivers with accidents (PROSA), Berichte der Bundesanstalt für Straßenwesen. Unterreihe „Mensch und Sicherheit“ (2012) Heft M228. [4] See §§ 11, 46 and annex 4 of §11 of the German Driving License Regulations (FeV). [5] H. Kaiser, Road Safety Programs with the Elderly from the Viewpoint of Differential and Gerontopsychology. Zeitschrift für Gerontopsychologie & -psychiatrie 16 (2003), 131-140. [6] S. Germann, M. Schaul, P. Strohbeck-Kühner, Compensation strategies of elderly drivers. Rechtsmedizin 26 (2016) 279. [7] H. Hoffmann, C. Wipking, L. Blanke, M. Falkenstein, Experimental study to support the development of advanced driver assistance systems for elderly drivers. Unterreihe „Fahrzeugsicherheit“, Heft F86 (2013). [8] T.M. Rudisill, M. Zhu, M. Abate, D. Davidov, V. Delagarza, D.L. Long, U. Sambamoorthi, J.D. Thornton, Characterization of drug and alcohol use among senior drivers fatally injured in U.S. motor vehicle collisions, 2008-2012. Traffic Inj Prev. 17 (8) (2016) 788-95. [9] Y. Du, C. Scheidt-Nave, H. Knopf, Use of psychotropic drugs and alcohol among non-institutionalised elderly adults in Germany. Pharmacopsychiatry 41 (6) (2008) 242-251. [10] A. Dettling, M. Vermesse, G. Skopp, H.T. Haffner, Consideration of back calculation lag time in drinking after the event constellations. Rechtsmedizin 24 (2014) 381-386. [11] K. Jahn, R.W. Kressig, S.A. Bridenbaugh, T. Brandt, R. Schniepp, Dizziness and Unstable Gait in Old Age. Dtsch Arztbl Int. 112 (2015) 387-393. [12] J. Ernst, S. Krapp, T. Schuster, H. Förstl, A. Kurz, J. Diehl-Schmid, Car driving ability of patients with frontotemporal lobar degeneration and Alzheimer’s disease. Nervenarzt 81 (2010) 79-85.
[13] D.J. Iverson, G.S. Gronseth, M.A. Reger MA et al., Practice Parameter update: Evaluation and management of driving risk in dementia. Neurology 74 (16) (2010) 1316-1324. [14] D. Piersma, A.B.M. Fuermaier, D. de Waard, R.J. Davidse, J. de Groot, et al., Prediction of Fitness to Drive in Patients with Alzheimer's Dementia. PLOS ONE 11 (2) e0149566 (2016). [15] R. Seeger, Driving with dementia. Therapeutische Umschau 72 (2015) 239-245. [16] GMO, Augenärzte fordern „Augen-TÜV“ Versicherungsmedizin 64 (4) (2012) 205.
für
ältere
Autofahrer.
[17] E. Desapriva, R. Harjee, J. Brubacher, H. Chan, D.S. Hewapathirane, S. Subzwari, I. Pike, Vision screening of older drivers for preventing road traffic injuries and fatalities. Cochrane Database of Systematic Reviews Issue 2 Art. No.: CD006252 (2014). [18] H. Knopf, D. Grams, Arzneimittelanwendung Erwachsener in Deutschland. Bundesgesundheitsbl. 56 (2013) 868-877. [19] G. Glaeske, Arzneimittelmissbrauch im Alter. Geriatrie-Report 02 (2012) 14-16. [20] M.H. Beers, J.G. Ouslander, I. Rollinger, D.B. Reuben, J. Brooks, J.C. Beck, Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 151 (1991) 18251832. [21] D.M. Fick, J.W. Cooper, W.E. Wade, J.L. Waller, J.R. Maclean, M.H. Beers, Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 163 (2003) 2716-2724. [22] S. Holt, S. Schmiedl, P.A. Thürmann, Potentially Inappropriate Medications in the Elderly: The PRISCUS List. Dtsch Arztebl Int. 107 (2010) 543–551. [23] B. Kirsch, R. Dettmeyer, Driving under the influence of alcohol. Rechtsmedizin 26 (2016) 258-263. [24] N. Wilke, K. Püschel, C. Edler, Alkohol, Alter und Verkehr. Z Gerontol Geriat. 42 (2009) 185–192.
7
> 2.0 ‰
37
26
1.1 - 2.0 ‰
184
12
0.5 - 1.1 ‰
99
4
< 0.5 ‰
35 0
20
40
60
80
100 ♀
120
140
160
180
200
♂
Fig. 1: Distribution of BAC by sex in the case of road users aged > 70 years at the time of blood collection (n=404)
60 50 40 30 20 10 0 70 - 74
75 - 79
> 79
< 0.5‰
0.5 - 0.79‰
0.8 - 1.09‰
1.1 - 1.39‰
1.4 - 1.69‰
1.7 - 1.99‰
2.0 - 2.49‰
> 2.49‰
Fig 2: Distribution of BAC at the time of the blood collection by age (n=375)
250
200
150
214
100 164
146 144 50
85
99
112
130
148
144 101
124
103 72
89
0 Tandem gait
Turn-around normal
Finger-to-finger disorder
Nose-to-finger
Post rotatory nystagmus
no information
Fig. 3: Abnormalities in the coordination tests at the time of the blood sampling according to the medical examination protocol (n=375)
Rheumatic disorders
2
Cutaneous conditions
2
Neoplasms
9
Genitourinary disorders
12
Psychiatric diseases
16
Pulmonary diseases
19
Gastrointestinal diseases
21
Neurological disorders
25
Musculosceletal disorders
32
Metabolic disorders
71
Cardio-vascular diseases
183 0
20
40
60
80
100
120
140
160
180
Fig. 4: Distribution of diseases by functional system according to the medical examination protocol
200
70 62 60 50 40 30
25
22 20 12 7
10
5 0
0 Driving accident
Accident involving stationary vehicles
Accident Accident Accident Accident Other accident between caused by caused by caused by vehicles turning into a turning off the crossing the moving along road or by road road in carriageway crossing it
Fig. 5: Distribution of types of traffic accident according to legal proceedings (n=133)
70
66
60 50 40 32 30 21 20
14
10 0 0 Material damage
Slightly injured
Severe material damage
Seriously injured
Fatal accident
Fig. 6: Distribution of traffic accident categories according to legal proceedings (n=133)
S0379-0738(17)30173-1 http://dx.doi.org/doi:10.1016/j.forsciint.2017.05.002 FSI 8840
To appear in:
FSI
Received date: Revised date: Accepted date:
31-1-2017 29-3-2017 2-5-2017
Please cite this article as: Benjamin Kirsch, Christoph G.Birngruber, Reinhard Dettmeyer, Senior Driving Under the Influence, Forensic Science Internationalhttp://dx.doi.org/10.1016/j.forsciint.2017.05.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Senior Driving Under the Influence A five-year retrospective study of alcoholized road-users aged 70 and over
Authors: Benjamin Kirsch Dr. med. Christoph G. Birngruber Prof. Dr. med. Dr. jur. Reinhard Dettmeyer
Corresponding Author: Dr. med. Christoph G. Birngruber Institute of Legal Medicine at Justus-Liebig-University Frankfurter Straße 58 35392 Giessen Germany E-mail: [email protected]
Highlights
404 cases of seniors driving under the influence of alcohol were analyzed. 72% of the alcoholized seniors participated in road traffic as car drivers. In 48.5% of the cases, drunk driving was associated with an accident. Medication intake was affirmed in 60% of the cases, pre-existing illness in 54.5%. Medical examination should be adapted to polypharmacy and multimorbidity.
Abstract The demographic development in Germany shows a steady increase to senior citizens. The driving suitability of older road-users is of large social and political concern, because awareness and reactivity can be influenced by age-related diseases and potential medication, particularly in combination with the consumption of alcohol. This study provides an overview of senior road-users under the influence of alcohol. Therefore, 404 cases of drunken-driving by road-users aged 70 and over within the purview of the Institute of Legal Medicine at Justus-Liebig-University, Giessen, from the years 2009 to 2013 were evaluated in retrospect. The vast majority of the drivers were male (88.4% of the cases). Distribution of the blood alcohol concentrations were almost equally in male and female drivers with 62.8% of all cases showing a blood alcohol concentration (BAC) of more than 1.1‰ and 10.9% a BAC of more than 2.0‰. In 48.5% of the cases, drunk driving was
associated with an accident. 54.5% of the drivers stated suffering from at least one disease and 60% admitted a regular medication or an intake prior to the incident. Moreover, the collected data includes aspects such as the kind of traffic participation as well as neurological and physiological deficits of the road-users. If accidents were caused by drunk driving, the external circumstances and consequences of these accidents were analyzed, too. The evaluation revealed, that the standard medical examination protocol proved to be improbable to cover polypharmacy and multimorbidity of older alcoholized drivers. So, an evaluation and adaptation of the common medical examination protocol must be considered.
Keywords Alcohol, traffic, senior, driving suitability, medical examination
1. Introduction In recent years, demographic trends in the Federal Republic of Germany led to a steady increase in the proportion of seniors among the population. According to the Federal Statistical Office, in 2013 16% of the German citizens were aged 70 years or older. Looking at current calculations, this share is expected to increase to 20% by the year 2030 [1]; therefore, also the share of the older road-users is steadily growing. In this respect, there is a large public interest in the driving suitability of elderly people, since perception and responsiveness can be influenced by an agerelated increase of morbidity. In 2007 the Higher Regional Court of Celle, Germany, decided, that the high age of a road-user alone, even in connection with major driving errors, does not justify the conclusion of physical deficiencies affecting driving safety [2]. Pottgießer et al. concluded similarly in 2012, when they said, that not the age alone but the individual combination of age-related, physical restrictions and possibly existing medication has evident influence on the driving safety [3]. However, if the driving fitness is affected by any kind of disease, such as unstable cardio-vascular disorders or diabetes, German law demands a reevaluation of the driving suitability [4]. Kaiser discussed the requirements for road safety programs for senior drivers in 2003. He proclaimed, there was a complex interaction of degenerative processes on one hand and compensation mechanisms, learned through years of experience, on the other hand. So, the need for assistance and problem management must be determined for each elderly traffic participant individually [5]. In 2016, Germann et al. compared different compensation strategies of elderly road-users. They concluded, that an individual amount of self-awareness helps to identify subjective limitations of driving skills. Similar to the reports mentioned above, high age alone was not considered a risk [6]. Currently developed driver assistance systems can possibly be adapted specifically to the needs and deficits of the elderly drivers [7]. As Rudisill et
al. discussed in 2016, the influence of alcohol on driving ability deserves a higher attention in the age group of the elderly, considering the influence of physical constitution and possibly existing medication on alcohol tolerance [8]. Alcohol consumption in higher ages is not a rare phenomenon as Du et al. showed in 2008, when they analyzed a collective of 1605 elderly German adults and showed a last week prevalence of 47.3% for alcohol consumption as well as 15.1% for risky drinking behavior [9]. So, a possible combination of high age and alcohol seems to be a risk to traffic safety, that should not be underestimated. Since data on that matter is scarcely to be found in literature, this work provides an overview of alcoholized elderly road-users, their impairments, and the consequences of drunken driving in high age. Additionally, we evaluate the current medical examination and check, if it captures the impairments of senior drunken drivers sufficiently.
2. Material and methods In the years 2009 - 2013, 26,395 blood alcohol tests had been analyzed at the Institute of Legal Medicine at Justus-Liebig-University, Giessen. Retrospectively, the data on blood alcohol tests of persons aged > 70 years were looked up in the digital archive of the institute using Microsoft Access®. Beforehand, study design and data collection were approved by the ethics committee of the medical faculty at JustusLiebig-University. Following the acquisition, the data was anonymized for further analysis, making it impossible to trace back information to a certain person. In 404 of these cases, blood alcohol tests were conducted in a drunkenness-associated event in road traffic. In addition to that, police reports and medical examination protocols of this collective were evaluated to gain insight into the circumstances of the drunkenness and the condition of the alcoholic user. Moreover, an insight into the corresponding files of the respective public prosecutor’s office took place. These files provided information about the legal consequences as well as the nature and implications of traffic accidents. The analysis of the data and the graphics shown in this article were created with Microsoft Excel®.
3. Results In the analyzed collective, the gender comparison shows a clearly unequal weighting with 47 female versus 357 male traffic participants in the age of 70 and over. Men and women, however, distribute similar by blood alcohol concentrations (BAC) (Fig. 1). 25.5% of the women and 27.7% of the men show a BAC of between 0.5 and 1.1‰, which would be a legal offence according to § 24a of the German Road Traffic Law (StVG), provided, that no additional change of behavior had occurred. Whereas 70.2% of the women and 61.9% of the men showed a BAC above the 1.1‰ limit at
the time of blood collection. Post-offence drinking aside, this level of BAC complies with the criminal offence mentioned in § 316 of the German Penal Code (StGB) [10]. The investigated cases were divided into 171 traffic offenses, 196 traffic accidents and 37 contraventions. Drunken driving was associated with an accident in 48.5% of the cases. In the 404 cases, 375 police reports and medical examination protocols were available for further research at the time of data collection.
A detailed look at the distribution of the BAC by the road-users’ age at the time of the blood sampling shows, that most of the examined individuals aged 70-74 had a BAC of between 1.40‰ and 1.69‰. The peak of the 75-79 age group can be located at between 1.10‰ and 1.39‰, while the persons aged 80 and over seem evenly spread in the per thousand range below 2,0‰ (Fig. 2). The evaluation of the medical examination protocols showed, that during the motor coordination tests, 144 disorders in tandem gait and 164 failed sudden turn-arounds were documented. Dysmetria could be diagnosed in 144 cases with the finger-tofinger-test and in 124 cases with the finger-to-nose-test. 89 Persons showed a coarse post rotatory nystagmus lasting at least five seconds. This nystagmus test was not performed in 57% of the examinations, while it was stated explicitly in 61 of these cases, that the reason for not performing this test was a high risk of falling due to an impaired motor system. According to the respective examiner, said impairment based on a gait disorder suspected to be age-related (Fig. 3). A further aspect of the medical examination protocol was the question regarding a regular medication intake. 60% of the examined persons admitted a regular medication or at least a single intake prior to the time, the blood sample was taken. 27% declined taking any medication and 13% denied a statement. 220 examined persons declared suffering from at least one acute, chronic, or preexisting disease. A detailed look at the distribution of the different diseases shows, that most of them were illnesses affecting the cardio-vascular system like arterial hypertension or coronary artery disease followed by metabolic disorders such as diabetes or dyslipidemia. Degenerative musculoskeletal disorders such as osteoarthritis were stated in 32 cases. 25 of the stated diseases affected the central nervous system or the sensory perception. Moreover, a total of 16 road-users admitted suffering from a psychiatric disorder, with eleven persons having a drinking problem, three suffering from depression, and two suffering from dementia (Fig. 4). Looking at the gender distribution, 71% of the women in comparison to 59% of the men affirmed a medication. As shown, the extent of the documentation of medication and pre-existing diseases depends on the examining physician, as well as on, the compliance of the investigated person. Thus, in some cases, imprecise descriptions
are found, such as ‘blood pressure medication’ or ‘heart pill’, so neither the active substance nor the exact dose can be deduced. With a share of 72% most of the seniors participated in road traffic as car drivers. 8% went by motorcycle, while vehicles such as trucks, tractors or bicycles were used in single cases only. The respective prosecutor’s office provided insight into 133 accident offence files of the 196 accidents mentioned above. These files include more detailed observations of the accident, like light conditions, location of the accident, accident category and type of accident. The analyses of the police reports as part of the legal proceeding show, that 64 accidents happened in darkness, 58 in daylight, and 10 in twilight. In addition to the light conditions, these reports provide information about the accident’s location. About 108 accidents took place in urban territory, whereas 25 happened outside of any city limits. As demonstrated in Fig. 5, the distribution of the different types of traffic accidents shows, that 47% of the accidents were driving accidents, in which the driver lost control over his vehicle. In 17% the accident involved one stationary vehicle. Rearend or head-on collisions happened in 9% of the cases, while 5% of the accidents were caused by a vehicle turning into a road or crossing it. With a share of 4% a vehicle collided while turning off the road. An amount of 19% was not further categorized by the respective policeman. The different accident categories distribute as follows: in 66 cases, the material damage caused by the accident left the damaged vehicle still functioning, while in 21 cases the material damage was more severe and least one vehicle had to be towed from the scene of the accident. In 32 accidents, at least one participant suffered a slight injury. Severe injuries were inflicted in 14 cases, which required an intense clinical treatment for at least 24 hours. A fatal outcome was not reported in the analyzed collective (Fig. 6).
4. Discussion A more detailed analysis of the factors contributing to the drunkenness as a basis for a risk assessment of traffic participation in the elderly age seems necessary. The results presented above can be summarized as follows: The group examined in this study showed a gender-specific male dominated data situation with a male share of 88.4%. The tendency of the mean BAC decreases with increasing age. The overwhelming majority of 72% took part in road traffic as car drivers. In addition to the alcohol consumption 60% of the examined persons admitted a medication intake prior to the blood collection. The introduction of an age-adjusted protocol for the
medical examination during the blood collection should be considered, to obtain a structured overview of the medication and the morbidity of the drunk driver. An adaptation of the individual tests is also necessary, for in 16.2% of the cases an examination of the motor system could not be carried out or was not evaluated by the examiner, as there was a gait and / or stability failure which was regarded as agerelated and could not be attributed to either the alcoholization or the general condition of the examined person. When carried out, the tests revealed in 38.4% of the cases a failing tandem gait and in 43.7% a failed sudden turn-around. As other publications show, dizziness and associated gait disorders are no rare phenomena in the higher age. A report by Jahn et al. (2015) stated, that nearly 30% of the seniors suffered from vertigo at such an extent, that they felt restrictions in everyday life. The etiology of this vertigo was described as a combination of different aged-related processes [11]. Often it was caused by neurological malfunctions such as bilateral vestibulopathy, polyneuropathy, reduction of visus or benign paroxysmal positional vertigo. Furthermore, other diseases of the central nervous system like cerebellar ataxia or normal pressure hydrocephalus are possible triggers for dizziness. Also, dementia or psychiatric illnesses like anxiety disorders must be considered relevant. It seems rather difficult to differentiate between the influence of alcohol and a preexisting disease as the cause for a balance disorder when examining an alcoholized senior. Therefore, for the physician conducting the examination it is eminent to capture the various abnormalities as detailed as possible. Physical or mental impairments can aggravate the effect of alcohol or even imitate it. It is conceivable that such impairments caused driving failures in the first place. At this point the driving suitability in general is in doubt. In order to distinguish between the effects of alcohol and morbidity, we presume to conduct a second examination on the driver, this time in a sober condition. Additionally, mandatory driving suitability evaluations related to age or certain diseases can be established as a precautionary measure. Although here only two persons actually admitted suffering from dementia, literature shows, that this disease must be taken into consideration, if elderly drivers show signs of conspicuous behavior. Various researches show, that different forms of dementia have a significant influence on the handling of a vehicle, depending on the severity of the particular form. At an early stadium of the disease an impairment of the driving suitability is not mandatory [12, 13, 14]. Seeger postulated in 2015, that each year more than 16,000 new cases of dementia occur among road-users in Switzerland, a country with an infrastructure and demographic development similar to those of Germany [15]. Of course, a detailed dementia test is too extensive to perform in the context of a blood collection for the BAC determination. And, due to the influence of alcohol its significance would be doubtful. But in individual cases a thorough recording of any neurocognitive deficit or behavioral abnormality could lead the way to diagnose dementia. Analyzing the different items of the medical examination protocol showed us, that the evaluation of the eyesight is not part of the protocol. In 2012 the German Ophthalmologic Society demanded a regular ophthalmologic checkup for road users
aged 50 and over. Millions of German citizens suffer from cataract, macular degeneration or glaucoma. Due to the subtle character of these diseases’ progressions, they become symptomatic not until a considerable decline of the visual field [16]. In 2014 Desapriva et al. considered vision to be one of the key domains required for safe driving [17]. Bearing this in mind, it seems only logical to conduct regular evaluations of the eyesight of elderly road users. Also, an ophthalmologic test should be implemented into the medical examination at the time of the blood collection. Surprisingly, only 60% of the examined persons affirmed a medication intake in the 24 hours prior to the blood collection. Looking at the results of a study carried out by the German Robert-Koch-Institute in 2013 this share seems much too small. In this study 96.7% of the women and 92.6% of the men between 65 and 79 years of age took a medication or a nutritional supplement at least once a week [18]. The fact, that the examination protocol features just one single line to document the medication, seems insufficient considering the common polypharmacy in the elderly. Consequently, the sometimes confusing documentation of more than one preparation is prone to failure. In a report about drug abuse in high age Glaeske (2012) explained, that polypharmacy in the elderly increases the risk for adverse drug reactions (ADR) to occur. Especially drugs targeting structures in the central nervous system pose a risk [19]. Over the last decades, miscellaneous international groups of experts published lists of potentially inappropriate medications (PIMs) with the ambition to reduce the prescription of these active substances in the elderly [20, 21, 22]. The current layout of the examination protocol cannot cover the complex nature of such a multimedication and therefore proves to be inappropriate for the age group of the elderly.
5. Conclusions The high number of 404 cases of senior drunken drivers in our purview as well as the insufficient layout of the existing examination protocol showed us, that the combination of high age and alcohol in road traffic is clearly underestimated. We presume an adaptation of the examination protocol, that can assess the various particulars of multimorbidity and polypharmacy in the elderly. In the case of an alcoholized, aged person, a detailed and clear medical history is essential, to comprehensively record the causes of existing impairments. It is eminent to conduct further analyses of this age group and in addition comparisons to younger road users to evaluate and improve the risk assessment for elderly participation in road traffic. The collective analyzed here represents the rural area of the northern and middle parts of Hesse [23]. In 2009 Wilke et al. already carried out an evaluation of examination protocols of road-users aged > 60 years in the urban area of Hamburg [24]. Considering the future demographic development in the Federal Republic of Germany, this issue should not be underestimated.
References [1] Federal Statistical Office Germany, Population Projection, https://www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Bevoelkerung/Bevoelker ungsvorausberechnung/Tabellen/AltersgruppenBis2060.html, 2013 (accessed: 24.01.2017). [2] Decision of the Higher Regional Court (OLG) of Celle, Germany, 07.08.2007, file number: 32 Ss 113/07. [3] S. Pottgießer, U. Kleinemas, K. Dohmes, L. Spiegel, M. Schädlich, G. Rudinger, Profiles of elderly drivers with accidents (PROSA), Berichte der Bundesanstalt für Straßenwesen. Unterreihe „Mensch und Sicherheit“ (2012) Heft M228. [4] See §§ 11, 46 and annex 4 of §11 of the German Driving License Regulations (FeV). [5] H. Kaiser, Road Safety Programs with the Elderly from the Viewpoint of Differential and Gerontopsychology. Zeitschrift für Gerontopsychologie & -psychiatrie 16 (2003), 131-140. [6] S. Germann, M. Schaul, P. Strohbeck-Kühner, Compensation strategies of elderly drivers. Rechtsmedizin 26 (2016) 279. [7] H. Hoffmann, C. Wipking, L. Blanke, M. Falkenstein, Experimental study to support the development of advanced driver assistance systems for elderly drivers. Unterreihe „Fahrzeugsicherheit“, Heft F86 (2013). [8] T.M. Rudisill, M. Zhu, M. Abate, D. Davidov, V. Delagarza, D.L. Long, U. Sambamoorthi, J.D. Thornton, Characterization of drug and alcohol use among senior drivers fatally injured in U.S. motor vehicle collisions, 2008-2012. Traffic Inj Prev. 17 (8) (2016) 788-95. [9] Y. Du, C. Scheidt-Nave, H. Knopf, Use of psychotropic drugs and alcohol among non-institutionalised elderly adults in Germany. Pharmacopsychiatry 41 (6) (2008) 242-251. [10] A. Dettling, M. Vermesse, G. Skopp, H.T. Haffner, Consideration of back calculation lag time in drinking after the event constellations. Rechtsmedizin 24 (2014) 381-386. [11] K. Jahn, R.W. Kressig, S.A. Bridenbaugh, T. Brandt, R. Schniepp, Dizziness and Unstable Gait in Old Age. Dtsch Arztbl Int. 112 (2015) 387-393. [12] J. Ernst, S. Krapp, T. Schuster, H. Förstl, A. Kurz, J. Diehl-Schmid, Car driving ability of patients with frontotemporal lobar degeneration and Alzheimer’s disease. Nervenarzt 81 (2010) 79-85.
[13] D.J. Iverson, G.S. Gronseth, M.A. Reger MA et al., Practice Parameter update: Evaluation and management of driving risk in dementia. Neurology 74 (16) (2010) 1316-1324. [14] D. Piersma, A.B.M. Fuermaier, D. de Waard, R.J. Davidse, J. de Groot, et al., Prediction of Fitness to Drive in Patients with Alzheimer's Dementia. PLOS ONE 11 (2) e0149566 (2016). [15] R. Seeger, Driving with dementia. Therapeutische Umschau 72 (2015) 239-245. [16] GMO, Augenärzte fordern „Augen-TÜV“ Versicherungsmedizin 64 (4) (2012) 205.
für
ältere
Autofahrer.
[17] E. Desapriva, R. Harjee, J. Brubacher, H. Chan, D.S. Hewapathirane, S. Subzwari, I. Pike, Vision screening of older drivers for preventing road traffic injuries and fatalities. Cochrane Database of Systematic Reviews Issue 2 Art. No.: CD006252 (2014). [18] H. Knopf, D. Grams, Arzneimittelanwendung Erwachsener in Deutschland. Bundesgesundheitsbl. 56 (2013) 868-877. [19] G. Glaeske, Arzneimittelmissbrauch im Alter. Geriatrie-Report 02 (2012) 14-16. [20] M.H. Beers, J.G. Ouslander, I. Rollinger, D.B. Reuben, J. Brooks, J.C. Beck, Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 151 (1991) 18251832. [21] D.M. Fick, J.W. Cooper, W.E. Wade, J.L. Waller, J.R. Maclean, M.H. Beers, Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 163 (2003) 2716-2724. [22] S. Holt, S. Schmiedl, P.A. Thürmann, Potentially Inappropriate Medications in the Elderly: The PRISCUS List. Dtsch Arztebl Int. 107 (2010) 543–551. [23] B. Kirsch, R. Dettmeyer, Driving under the influence of alcohol. Rechtsmedizin 26 (2016) 258-263. [24] N. Wilke, K. Püschel, C. Edler, Alkohol, Alter und Verkehr. Z Gerontol Geriat. 42 (2009) 185–192.
7
> 2.0 ‰
37
26
1.1 - 2.0 ‰
184
12
0.5 - 1.1 ‰
99
4
< 0.5 ‰
35 0
20
40
60
80
100 ♀
120
140
160
180
200
♂
Fig. 1: Distribution of BAC by sex in the case of road users aged > 70 years at the time of blood collection (n=404)
60 50 40 30 20 10 0 70 - 74
75 - 79
> 79
< 0.5‰
0.5 - 0.79‰
0.8 - 1.09‰
1.1 - 1.39‰
1.4 - 1.69‰
1.7 - 1.99‰
2.0 - 2.49‰
> 2.49‰
Fig 2: Distribution of BAC at the time of the blood collection by age (n=375)
250
200
150
214
100 164
146 144 50
85
99
112
130
148
144 101
124
103 72
89
0 Tandem gait
Turn-around normal
Finger-to-finger disorder
Nose-to-finger
Post rotatory nystagmus
no information
Fig. 3: Abnormalities in the coordination tests at the time of the blood sampling according to the medical examination protocol (n=375)
Rheumatic disorders
2
Cutaneous conditions
2
Neoplasms
9
Genitourinary disorders
12
Psychiatric diseases
16
Pulmonary diseases
19
Gastrointestinal diseases
21
Neurological disorders
25
Musculosceletal disorders
32
Metabolic disorders
71
Cardio-vascular diseases
183 0
20
40
60
80
100
120
140
160
180
Fig. 4: Distribution of diseases by functional system according to the medical examination protocol
200
70 62 60 50 40 30
25
22 20 12 7
10
5 0
0 Driving accident
Accident involving stationary vehicles
Accident Accident Accident Accident Other accident between caused by caused by caused by vehicles turning into a turning off the crossing the moving along road or by road road in carriageway crossing it
Fig. 5: Distribution of types of traffic accident according to legal proceedings (n=133)
70
66
60 50 40 32 30 21 20
14
10 0 0 Material damage
Slightly injured
Severe material damage
Seriously injured
Fatal accident
Fig. 6: Distribution of traffic accident categories according to legal proceedings (n=133)