Arrhythmias and Mobility

Mobility is, and will continue to be, an important issue in healthy aging; it enables older adults to visit friends and family, participate in activities, attend school, dine, shop, and receive health care. Among the elderly, the loss of such mobility is often tantamount to a loss of independence that can effect social isolation. 1,2 Throughout most of their lives, American adults have relied on themselves to drive, and this accustomed sovereignty is reflected in the growing rate of people age 65 and older who remain licensed drivers. 3 Americans aged 65 and older now number 34 million, 13% of the total population, and this proportion is increasing. Since 1900, the percentage of Americans in this age group has more than tripled, from 4.1% in 1900 to 13% in 2000. In 1996 the 65-to-74-year-old age group (18.7 million) was eight times larger than it was in 1900, the 75-to-84-year-old group (11.4 million) was 16 times larger, and the 85-year-old-and-older age group (3.8 million) was 31 times larger. As the baby boom generation reaches retirement age, the population of older adults will continue to grow, with the most rapid increase expected between the years 2010 and 2030, at which time it is estimated that there will be approximately 70 million older adults constituting 20% of the American population. 4 As this population increases, so does the number of injuries in this group, resulting from a decline in normal physiologic reserves that causes decreased muscle mass, fragility of bones, and diminished baroreceptor sensitivity. Additionally, functional decline affects both short-term and long-term survival after injury, 5 and this circumstance, combined with the greater incidence of comorbidities, makes the elderly trauma victim difficult to manage. Of particular concern is heart disease that involves arrhythmias, which affects one in four Americans but is most common among those older than 65, 6 and puts aging drivers at increased risk because of impaired cognition or loss of consciousness. At this writing, there are no standard recommendations in the United States that limit driving privileges of these patients. Discussions relating to driving capabilities are sensitive, not only for patients with heart disease but also for medical practitioners who provide their care. Although driving is listed by the American Occupational Therapy Association as one of the activities of daily living, 7 it is not addressed in discharge planning and outpatient counseling. With the growing number of older drivers, a significant public health and safety issue exists regarding them, the passengers whom they may transport, and other motorists and pedestrians who may be injured or killed in motor vehicle collisions (MVCs). AGING AND CARDIAC CONDITIONS Apart from age, medical conditions, functional impairment, and the use of medication place drivers, particularly older ones, at greater risk for MVCs. When evaluating driving ability, age-related cardiovascular changes present special considerations. 8 With age, the cardiovascular system loses its ability to respond as quickly to exogenous and endogenous catecholamines. The aging heart is often unable to increase cardiac output to meet an increased demand for oxygen. Increased systemic vascular resistance places a strain on its left side, further reducing the force of contractility and cardiac output. The valves of the heart tend to become thick and rigid as a result of sclerosis and fibrosis, complicating cardiac disease, while blood vessels may become thick and rigid, causing elevation of blood pressure. Impaired blood pressure regulation can result from changes in baroreflex sensitivity and inhibited cardioacceleration (increased heart beat). The stress of a traumatic event can cause cardiac arrhythmias, heart failure, or sudden death. 9 Although it is not clear what the relationship is between environmental stress induced by aggressive drivers, congested roadways, rush-hour traffic, inclement weather, complex intersection designs, and the increased risk of MVC among persons with cardiovascular disease, driving under highly stressful conditions is known to increase the heart’s response to oxygenation requirements, thus contributing to an increased incidence of cardiac arrhythmias. 10,11 Although aging doesn’t cause a change in either resting heart rate or heart size, the return to a resting heart rate in response to stress may become slower, so that once the heart rate is elevated, it takes longer for the patient to return to baseline heart rate. 9 Drugs used to control hypertension, heart failure, and heart disease may blunt the ability of the cardiovascular system to respond to sympathetic stimulation associated with stressors. 6,12 Such medications include calcium channel blockers that limit myocardial as well as smooth muscle contraction and that cause peripheral arterial vasodilation; beta blockers that decrease heart rate, contractility, and lower blood pressure; and angiotensin converting enzyme (ACE) inhibitors and nitrates that cause vasodilation. Studies suggest that at least three quarters of those older than 65 use prescription medications generally, and that Medicare recipients take an average of 10 medications daily. 13 The confluence of illness, comorbidity, and multiple medications are significant considerations in evaluating fitness to drive. 13 The combined effects may be more indicative of adverse drug reaction than is age alone. The likelihood of adverse drug reactions dramatically increases with age as well, as is indicated by an incidence among those aged 65 or older that is three to seven times that of young adults. Older people are more sensitive to medications than are younger adults, and reduced hepatic and renal function, as well as altered body composition, diminish the capacity for the metabolization of medication. 13,14 ARRHYTHMIAS Arrhythmias, abnormal heart rhythms that occur as a result of multiple factors, can cause the aging heart to pump even less effectively. Various arrhythmias may be associated with cognitive impairment and syncope. If the patient is driving a motor vehicle, loss of consciousness may result in injury to or death of the drivers and passengers in all vehicles, pedestrians, and bicyclists. 14 Research studies, although relatively few in number, have documented a significant correlation between irregular heart rates and self-reported crashes, 15 collision and violation rates among persons with cardiovascular disease, and unrestricted driving privileges that are twice those in a control group, 16 and the need to consider the effect of multiple medical conditions on the ability to drive. 17 Among the more common arrhythmias in older adults and the most common cause of embolic stroke is atrial fibrillation (AF). The prevalence of AF doubles with each decade in those who are 50 years old and older, and is estimated at 10% among those 80 years old and older. 18 Diagnosis of this type of arrhythmia is a challenge because older adults present with symptoms that are either common to diabetes and pulmonary and neurological disorders, such as palpitations, fatigue, dyspnea, and dizziness, or atypical symptoms such as electrolyte imbalances, depression, and changes in functioning, mood, or cognition. 18 It has been estimated that approximately 30% of all people with AF experience at least one embolic event. Finally, AF can impair driving performance as a result of hemodynamic consequences such as cerebral ischemia. Patients with bradyarrhythmia (a heart rate less than 60 beats per minute) or bradycardia can be divided into those who present with either syncope or presyncope (signs and symptoms before loss of consciousness) and those who do not. 14 Those without symptoms do not need a pacemaker and may drive as long as that is the case. For safe driving, cardiac pacing is recommended in individuals with symptomatic bradycardia. Recurring symptoms are more likely to result from underlying cardiac pathology manifested typically in tachyarrhythmias, an excessively rapid heartbeat, than from bradyarrhythmias caused by pacemaker malfunction. Although restriction of driving may be unnecessary in those who are asymptomatic after pacemaker implantation, education to recognize potential symptoms associated with disturbances in cardiac rhythm is essential. When pacemakers first came into use, concerns about driving were raised, but dissipated as it was recognized that patients no longer experienced the symptoms they had before implantation. 14 One hundred and seventy five thousand pacemakers are implanted annually in the United States. Most of them are single-chamber ventricular pacemakers implanted to prevent symptomatic bradycardia. 19 However, little has been said about how such pacing adversely affects a patient’s health. One common complication of cardiac pacing is “pacemaker syndrome,” in which a loss of atrioventricular synchrony resulting in a reduction of cardiac output can lead to signs and symptoms resembling those associated with heart failure and coronary artery disease. Typically, patients report dizziness and syncopal episodes. Travill and Sutton reported signs or symptoms of pacemaker syndrome in 20% of patients with single-chamber ventricular pacemakers. 20 However, a similar study headed by David Heldman revealed that 83% of single-chamber ventricular pacemaker recipients had some signs or symptoms of it. 20,21 Those at greatest risk of pacemaker syndrome are elderly patients with left ventricular disease, and recipients of single-chamber ventricular pacemakers, 12 all of whom are at a higher risk of MVC resulting from syncope. Advancements in the treatment of acute ischemic syndromes have led to improved survival of older patients with coronary artery disease. One such result is the increase in the number of survivors of myocardial infarction (MI) with impaired cardiac function, reduced ejection fraction, and unsustained or sustained ventricular arrhythmia. Identifying persons in this population who are at risk for serious ventricular arrhythmias, cardiac arrest, and sudden cardiac death is a challenge. Management is guided by the individual patient’s comorbidities, cardiac function, history of ischemia, and the health care provider’s perception of risk. Oral antiarrhythmic drugs and the increasing use of implantable cardioverter-defibrillators (ICDs) are common therapeutic approaches in treating ventricular arrhythmias. Symptoms before delivery of ICD therapy are related to hemodynamic tolerance to the arrhythmias, which is related to rate and duration of the arrhythmia before implantation and status of the underlying myocardial function. Predicting the timing and frequency of ventricular arrhythmia recurrence may be difficult. Patients may also experience an arrhythmia that actually results from the ICD therapy or arrhythmia instability or from acceleration with hemodynamic collapse. Although several studies have attempted to determine when or how many times the ICD may trigger, it is impossible to predict when the arrhythmia causing this will actually occur. Although the ICD is an effective therapy for terminating ventricular arrhythmias and preventing sudden cardiac death, it may be difficult to determine if and when the patient can return to driving. ICD shock therapy may cause discomfort and startle the patient, which could lead to loss of control of a vehicle when driving, even in the absence of symptoms resulting from the arrhythmia. Patients with ICDs may occasionally experience severe symptoms or even hemodynamic collapse before termination of the arrhythmia. 14,20 SUPPORTING MOBILITY IN PRACTICE SETTINGS A holistic case-by-case approach is needed to fully evaluate a person’s capability to drive safely. Driving is a complex task that involves intact vision, cognition, and physical motor performance, which can be impaired by a number of factors including progressive medical conditions, acute events resulting in a change in function, and by therapeutic drug regimens. There is a need for more discussion and counseling by members of the health care team regarding driving safety and support for the needs of nondrivers. 3 Often practitioners do not even ask questions like, “How did you get here today?” or “Do you have any concerns about your driving safety?” Questions regarding mobility may not be concerned with whether or not to drive at all but rather with the necessity for a suspension of driving to allow for a response to the treatment of a medical condition. A minority of patients actually need to be counseled to cease driving and, typically, there is an associated level of cognitive impairment. In the United States, the licensing of drivers and most aspects of road safety are within the jurisdiction of a state’s Department of Motor Vehicles (DMV). However, there are no nationally standardized assessment criteria of fitness to drive. In other countries (Canada, for example) there are recommendations related to fitness to drive pertaining to a number of medical conditions, including cardiac conditions, for both private and commercial drivers. 1 Depending on the severity of cardiac dysfunction, the recommendations range from no driving restriction to a period of suspension of driving until the acute event is medically evaluated and controlled, and, in some cases, to permanent suspension of driving privileges. The role of the health care team, then, is to identify whether a patient who presents with specific signs, symptoms, behavior, or a condition that places him at risk is fit to drive. Health Care Practitioner Red Flags for Crash Risk, page 7, provides a list of questions that identify general behavioral patterns of which health care practitioners need to be aware. Teams can greatly benefit from nurses who share the responsibility of identifying the effects that heart disease, arrhythmias, or therapeutic measures can have on safe driving practices. The nursing profession can also provide leadership in supporting transportation options for people who are no longer permitted to drive. This effort will serve to benefit older adults today and in the future. A specific list of at-risk conditions typically seen can be developed in each practice setting. A history of recent adverse driving events, for example, should raise suspicions. A review of relevant medical conditions, functional impairments, and medication use is helpful in identifying potential interventions and remediation strategies as well as in determining the need for changes in driving practices (see Fitness to Drive: Arrhythmias and MVC Risk, page 8). The entire practice team has an ethical obligation to ensure public safety and physicians should be held liable in the event that they do not appropriately counsel their patients who are high-risk drivers. 2 Staff members need to be educated in the guidelines used by health care providers in reporting medical conditions affecting driving safety to the state’s DMV. (This includes knowledge of the correct form to complete and send by fax or mail.) The health care team needs to be aware of professionals who are trained to perform driving assessments, either occupational therapists or certified driving rehabilitation specialists in acute care settings, at rehabilitation facilities, or at community-based centers. They can assist with comprehensive testing of driver capabilities, offer remediation strategies, and recommend referrals to resources such as the American Association of Retired Persons (AARP) “55 Alive” courses related to safe driving, driving schools, or memory disorder centers. If restrictions or suspensions become necessary, identifying alternate means of transportation helps ease the transition for the patient. Those who present as no longer comfortable with or competent to drive safely may benefit from mobility counseling, an emerging facet of practice that provides counseling services and referrals to sources of transportation as well as to other community resources such as Meals on Wheels. In the absence of a mobility counselor, it’s important that each provider has a list of community-based transportation services as well as a list of senior service agencies such as the Department of Elder Affairs Area Agencies on Aging, which provide elder support services. Inservice time can be dedicated to ensuring that all members of the team are aware of the necessity of promoting safe mobility of patients. The health care team’s objective is to maximize the independence, autonomy, mobility, and level of activity of the patient regardless of driving status. It also needs to be sensitive to the importance many people attach to being able to drive. The awareness of community referral pathways to assist people who no longer drive is critical. AN URGENT NEED TO SUPPORT PUBLIC POLICY Approximately 40,000 deaths and three million injuries occur annually in the United States as a result of the more than six million vehicular traffic collisions reported by the police. 22 The overall contribution of medical conditions to MVCs that result in property damage, injuries, or fatalities is unknown. The majority of sudden deaths while driving have been attributed to myocardial infarction, 23,24 but this occurrence is rare, contributing to fewer than 1% of all fatal crashes in the United States. 24 In light of both the foregoing factors and the proportional aging of the population, it is important to raise awareness of the need for counseling in both acute-care and outpatient practice settings as well as to develop public policy related to fitness to drive, particularly among people demonstrating significant cardiac arrhythmias. The conditions in which people live have always been determined in part by the ease and speed with which they have been able to transport themselves and their materials from one place to another. In the United States the automobile represents the driver’s independence and well being, and contributes significantly to his self-image. The social significance of the automobile subsists in the means of rapid, independent transportation and the far greater choice of residential location it affords. 3 A significant proportion of the aging population resides in suburban or rural areas where alternative modes of transportation are not available. Most American suburbs are designed in such a way that residents have no choice but to travel from residential areas to commercial and business areas, 9 and the lack of public transportation, particularly in rural areas, further increases reliance on the automobile. 25 Despite the importance of transportation in personal life little government policy has developed regarding the maintenance of mobility of older Americans. This may soon change, however, as the Department of Transportation develops a strategic plan, based on a series of national forums and community focus groups, to support safe mobility with a resultant urgent call to action. 25 Health care practitioners need to support initiatives that support the strengthening of community-based transportation services in their areas. Encouraging safe pedestrian travel may assist in promoting healthier lifestyles. TABLETABLETable: Health Care Practitioner Red Flags for MVC RiskTable: Fitness To Drive: Arrhythmias and MVC Risk

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