Letters to the Editor
Resources for Evaluating the Elderly Driver
TO THE EDITOR: The recent article(1) that reviews the medical evaluation of the elderly for automobile driving provided information of practical value to primary care physicians; however, I would like to furnish additional sources of information that also may be of benefit to readers.
I agree with the author that individualized decisions are necessary in assessing the ability of patients with dementia to drive safely, notwithstanding a 1994 consensus conference conclusion that patients with moderate dementia are considered sufficiently impaired to preclude safe driving.(2) For forced cessation of driving, a particularly helpful document can be downloaded from the Alzheimer’s Association Web site that describes steps to take away the car keys (http://www.alz.org).
The author also correctly points out that comorbid conditions in the elderly may have an effect on their ability to drive. When treating patients with comorbid conditions, primary care physicians can access several guidelines available in the literature. The American Medical Association released a guideline document in 1986, but it may be difficult to access because it is not widely available at medical libraries(3); moreover, it has not been revised since its original publication. A more recent document is available from the Canadian Medical Association and can be downloaded from its Web site at http://www.cma.ca/cpgs/ drivexam/index.htm.4 Many states in the United States also have their own medical criteria that can be obtained from the medical review section, division of driver’s license, department of transportation. The Web site http://www.carbuyingtips.com/driver-licenses. htm serves as a portal to access 48 of the 50 Division of Motor Vehicles, State Department of Transportation’s Web sites. These sites contain considerable information, and many of them also list important telephone numbers. As of this writing, Delaware and Oklahoma do not have corresponding Web sites.
It should be noted that the above guidelines represent expert opinions that are usually not supported by scientific data. Nonetheless, the availability and access of these guidelines allow primary care physicians to provide counseling using the most current information.
Finally, as Dr. Carr points out, in the United States, the legal responsibility of physicians to report medical conditions to the state authorities varies from state to state. I believe there is an urgent need to have uniform standards or driver’s license requirements and guidelines for physicians to report medically unfit drivers. One mechanism for accomplishing this goal is to enact uniform laws that are adopted by the legislatures of all 50 states. Perhaps a federal commission can be created to bring about this change.
RAM KAKAIYA, M.D.
University of Illinois College of Medicine at Rockford
Department of Family and Community Medicine
Rockford, IL 61072
(1.) Carr DB. The older adult driver. Am Fam Phys 2000;61:141-6.
(2.) Johansson K, Lundberg C. The 1994 International Consensus Conference on Dementia and Driving: a brief report. Alzheimer Dis Assoc Disorders 1997; 11(suppl 1):62-9.
(3.) Doege TC, Engelberg AL (eds). Medical conditions affecting drivers. Chicago: American Medical Association, 1986.
(4.) Physician’s guide to driver examination, 5th ed. Ottawa, Ontario: The Canadian Medical Association, 1991.
IN REPLY: I appreciate Dr. Kakaiya’s comments about additional resources that could be of benefit to readers. I would also add to these resources the nice summary in the Canadian Journal of Neurological Sciences(1) that addresses ethical issues.
Dr. Kakaiya also points out the difficult situation when many primary care physicians are faced with patients with comorbid conditions. Currently, the Association for the Advancement of Automotive Medicine has formulated a medical advisory steering group that will update medical standards for driving and hopefully be a resource for primary care physicians. I wholeheartedly agree that there is an urgent need to adopt uniform standards across the country. Nothing short of federal legislation would be required to accomplish this goal.
DAVID B. CARR, M.D.
Washington University in St. Louis
Division of Geriatrics and Gerontology
St. Louis, MO 63108
(1.) Fisk JD, Sadovnick AD, Cohen CA, Gauthier S, Dossetor J, Eberhart A, et al. Ethical guidelines of the Alzheimer’s Society of Canada. Can J of Neurol Sci 1998;25:242-8.
Adenocarcinoma Arising in Endometriosis
TO THE EDITOR: We read with interest the recent review article on endometriosis by Dr. Wellbery.(1) We would like to add one additional comment about estrogen replacement therapy following hysterectomy and oophorectomy for symptomatic endometriosis.
We describe the case of a 68-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1972 for intractable pelvic pain due to endometriosis. She was subsequently placed on estrogen-only replacement therapy. In November 1999, she presented to her primary care physician complaining of vaginal pressure and bleeding. A pelvic examination revealed a submucosal nodule at the vaginal apex, which was confirmed on pelvic ultrasonography as a 3 3 2.6-cm mass.
The patient subsequently underwent surgical resection with pelvic lymph node dissection. Pathologic examination of the vaginal mass revealed a moderately differentiated endometroid adenocarcinoma (see the accompanying figure). No associated foci of endometriosis were identified.
The increased risk of developing intrauterine endometrial adenocarcinoma with prolonged unopposed estrogen therapy is well established. However, numerous investigators have reported endometrial malignancies arising in endometriotic foci following unopposed estrogen stimulation.(2-4) Adenocarcinomas comprise the majority of these tumors, but stromal sarcomas also have been reported.(5) Reported sites of malignancy include the vagina, rectum, cul-de-sac and rectovaginal septum.(2)
According to Sampson,(6) who first described adenocarcinoma arising in endometriosis, histologic evidence of endometriosis in close proximity to a tumor should be identified before a definitive correlation between the two can be established. Although we did not see endometriosis in the current case, the patient’s history and the site of the tumor were suggestive of an association.
Although unopposed estrogens are commonly administered to women who have undergone hysterectomies, physicians are urged to bear in mind the original indications for the procedure. If the hysterectomy was performed in the context of endometriosis, combined (estrogen and progesterone) hormone replacement therapy should be considered.
ROBIN ECKERT, M.D.
University of California, Davis, Medical Center
Sacramento, CA 95817
ROBERT ECKERT, M.D.
Mercy Clinic Norwood
Sacramento, CA 95838
(1.) Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician 1999;60:1753-62.
(2.) Gucer F, Pieber D, Arikan MG. Malignancy arising in extraovarian endometriosis during estrogen stimulation. Eur J Gynaecol Oncol 1998;19:39-41.
(3.) Reimnitz C, Brand E, Nieberg RK, Hacker NF. Malignancy arising in endometriosis associated with unopposed estrogen replacement. Obstet Gynecol 1988;71(3 pt 2):444-7.
(4.) Abu MA, Sinha P, Totoe L, McCune G. Endometrial cancer thirteen years after total abdominal hysterectomy and bilateral salpingo-oophorectomy and hormone replacement therapy: a case report. Eur J Gynaecol Oncol 1997;18:482-3.
(5.) McCluggage WG, Bailie C, Weir P, Bharucha H. Endometrial stromal sarcoma arising in pelvic endometriosis in a patient receiving unopposed oestrogen therapy. Br J Obstet Gynaecol 1996; 103:1252-4.
(6.) Sampson JA. Endometrial carcinoma of the ovary, arising in endometrial tissue in that organ. Arch Surg 1925;10:1-72.
EDITOR’S NOTE: This letter was sent to the author of “Diagnosis and Treatment of Endometriosis,” who declined to reply.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
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