Alice Pomidor, a Florida State University geriatrician, brings up the subject of driving with her patients over age 75 by asking a simple question: "How did you get here today?"

As the editor of a newly revised American Geriatrics Society guide for medical clinicians on older people and driving, Pomidor understands why many doctors don't initiate the driving talk. For one thing, they don't have much time and older patients often have many serious medical problems. For another, many people don't take kindly to the suggestion that it's time to start thinking about giving up the keys.

"People highly value their relationships with their patients," she said, "and they don't like to discuss things that are going to make their patients very angry or unlikely to come back."

Doctors can actually help many patients stay on the road awhile longer, Pomidor said. If a patient tells her that she's stopped driving at night, Pomidor can order a vision check. Maybe the patient needs new glasses, or treatment for cataracts or macular degeneration. Physical therapy might help someone with arthritis who's having trouble gripping the steering wheel or turning his head to see. Extra-wide side mirrors and a spinner knob on the steering wheel can also help.  Medications affect alertness; perhaps a dosage can be adjusted.

Some people can keep driving if they're willing to accept some limitations, such as staying off highways or driving only during the day.

But some should not drive at all — and don't want to hear it.

"These are the group of people who tell you, 'I will stop driving when you take the keys from my cold dead fingers,' " she said. They see driving as their last scrap of independence or the sole reason they can stay in a suburban house. "They see stopping driving as the first step down the line to the nursing home," Pomidor said.  Some will drive even without a license.

Pomidor recommends tips from the American Geriatrics Society Health in Aging Foundation. Here are her ideas for managing cognitively impaired drivers who won't stop driving (bear in mind that some people with dementia may have more trouble with judgment than memory):

  • Confiscate keys.
  • Park vehicle out of walking distance where it is not visible.
  • Discontinue insurance and tell the person about it.
  • Sell or donate the car to a grandchild or charity — a graceful reason for exiting from driving. If a grandchild gets the car, extract promises to be a part-time chauffeur.
  • Consider having a safe copilot. This is controversial because you may be putting two people at risk. However, it may keep confused drivers from getting lost.
  • Provide state picture ID. This often feels and looks like a driver's license and serves as official identification. It's easier to get when turning in a driver's license. Some people willingly make the exchange.
  • Grind keys down. It allows the older adult to keep possession. Similarly, take the battery out of keyless entry key fobs.
  • Disable the vehicle, and leave a note under the hood informing anyone who may be called to call you and not repair the car. You can also try saying the car is "still in the shop."

Pomidor thinks families need more support.  "I view really the community as needing to take this on as an awareness issue," she said. Pharmacists, staff at a senior center, or people at church may see when an older driver is becoming unsafe. Some of them could gently intervene and say, "It looks like it may be getting harder for you to get around. Can I help you?"