Evidence-Based Reviews

Driving with dementia: How to assess safety behind the wheel

Current Psychiatry. 2008 December;7(12):37-48

References

1. Stowell-Ritter A, Straight A, Evans EL. Understanding senior transportation: report and analysis of a survey of consumers age 50+. Washington, DC: American Association of Retired Persons; 2002.

2. Marottoli RA, de Leon CFM, Glass TA, et al. Consequences of driving cessation: decreased out-of-home activity levels. J Gerontol B Psychol Sci Soc Sci 2000;55(6):S334-40.

3. Marottoli RA, Mendes de Leon CF, Glass TA, et al. Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Established Populations for Epidemiologic Studies of the Elderly. J Am Geriatr Soc 1997;45(2):202-6.

4. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol 2003;60(8):1119-22.

5. Jang RW, Man-Son-Hing M, Molnar FJ, et al. Family physicians’ attitudes and practices regarding assessments of medical fitness to drive in older persons. J Gen Intern Med 2007;22(4):531-43.

6. Herrmann N, Rapoport MJ, Sambrook R, et al. Predictors of driving cessation in mild-to-moderate dementia. CMAJ 2006;175(6):591-5.

7. Hedlund J. Countermeasures that work: a highway safety countermeasure guide for state highway safety offices. Washington, DC: National Highway Traffic Safety Administration; 2006.

8. Dobbs B. Medical conditions and driving: a review of the literature (1960-2000). Washington, DC: National Highway Traffic Safety Administration; 2005. Available at: http://www.nhtsa.dot.gov/people/injury/research/Medical_Condition_Driving/pages/TRD.html. Accessed September 29, 2008.

9. Li G, Braver ER, Chen LH. Fragility versus excessive crash involvement as determinants of high death rates per vehicle-mile of travel among older drivers. Accid Anal Prev 2003;35(2):227-35.

10. Physician’s guide to assessing and counseling older drivers. Washington, DC: National Highway Traffic Safety Administration; 2003. Available at: http://www.nhtsa.dot.gov/people/injury/olddrive/OlderDriversBook. Accessed September 29, 2008.

11. Yeudall LT, Reddon JR, Gill DM, et al. Normative data for the Halstead-Reitan neuropsychological tests stratified by age and sex. J Clin Psychol 1987;43(3):346-67.

12. Brown LB, Ott BR, Papandonatos GD, et al. Prediction of on-road driving performance in patients with early Alzheimer’s disease. J Am Geriatr Soc 2005;53(1):94-8.

13. Determining medical fitness to operate motor vehicles. CMA driver’s guide. 7th ed. Ottawa, Ontario, Canada: Canadian Medical Association; 2006.

14. Molnar FJ, Patel A, Marshall SC, et al. Systematic review of the optimal frequency of follow-up in persons with mild dementia who continue to drive. Alzheimer Dis Assoc Disord 2006;20(4):295-7.

15. Rapoport MJ, Herrmann N, Molnar FJ, et al. Psychotropic medications and motor vehicle collisions in patients with dementia (letter). J Am Geriatr Soc 2008;56(10):1968-70.

16. Molnar FJ, Patel A, Marshall SC, et al. Clinical utility of office-based cognitive predictors of fitness to drive in persons with dementia: a systematic review. J Am Geriatr Soc 2006;54(12):1809-24.

17. Rapoport MJ, Herrmann N, Molnar FJ, et al. Sharing the responsibility for assessing the risk of the driver with dementia. CMAJ. 2007;177(6):599-601.

18. Herrmann N, Gauthier S, Lysy PG. Clinical practice guidelines for severe Alzheimer’s disease. Alzheimers Dement 2007;3(4):385-97.

19. Hogan DB, Bailey P, Carswell A, et al. Management of mild to moderate Alzheimer’s disease and dementia. Alzheimers Dement 2007;3(4):355-84.

19. Assessing fitness to drive for commercial and private vehicle drivers. Sydney, Australia: National Library of Australia; 2006. Available at: http://www.austroads.com.au/aftd/index.html. Accessed November 4, 2008.

21. Medical aspects of fitness to drive. A guide for medical practitioners. Wellington, New Zealand: Land Transport Safety Authority; 2002. Available at: http://www.transfund.govt.nz/licensing/docs/ltsa-medical-aspects.pdf. Accessed September 29, 2008.

22. At a glance guide to the current medical standards of fitness to drive. Swansea, UK: Drivers Medical Group, Driver and Vehicle Licensing Agency; 2008. Available at: http://www.dvla.gov.uk/medical/ataglance.aspx. Accessed September 29, 2008.

23. Man-Son-Hing M, Marshall SC, Molnar FJ, Wilson KG. Systematic review of driving risk and the efficacy of compensatory strategies in persons with dementia. J Am Geriatr Soc 2007;55(6):878-84.

24. Cox DJ, Quillian WC, Thorndike FP, et al. Evaluating driving performance of outpatients with Alzheimer disease. J Am Board Fam Pract 1998;11(4):264-71.

25. Duchek JM, Carr DB, Hunt L, et al. Longitudinal driving performance in early-stage dementia of the Alzheimer type. J Am Geriatr Soc 2003;51(10):1342-7.

26. Ott BR, Heindel WC, Papandonatos GD, et al. A longitudinal study of drivers with Alzheimer disease. Neurology 2008;70(14):1171-8.

27. Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M. In-office evaluation of medical fitness to drive: practical approaches for assessing older people. Can Fam Physician 2005;51:372-9.

Clinical Point

Acknowledge that it is normal to be unhappy upon learning that one’s driving privileges are being revoked

All participants with mild dementia were rated as “not safe” by the end of 2 years by Duchek et al.²⁵
Median time to “failure” (or a rating of unsafe) was 324 days for drivers with mild dementia vs 605 days for those with very mild dementia, as reported by Ott et al.²⁶

Mr. D’s passionate plea for reconsideration highlights the need for communities to develop alternate transportation for seniors whose driving becomes unsafe (Box 2).

Legal liability? Physicians often are concerned about legal responsibilities and risks involved in reporting unsafe drivers. Be aware of local statutes or legislations regarding mandatory reporting of patients you deem unsafe to drive.¹⁷ These laws usually protect physicians from lawsuits related to violating patient confidentiality. Civil lawsuits remain possible, however, if clinicians fail to report an unsafe driver who subsequently is involved in a motor vehicle collision.²⁷

Box 2

When your patient is unfit to drive: 4 steps to driving cessation

1. Meet with family first. Help them assume a positive and supportive role. Explain concretely and empathically your concern for the safety of the patient and others. Clearly outline your findings that the patient is not fit to drive, and explain that the law requires you to report the patient to the authorities.

Remind family members that the goal of driving assessment is to prevent a collision, and they carry some responsibility because they are aware of the potential risk of letting their family member continue to drive. If necessary, have family members witness a repeat performance by the patient on the most revealing test. Discuss the importance of finding alternate transportation to reduce the risk of isolation and depression that can follow driving cessation.

2. Meet with patient. Having the family present can be helpful, but ask them to assume a supportive role. Give the patient a positive role by recognizing that he or she has been a responsible driver, and part of this responsibility is to stop driving before an accident occurs. Acknowledge that it is normal to be unhappy upon learning that one’s driving privileges are being revoked.

Sometimes it helps to give the patient a prescription in their name that says, “Do not drive.” Families who receive a copy may find this very helpful, too, for reminding the patient later about what you said.

If your patient argues with your position, remain firm and do not argue. Indicate that you have made notes on the meeting and are notifying the authorities about the patient’s unsafe driving. You can add that your chart could be subpoenaed and the patient may be legally liable and financially responsible should he or she continue to drive and have a collision.

3. Talk about transportation options. Family members could share driving responsibilities. Taxi rides can cost less than maintaining a car if the patient drives <4,000 km (2,500 miles) per year. Suggest that patients or families find volunteer drivers or contact helpful taxi drivers a day before an outing is planned.

4. If patient refuses to comply, meet with the family again and encourage them to remove the patient’s opportunity to drive (confiscate the keys, disable the car, or remove the car altogether).

Provide a written statement to the patient and family outlining why the patient can no longer drive. Indicate that it is your legal responsibility to report unsafe drivers, and you intend to notify the authorities regarding the patient’s driving status. If the patient remains noncompliant, continue to encourage family to remove the opportunity to drive.

Related resources

Physician’s guide to assessing and counseling older drivers. American Medical Association and the National Highway Traffic Safety Administration, 2003. www.nhtsa.dot.gov/people/injury/olddrive/OlderDriversBook.
Determining medical fitness to operate motor vehicles. Canadian Medical Association. 2006. www.cma.ca/index.cfm/ci_id/18223/la_id/1.htm.
Canadian Driving Research Initiative for Vehicular Safety in the Elderly (CanDRIVE). www.candrive.ca.

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Rapoport receives grant/research support from the Canadian Institute of Health Research and the Ontario Neurotrauma Foundation.