Considerations and Risks of Driving with Dementia
Last year I discussed an important topic that I believe is worth revisiting. I say this because in our weekly patient discussion, it is discussed more often than any other topic, except for the individual diagnosis for each patient. The topic that I am referring to is driving. For personal, economic, social, medical and many other reasons, driving is an important part of our lives. It allows independence and mobility and, for many of us, was a marker that indicted we were approaching adulthood. It is these issues that make it very difficult for many people to give up their driving privileges and why it is equally difficult for family members (and many medical personal) to take them away.
So, how should the decision be made? One might think there would be laws, such as there are used for patients with epilepsy, that govern who can keep and who should loose their driving privileges because of dementia. However, the laws regarding dementia usually are worded to require someone to determine if cognitive (thinking and memory) impairments significantly impair driving. What does that mean? Does this mean driving less well than in the past, driving less well than the average driver, driving less well than a new teenaged driver, or does it mean having had one or more accidents? Often, it is left to a health care professional to tell a patient to not drive. However, I have heard some physicians say that they believe anyone who is taking a cholinesterase inhibitor should not drive. However, how does this then apply to patients who are put on a cholinesterase inhibitor for mild cognitive impairment? Remember that mild cognitive impairment may include impaired memory but otherwise normal performance on testing and normal day to day functioning. Does this seem reasonable? If you have been following this, you may be realizing that there are as many questions as answers.
Therefore, let’s take a logical look at dementia and driving. What are the common impairments in people with Alzheimer’s dementia? I have discussed them in previous blogs and they include amnesia (impaired memory), aphasia (impaired speech and language), apraxia (impaired complex motor function), agnosia (impaired understanding of objects), executive dysfunction (decision making and judgment), impaired attention, personality change and spatial impairments. One need not be a medical professional to realize how all of these abilities are important if one is to be a skilled driver. But how much loss of which skills are crucial? There is no clear answer to that. However, we can make certain observations. First, in judging if someone has impaired driving from dementia, it is ideal if that judgment is aided by some direct observation of the patient’s driving. Our society does not allow people to acquire driving privileges without direct observation. It would seem that direct observation is a useful tool for determining that a person should maintain or loose those privileges. Therefore, road tests, and/or testimonials from friends or family who have directly observed the person while driving are important in making this important decision.
The Association for Driver Rehabilitation Specialists (aded.net) provides driver evaluations to determine a driver’s safety. They developed a list of warning signs that someone with Alzheimer’s disease may be driving in an unsafe manner. Importantly, these signs can be viewed in terms of the common areas of cognitive impairment that occur in Alzheimer’s disease. This relationship is summarized here.
- Unsafe Driving Signs Area of Cognitive Impairment
- Driving to slowly Apraxia
- Not obeying signs or signals Aphasia
- Difficulty interpreting driving situations Executive dysfunction
- Failure to yield Agnosia (impaired interpretation of the yield sign)
- Easily frustrated or confused Personality change
- Frequently getting lost Memory loss
- Poor road position (driving the wrong way down streets) Spatial impairment
- Needs instructions from passengers Any or all of the above
Clearly this simple one to one comparison is an oversimplification. However, I have written it this way to stress that there is nothing unique about the loss of driving skills. Loss of these skills and the need to have the driving privileges discontinued is part of the unfortunate disability that occurs in this devastating disease.