Dementia Care: What About Driving?
Persuading an elderly driver to hand over the car keys is a delicate and often difficult task. But it’s one that many adult children and caregivers will have to face sooner or later, especially when the driver has dementia.
Driving is a privilege and a symbol of independence and competence. It’s no wonder that drivers are often hurt, angry, hostile, or obstinate in response to any suggestion that they shouldn’t be behind the wheel.
The implications of no longer driving are immense. Most notably it means becoming entirely dependent on others for everyday activities like grocery shopping or visiting friends; this is particularly true for people who don’t live in an area that is easily walkable or has mass transportation.
Not surprisingly, being forced to stop driving has been associated with depression and social isolation among the elderly. Nevertheless, safety is the paramount concern. Studies suggest that drivers with dementia have at least double the risk of being involved in a crash compared with older drivers whose cognition is intact.
Still, experts note that a diagnosis of dementia is not necessarily an indication that the person should immediately turn over the keys. Some people may be able to keep driving and maintain their independence, at least for a time. But others represent a clear and present danger if they continue to drive.
Following are the different categories of dementia and advice on whether to hang up the car keys.
Mild dementia: The gray area
For the purposes of evaluating driving ability and other aspects of daily functioning, doctors sometimes use the Clinical Dementia Rating (CDR) scale to determine dementia severity. Severe dementia has a CDR score of 3; moderate is 2; mild dementia is 1; and very mild is 0.5.
Decisions about driving are clear-cut for people with CDR scores of 3 or 2: Professionals agree that anyone whose dementia is beyond the mild stage should not be allowed to drive. There is also agreement that individuals with very mild dementia (a CDR of 0.5) can continue behind the wheel. The gray area: mild-stage dementia (a CDR of 1).
While some groups, such as the American Academy of Neurology, recommend that people with mild dementia strongly consider discontinuing driving, others argue that a good number of people in that group may be competent to drive. Studies to support that claim show that as many as 76 percent of people with mild dementia could pass an on-road driving assessment.
Testing driving skills
An on-road test is, in fact, the most accurate way to determine an individual’s capacity to drive. Simulator testing, another option, offers a reasonable approximation of road conditions, but on-the-road testing remains the gold standard.
An on-road test should be conducted as part of a complete evaluation of a person’s driving skills, which also includes an assessment of vision, cognition, and motor skills.
On-road testing can be performed by a driving rehabilitation specialist or, in some states, the department of motor vehicles (DMV). One drawback is the expense—about $350 to $500—which is not typically covered by insurance.
If it isn’t possible to get an on-road test, the results of some standard cognitive tests may provide insights into how well a person can drive.
The American Medical Association recommends the Clock-Drawing Test, which assesses how accurately the patient draws a clock, and the Trail Making Test Part B, in which patients must take numbers and letters scattered in circles on a piece of paper or computer screen and connect them in an alternating pattern (1-A-2-B, etc.) as quickly as possible.
Your family physician may be willing to administer these tests, which evaluate visual/spatial ability, attention, executive function, and memory—important skills for driving. Poor results on these tests alone should not lead to the revocation of driving privileges, but they do indicate a need for further evaluation.
Even if a person with mild or very mild dementia is deemed competent to drive, driving skills can deteriorate rapidly. Therefore, cognition and road test skills should be frequently re-evaluated, possibly as often as every six months.
Signs of trouble
Perhaps the simplest way to determine if a person with mild dementia is fit to drive is to let common sense be your guide. Many warning signs, from subtle to strong, indicate that an individual shouldn’t be driving. These include:
• Driving too slowly or too fast
• Receiving traffic tickets
• Being honked at or yelled at by other drivers
• Becoming upset or angry while driving
• Dents, dings, or scraped paint on the car, mailbox, or garage
• Misunderstanding or not noticing signs on the road
• Getting lost in familiar places
• Stopping at a green light
• Changing lanes without looking
• Drifting into another lane
• Having difficulty making left turns
• Misjudging distances
• Mistaking the gas pedal for the brake
• Causing any crash or near crash
You can also follow the “grandchild test”: If you would not feel safe having this person drive his or her grandchild, it’s time to have a talk about handing over the keys.
Having “the talk”
Ideally, conversations about an inevitable decline in driving ability should begin long before deteriorating skills become a crisis. Starting these talks early allows the person to adjust to the idea that eventually he or she will need to stop driving.
Also, discuss the importance of periodic reassessments of driving performance and changes in driving habits that may be necessary over time, such as no driving at night or driving only for short distances. You can also make plans for alternative means of transportation.
What do you do when an obviously impaired family member refuses to stop driving? It may be easier for the person to accept the decision if it comes from a neutral party, such as the family physician.
The doctor can discuss the personal and financial risks involved in driving while cognitively impaired and can write out a “prescription” that says “No Driving.”
Involving the physician may also save your loved one—and innocent bystanders—from harm. According to a study in The New England Journal of Medicine, physicians’ warnings to patients who are potentially unfit to drive reduced the risk of serious road crashes.
Healthcare professionals in some states are required to report to the state’s DMV that a person in their care has a medical condition that interferes with driving ability. The state may then test the person and revoke his or her driver’s license if that is appropriate.
If mandatory reporting isn’t required in your state, you can contact the DMV independently to find out what steps can be taken to get an impaired driver off the road.
In some cases, you may have to use drastic measures: Hide the car keys, disable the car by removing the battery or distributor cap, park the car where the person can’t see it, or sell the vehicle.
If appropriate and financially feasible, moving your loved one to an assisted living facility also can solve the problem. Many facilities provide transportation to grocery stores, doctors’ appointments, and community events, which enables your loved one to continue to feel socially engaged and independent.