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ORLANDO, FLA—As the elderly population continues to grow, health care professionals are more frequently encountering the issue of dementia and driving safety. Determining whether a driver is unsafe, addressing and treating the patient with dementia, and, perhaps most difficult, telling a patient that he or she should no longer drive are all challenging issues that confront doctors today.
“There are some consequences to asking people not to drive anymore,” said William H. Roccaforte, MD, at the 15th Annual Meeting of the American Association for Geriatric Psychiatry. “The biggest is loss of independence, a huge lifestyle change for these folks. Some will feel like they’re now a burden on their family even if the family is very willing to drive them wherever they need to go. And this all really can diminish quality of life.” Dr. Roccaforte is an Associate Professor and Director of the Geriatric Psychiatry Fellowship, Department of Psychiatry, University of Nebraska, Omaha.
Physicians are not alone, however, in dealing with this growing problem. Caregivers, government agencies, the insurance industry, and advocacy groups such as the American Association of Retired Persons (AARP) and the American Automobile Association also play a role in the effort to make highways safer. The National Highway Traffic Safety Administration (NHTSA) has made one of its goals to get unsafe drivers off the road.
AGING DEMOGRAPHICS
Currently, said Dr. Roccaforte, about 12.7% of the US population is older than age 65. By the year 2030 it is expected to be 20%, which means that the number of people 65 and older will increase from about 34 million to approximately 70 million. Seventy-five percent of the elderly have a driver’s license, and 72% of all elderly people live in suburban or rural areas. “So they’re in places where there’s a great deal of distance between different services and where having ready access to transportation is even more important,” said Dr. Roccaforte. “And those happen to be the areas where public transportation is less readily available.”
According to the NHTSA, several consequences of normal aging have been reported to be associated with an increased rate of motor vehicle accidents or motor fatalities. The first is vision decline, including macular degeneration and dynamic visual acuity, which affects one’s ability to gauge speed and distance. Hearing loss and increased reaction times are also associated with aging. Vascular disease and peripheral neuropathy or retinopathy that comes with vascular disease also can affect driving skills, as can diabetes and associated hyperglycemia, hypoglycemia, retinopathy, and neuropathy. About 50% of people develop significant arthritis as they get older, which decreases cervical range of motion. Another factor that can affect driving is use of sedating medications. “The elderly get a disproportionate number of prescriptions for benzodiazepine, so we need to check on what medications they are taking,” said Dr. Roccaforte.
Elderly people adapt their driving behavior as they get older, he said. “They almost self-police in that way. They drive substantially fewer miles than younger adults do. And sometimes, to a very frustrating extent for some other drivers, they may drive quite a bit slower, and they tend to restrict themselves to more optimal conditions—for example, driving only during daylight, avoiding busy highways, staying out of bad weather, or avoiding rush hour. So they’re really pretty adept as a group at cutting down on some of the times when driving might be more difficult.”
Two NHTSA reports claim that individuals older than 65 make up 14% of all drivers. However, one report concluded that this group accounted for 18% of road fatalities, and another study, only 11%. “One of the frustrating things of reading in this area is that you can find studies that almost directly contradict each other, even when you try to make sure that they are reasonably comparable in the way that they were done,” said Dr. Roccaforte. “As a point of comparison, people between the ages of 16 and 24 also make up 14% of all drivers. And they account for about 26% of all road fatalities. Looked at this way, this is the most dangerous group.”
ROAD DEMENTIA
The prevalence of dementia increases dramatically with age, said Dr. Roccaforte, and several characteristics of dementia can have a profound impact on driving, beginning with memory loss. “If you can’t remember the rules of the road, or you can’t remember where you’re going or the routes that you’ve taken before, you could run into some trouble,” he said. Another symptom and potential driving hazard is agnosia, which could lead someone to have trouble recognizing road signs or controls inside the car. Apraxia, or loss of ingrained motor memory, can impede the handling of the instruments in one’s car or remembering how to use a cell phone to call for help. Although not a criterion for dementia, visuospatial distortion frequently accompanies dementia, said Dr. Roccaforte. Maintaining lane integrity and being able to maneuver around corners safely could be affected by dementia. Executive function decline—the decreased ability to solve problems and to get out of tight spots—is also a potential problem. The last criterion for dementia is cognitive trouble that leads to functional impairment.
WHO IS UNSAFE?
Three ways to assess how safely people drive have been reviewed—caregiver reports, Department of Motor Vehicle (DMV) records, and driving performance tests, which most people consider the gold standard, said Dr. Roccaforte.
In one study involving 72 elderly individuals with mild to moderate dementia (those with an average Mini-Mental State Examination score slightly higher than 17), Lucas-Blaustein and colleagues interviewed the drivers’ caregivers. Thirty percent of the subjects were still driving, and of those 30%, their caregiver thought 60% of them were safe drivers. In a three-year span since onset of dementia, 30% of the drivers had an auto accident, and another 11% caused someone else to have an accident.
The DMV can revoke an unsafe driver’s license, but many times that doesn’t stop the person from driving, said Dr. Roccaforte. “So really, it comes down to what the family is able to do with that person on a day-to-day basis. One of the things I feel real comfortable in doing is to try and take the blame off the family with regard to the patient. For some patients, it still works if they say, ‘Well, the doctor said that you can’t drive anymore.’ In this age-group, it still carries a little more weight, I think, than it does in some of the younger age-groups.... However, we’re not experts at making this kind of determination. When there is any doubt about driving safety, we should refer them to experts.”
Dr. Roccaforte reviewed four separate studies that have assessed the driving skills of mildly demented individuals: In the best case, 24% failed the test, and in the worst case, 60% failed. Overall, he said, the studies showed that a substantial proportion of even mildly demented drivers are not safe drivers.
“We don’t have a simple screening test,” he said. “There is a growing opinion that something has to be done, but we don’t have a good way to do it yet, unless we use a fair amount of resources. I think that’s really the bottom line in all of this. We have to have a way to individually test folks if we want to assess people fairly.”
Most states do not require physicians to report anyone diagnosed with dementia, said Dr. Roccaforte. One exception is California, which, in 1988, convened an expert panel of representatives from the Alzheimer’s Association, AARP, DMV, geriatricians, psychologists, geriatric psychiatrists, and attorneys. Collectively, they recommended mandatory physician reporting to the DMV of anyone diagnosed with dementia. The American Academy of Neurology published its own practice parameters within the past year and a half. The association concluded that only people with a very mild stage of dementia should be permitted to continue to drive, and they should have formal, serial evaluations.
PRACTICAL ADVICE
Dr. Roccaforte advised a systematic approach toward dealing with elderly patients with dementia and the topic of driving. The first thing to do, he said, is ask if the person is driving and if there are any problems while he or she is driving. “I always ask both the patient and the caregiver to see if there’s a discrepancy in their perceptions. Often there is.” He also recommended asking the caregiver if he or she is comfortable driving with the person. “When I think something needs to be done, the first thing I’ll do is review the risk with the driver and the caregiver. I tell them that their risk every time they drive is substantially higher than for the average person. I show them some of the disastrous outcomes that can potentially happen. I usually will recommend to folks that they not drive. I say ‘The safest thing for you to do is to stop driving.’ And very commonly, I get a fair amount of protest. I’ll acknowledge that I’m not an expert but I am willing to write a letter to the DMV; then it can be up to those experts to decide whether [a patient is] a safe driver or not.” He added that an alternative is to have an occupational therapist write a report on the driver’s skills and deficits and to recommend specific limitations.
“The other important thing is to document what you recommend to the person and why,” said Dr. Roccaforte. “There’s a lot of concern about legal liability.” To date, there has been no lawsuit against a physician who has not reported a demented driver to the DMV. “I imagine there’s going to be a time when that happens, but so far the legal risk doesn’t seem to be that high. If you document really well what you did and why you did it, even if you do get sued, the chances of the lawsuit being successful are substantially diminished.”
Dr. Roccaforte said the family is “front line,” ie, the ones who are actually going to have to stop a person from driving. If the family can’t do it, sometimes a trusted ally or family lawyer can, or even an insurance agent, who can explain the situation in financial terms. Other methods used by family members include destroying the driver’s license (if the person is fairly law-abiding), hiding the keys, disabling the car, putting a locking device on the steering wheel, changing door locks, or even hiding or selling the car.
The goal in caring for the patient, he said, is to “obtain enough information to determine driving safety and to recommend specific actions that the patient and family can take to ensure a quality of life that is as good as possible.”
NR
—Colby Stong
Suggested Reading
Lucas-Blaustein MJ, Filipp L, Dungan C, Tune L. Driving in patients with dementia. J Am Geriatr Soc. 1988;36:1087-1091.
Shua-Haim JR, Gross JS. The “co-pilot” driver
syndrome. J Am Geriatr Soc. 1996;44:815-817.
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