Dementia and Driving Dangers: When is it Time to Give Up the Keys?

Zaldy S. Tan, MD


September 08, 2016

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When should patients with dementia give up the car keys?

Response from Zaldy S. Tan, MD
Associate Professor, Department of Medicine, Division of Geriatrics, University of California Los Angeles; Medical Director, UCLA Alzheimer's and Dementia Care Program, Ronald Reagan UCLA Medical Center, Los Angeles, California

With usual aging come physical and sensory changes that may impair one's driving ability. Visual changes from presbyopia and cataracts may make it more challenging for older drivers to see objects on the road, judge distances, accommodate to darkness, and recover from glare. Similarly, hearing loss and joint diseases that cause pain or limit flexibility may compromise their attention and reaction time. Older persons are more likely to be on medications that may impair their ability to drive safely. It thus comes as no surprise that drivers aged 85 years or older have among the highest per-mile crash rates and driving fatality rates.[1] According to the National Highway Traffic Safety Administration (NHTSA), older Americans are overrepresented in traffic fatalities; they make up 9% of the population yet are involved in 13% of fatal crashes and 17% of pedestrian fatalities. The fatality rate for older drivers is 17 times higher than the rate for those 25-65 years of age.[2] Cognitive changes in persons with Alzheimer disease and other dementias further add to the risks of driving.

Dementia-related cognitive deficits that may impair driving ability include memory loss (eg, increased likelihood of getting lost), visuospatial problems (eg, difficulty judging distance and staying in lanes), impaired judgement (eg, challenges on turns and in changing lanes), and decreased insight (eg, lack of awareness of dangerous driving). Outpatient surveys estimate that 30% of older adults with dementia still drive.[3] Clinicians have a professional—and, in certain states, legal—obligation to assess driving safety and report unsafe drivers to the local authority. A history from an informant who is familiar with the patient's driving skills and habits will be invaluable to detect unsafe driving behaviors. Telltale signs of driving problems include crashes, unexplained dents on the car, confusion with traffic signs, miscalculation of speeds and distances, getting lost in familiar places, and "near misses."

The stage of dementia should be taken into consideration. Although dementia affects driving performance even in mild stages, some patients with early dementia may still be able to drive safely.[4] Office-based cognitive tests such as the Clock Drawing Test[5] and Trail Making Test part B[6] may reveal deficits in divided attention, executive function, memory, and visuospatial skills that can affect driving ability. Performance-based road testing with a trained professional will provide information on practical driving skills. At the outset, however, it should be recognized that dementia is a progressive, incurable disease and that driving skills will invariably deteriorate over time.

Exploration of alternative transportation options and planning for driving cessation should commence soon after dementia diagnosis. Transportation options for persons with dementia vary depending on a number of factors, including geographic location, financial ability, and availability of social support systems. Even though public transportation options such as trains and buses may be available in urban and suburban areas, a person with dementia will eventually lose the cognitive and physical ability to safely use these services. Paratransit service may provide a more appropriate level of service to people who cannot get around using the public transportation system. In many places in the United States, meals, medicines, groceries, and other necessities may be delivered to one's home. More information on local resources and options can be obtained from the Eldercare Locator, a service provided by the US Administration on Aging.

In summary, persons with Alzheimer disease and other forms of dementia are at higher risk for driving accidents. The clinician has the ethical, professional, and public health responsibility to address driving safety and identify alternative transportation options, with the goal of eventual driving cessation. In the end, however, driving is a privilege granted by the State, not by the physician. Thus, only local authorities can take a person's driver's license away or, conversely, allow them to drive.

For more information, the American Medical Association and the NHTSA published an informative guide to assessing and counseling older drivers, which also includes state-specific reporting requirements.


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