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To Drive or Not to Drive? That Is the Question
Abstract & Commentary
By Allan J. Wilke, MD, MA, Professor and Chair, Department of Integrative Medicine, Ross University (Bahamas) Limited, Freeport, Grand Bahama, The Bahamas. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Patients with dementia and their physicians face the difficult decision to cease driving with little solid evidence to guide them.
Source: Iverson DJ, et al. Practice parameter update: Evaluation and management of driving risk in dementia: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1316-1324.
The American Academy of Neurology has issued a new practice parameter that updates the literature on the risk of demented patients driving. The authors reviewed articles from 1970 through 2006. They identified 6000 studies and selected 422 for full review. An additional 80 references were added after secondary bibliography search. Successfully completing an on-road driving test (ORDT) was chosen as the gold standard for safe driving. The parameter addressed 5 questions:
1. How strongly are global measures of dementia severity associated with decreased driving ability? The Clinical Dementia Rating (CDR) can identify patients at increased risk for unsafe driving.1 However, many patients identified by CDR will pass ORDT. The Folstein Mini-Mental State Examination (MMSE) was not designed to identify unsafe drivers and performs poorly when used to do so. A score ≤ 24 may identify an individual at risk.
2. To what extent are patients and their caregivers able to assess driving ability and risk? Not very. Patients with Alzheimer's dementia who identify themselves as "safe drivers" more often than not fail ORDT. A caregiver's opinion may be helpful if it is negative.
3. Which elements of the driving history are associated with decreased driving ability? A history of a crash in the last 5 years, a traffic citation in the last 2-3 years, self-imposed reduced driving mileage, self-reported avoidance of unsafe conditions (nighttime driving, driving in the rain, etc.), and aggressive or impulsive personality traits are possibly useful in identifying patients with decreased driving ability.
4. What neuropsychological tests provide additional prognostic information? No comprehensive neuropsychological assessment has yet been devised to reliably evaluate driving risk in patients with dementia; they can help determine the severity of the dementia.
5. Are there interventions that reduce driving risk? No beneficial interventions have been demonstrated for patients with dementia. This includes licensing restrictions and driver's training.
The authors offer an algorithm that incorporates the CDR and historical risk factors such as those listed above to estimate the driving risk and recommend that physicians reevaluate patients who continue to drive every 6 months. They conclude with the recommendation for more research into this subject.
Let's put this into perspective. If you were 24 when Ronny and the Daytonas recorded "GTO" in 1964, immortalizing the Pontiac model of the same name, you would be staring 70 in its face and maybe, just maybe, be wondering whether your memory and your reaction times are what they once were. The baby-boom generation embraced the automobile and the freedom and mobility it provided. We are not going to let go easily. Because this population is aging and because physicians are expected to advise their patients and their caregivers on this topic, there has been a flurry of articles about the at-risk driver in the literature lately. The Journal of the American Medical Association recently published a similar article in its "Care of the Aging Patient" section.2 It covers much the same ground and evidence, but also includes a vignette that has a patient, his spouse, and his physician reflecting on the difficulty of terminating a patient's driving privileges. It also includes some resources that primary care physicians may find useful: the website for the Association for Driver Rehabilitation Specialists,3 a patient handout on driving and dementia from the American Academy of Family Physicians,4 and a guide on state licensing requirements and reporting laws from the American Medical Association.5
To whom is the physician responsible in this situation? The patient or the public? As Eby and Molnar point out in their editorial, there is a wide expanse of gray landscape between premature cessation of driving privileges that isolates the patient and places additional responsibilities on the caregiver and continued driving that places the patient and others in harm's way.6 Additionally, there are inconsistent legal requirements for physicians to report unsafe drivers. They note that 22 states encourage reporting and 12 require it. However, only 25 states provide immunity to physicians from civil lawsuits that result from reporting and only 19 protect the identity of reporting physicians.
The determinants of unsafe driving are more than just dementia. Poor eyesight, poor hearing, distractibility, and arthritis all play a role. Sometimes, physicians add to the problem by prescribing medications that exacerbate cognitive decline. A new tool that considers crash history, family concerns, clinical condition, and cognitive functions may be a useful marker to identify at-risk elderly drivers,7 but as a Cochrane review states, "Driving legislation and recommendations from medical practitioners require further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public."8
1. Regional Geriatric Program of Toronto. Available at: http://rgp.toronto.on.ca/. Accessed June 5, 2010.
2. Carr DB, Ott BR. The older adult driver with cognitive impairment: "It's a very frustrating life." JAMA 2010;303:1632-1641.
3. Association of Driver Rehabilitation Specialists. Driv-ing and Alzheimer's/Dementia. Available at: www.driver-ed.org/i4a/pages/index.cfm?pageid=104. Accessed June 5, 2010.
4. American Academy of Family Physicians. Driving and dementia: What you should know. Available at: www.aafp.org/afp/2006/0315/p1035.html. Accessed June 5, 2010.
5. American Medical Association. State licensing and reporting requirements. Available at: www.ama-assn.org/ama1/pub/upload/mm/433/chapter8.pdf. Accessed June 5, 2010.
6. Eby DW, Molnar LJ. Driving fitness and cognitive impairment: Issues for physicians. JAMA 2010;303:1642-1643.
7. O'Connor MG, et al. The 4Cs (crash history, family concerns, clinical condition, and cognitive functions): A screening tool for the evaluation of the at-risk driver. J Am Geriatr Soc 2010 May 7; Epub ahead of print.
8. Martin AJ, et al. Driving assessment for maintaining mobility and safety in drivers with dementia. Cochrane Database Syst Rev 2009;(1):CD006222.