The Driving Dilemma

Presented by

Theresa Braford MHS, OTR/L

7th Annual Alzheimer’s Conference:

Issues in Early Stages of Alzheimer’s Disease
 Acknowledgements
Thanks to Dr. Jan Duchek, Ph.D. and
Dr. Peggy Perkinson , Ph.D.
for providing the research data for presentation
and
Dr. John Morris, M.D.
Dr. David Carr, M.D.
Dr. Linda Hunt, Ph.D.
for their dedication and research in the field of driving
and dementia.
 Why is this a dilemma?
• Driving represents independence and freedom.
• Difficult to know when a person with dementia should
stop driving.
• Safety of driver and public is at risk.
• Person with dementia may lack insight and judgement.
• Dementia signs may not be recognized or diagnosed.
• Family and medical community may:
• not be aware of the problem
• not know what to do
• not want responsibility for taking away the keys
 Trends that Affect Dilemma
• Increasing number of older drivers
By 2050, 39% of drivers will be > 65 (Malfetti, 1995)
Traffic violation rates are high for both young and old drivers
(Graca, 1986)

• Increasing number of accidents with older

adults
Although the absolute number of crashes for older adults is
relatively low, there is nonetheless an increased crash rate per
miles driven for all drivers 70 years or older in comparison to
middle-aged drivers (Ray, 1997: Evans, 1988)
This increased risk has been attributed to age-related changes in
motor/perceptual skills associated with driving and to various
illness processes (Reuben, 1991: Walker, 1967)
 Crash Rates across Age Groups:
Is there really a problem?
2500

2000

1500

1000

500

0
15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+
19 24 29 34 39 44 49 54 59 64 69 74 79 84
Santa Monica incident
Causes of Accidents: Age < 20
Other Alcohol
11% 12% Alcohol
Speed
Signal Wrong
8% Turn
Right of way
Signal
Right of way Other
20% Speed
38%
Turn
5%
Wrong
6%
Causes of Accidents: Age 70 +
Alcohol
Other
3% Speed
13%
15% Alcohol
Speed
Wrong Wrong
Signal 4% Turn
12% Right of way
Turn
Signal
8%
Other

Right of way
45%
Increasing # of drivers with dementia

• More than 4 million people in US have AD or

other related dementias.

• Increased number of older drivers, including

those with Alzheimer’s disease (AD) and other
dementia (Carr et al, 1998).
 Driving and Dementia
• Demented drivers exhibit more unsafe driving behaviors in
comparison to non-demented controls (Carr et al, 1998).
• Some studies show increased crash rates for demented drivers
relative to controls (Friedland et al, 1993; Drachman et al, 1993).
• Recent research indicates that almost 50% of those diagnosed with
AD are still driving three years after they have been diagnosed.
Additionally, individuals with AD are twice as likely to be involved in a
traffic accident as non-demented people in the same age group.
• Common cause of accidents - “driver inattention” and accidents tend
to occur at intersections.
• Swedish researchers conclude that even in the early stages of AD,
driving can be dangerous.
 Driving and Dementia
• A recent longitudinal study found evidence for declines in
driving performance among persons with very mild and
mild AD over a 6-month period (Duchek et al, under revision)
• Not all individuals with early dementia are necessarily
unsafe to drive (Hunt, Carr, & Ducheck, 1997), however,
controversy continues as to the most effective methods to
ensure driving cessation in those who are truly unsafe.
• A recent practice parameter from the American Academy
of Neurology on the demented driver recommended that
even mildly demented individuals be discouraged from
driving because of safety concerns (Dubinsky et al, 2000)
 Cognitive changes with AD that can
affect driving
•Memory loss affecting ability to do things
•Confusion about time and place
•Difficulty performing familiar tasks
•Poor or decreased judgement
•Poor concentration or inattention
•Decreased reaction time
•Diminished problem-solving abilities
AD is progressive, gradual and somewhat unpredictable.
What can a caregiver or loved one do?
• Do NOT wait for an accident to happen
• Take action immediately
• Observe daily behaviors and driving warning signs
• Develop a plan
• Individuals with early stage or mild dementia should have
driving skills evaluated immediately.
• Individuals with moderate or severe dementia should NOT
drive.
 Observe Daily Behavioral Signs
• Gets lost in familiar areas
• Easily rattled, distracted, confused or irritable
• Problems with unusual circumstances, integrating new
information and reacting quickly
• Less coordinated
• Difficulty engaging in multiple tasks
• Increased memory loss
• Difficulty with decision-making & problem-solving
• Other problems: vision, hearing, ROM, reflexes
 Warning Signs Regarding Driving
• Incorrect signaling
• Trouble navigating turns
• Moving into a wrong lane
• Confusion at exits
• Parking inappropriately
• Hitting curbs
• Driving at inappropriate speeds
• Delayed responses to unexpected situations
• Not anticipating potential dangerous situations
 Warning Signs Regarding Driving
• Increased agitation or irritation when driving
• Scrapes or dents on the car, garage, or mailbox
• Getting lost in familiar places
• Near misses
• Ticketed moving violations or warnings
• Car accidents
• Confusing brake and gas pedals
• Stopping in traffic for no apparent reason
 Things to Consider

• Write these down

note frequency and severity
• Talk to family and get their feedback
• Take immediate action if you notice a severe
sign!
 The Best Test

Ask yourself, honestly...

“Would I let my child ride in the car
with ______________?”
Impact of Not Driving for Older Adult

• Threat to independence & self esteem

• Fearful of future
• Feeling trapped and isolated
• Don’t want to burden family
• Lacks alternative transportation
Reasons Caregivers Don’t Address
Driving Concerns

• Fearful of conflict
• Not comfortable saying no to parent
• Burden on caregiver for transportation
• Invokes feelings of guilt
• Lacks awareness or in denial
• Rationalizes
 How to Address Driving Concerns
Least threatening:
• Develop a plan
• Openly discuss concerns with older adults
use “I” statements and be sensitive
listen and be prepared for anger (avoid
defensiveness)
• Older adult may modify own behavior such as:
driving shorter distances and only on familiar roads
avoiding difficult left-hand turns, night driving or
driving in heavy traffic
 How to Address Driving Concerns Least
threatening (continued)

• Co-piloting is not the answer

• Ease the transition from driver to passenger
• Let others do the driving
• Use public transportation or taxis
• Have friends and relatives share transportation responsibilities
• Reduce the need to drive
• Enlist support from
• family members
• medical professionals
• physician
How to Address Driving Concerns
More directly
Seek help from Dept. of Revenue/DMV
·Missouri Impaired Driving Laws (effec. Jan. 1, 1999)
·“others” can confidentially report unsafe driver
·panel at Department of Revenue can determine testing for
unsafe driver
·driver reports to local DMV office for testing
·driver can have license revoked

WARNING:
Older adult can still drive without a license!
How to Address Driving Concerns
More directly (continued)

Obtain driving assessment

·Performed by licensed OT
·Not covered by insurance
·Objective measure of performance
·Gives a broad-based assessment of strengths and
weaknesses in many skill areas
·Not a driving safety course
 Areas Tested in Driving
Assessments
• Range of motion and functional strength
• Cognitive screening
• Visual skills
·depth perception
·contrast sensitivity
·visual field and search
• Reaction time and balance
• Open road test (traffic signs, negotiating intersections,
signaling and maintaining speed)
 If all else fails…
Most drastic measures

• Take car keys

• Disable the car

• Take away the car

• Sell the car

 What should professionals do?
• Gather information from patient or family about
status of driving.
• Speak directly to patient and family about safety
and your concerns: be firm.
• Alert the patient’s MD about your concerns and
have him/her discuss with the family.
• Provide driving assessment referrals.
• Provide alternative transportation resources.
 Key Points to Remember
• Older drivers are at risk for unsafe driving
• AD greatly increases this risk
• Individuals with early stage or mild
dementia should have driving skills
evaluated immediately.
• Individuals with moderate or severe
dementia should NOT drive.
 Key Points to Remember (continued)

• A person with dementia will probably NOT

admit they are an unsafe driver because
they lack the insight and judgement.
• Public safety is a high priority
• Driving is NOT a right -- it is a privilege
 Key Points to Remember (continued)

• Remember: the issue goes beyond self-esteem

and independence.

Driving affects the lives of

everyone else on the road.
(Alz. Assoc.)