Older Patients, Wiser Care
Dementia and Driving
Last updated:May 31, 2010
The case: A happy driver, an oblivious family
A family friend, T, was updating me about his 80-year-old brother, H. He'd been diagnosed a few years earlier with mild dementia, probably due to Alzheimer's disease. H, who had never married, was fairly disorganized, and could no longer manage living in his Manhattan apartment on his own. Fortunately he'd purchased a small house in a retirement community with home services near his New Jersey hometown.
"He seems to be doing fairly well since he moved," his brother told me. "And since he has a car there, he even drives around town, which he very much enjoys."
"Drives?" I said in surprise. Between my own observations and T's previous descriptions of H's struggles with certain household tasks, I said I wasn't at all convinced that it was safe for H to be on the road.
T seemed taken aback. "He says he's fine to drive, and I think he'd be very upset if we told him he couldn't."
"He may well get upset," I answered. "But you absolutely can't let him be the judge of whether he can drive."
The challenge: Unsafe drivers who don't realize they're a hazard
Driving and dementia is a difficult combination for everyone involved. For the person with dementia, it's often terrifying to face losing the independence and autonomy that a car provides. For families, it can be daunting to have to meet the person's transportation needs.
As for doctors, a recent American Academy of Neurology review of research evaluating driving risk confirmed what we wrestle with all the time: There's still no way to reliably tell in the doctor's office whether or a patient with early dementia is safe behind the wheel. In other words, although you ask us all the time, we usually can't be sure, although we can check that vision and medications aren't making things worse.
So for now, the best advice is for a person with early dementia to be tested on the road, through the local Department of Motor Vehicles or by a special occupational therapist. Especially if you've been feeling uncomfortable as a passenger with such a driver, I recommend this route. (If the patient has a history of traffic citations or crashes, then I suggest hiding the keys until the driving test takes place). By the time the person reaches moderate (middle) stages of dementia, most doctors can comfortably say it's time to turn in the keys, but by then it's obvious to family, too. The catch is to stop the driver before cognitive skills deteriorate that much.
One thing the review did confirm is that a person with mild dementia tends to be a very poor judge of his or her own abilities. Self-rated driving ability should never be used as justification for letting a person with dementia keep driving.
The solution: Involve a trained third party to evaluate driving ability, and be prepared to override resistance.
Most caregivers want to respect their loved one's feelings and autonomy, so it can be hard to insist on a driving evaluation when an older person is resisting. I usually encourage family members to accommodate a loved one's preferences whenever possible, but I take a tougher stance when it comes to driving.
That's because driving, unlike, say, insisting on remaining in a cluttered house with stairs, poses a very real safety hazard to many beyond the driver with dementia: the pedestrians, bikers, and other drivers who share the road.
That's why I err on the side of caution, even though many people with early Alzheimer's can drive safely, and recommend patients consider quitting once they're diagnosed.
I reminded T that since his brother now lived in a walkable senior community with access to transportation alternatives, this might be a good time to get him to stop driving altogether. After all, even if H passed his on-the-road driving test (and 40-80 percent of those with very early dementia do), he still had a higher crash risk than a healthy adult. Besides, it was only a matter of time before H's Alzheimer's dementia worsened. (His "early stage" diagnosis was already several years old.)
A few weeks later, T reported that the family had replaced his brother's car key with a similar-looking key that doesn't work. "H likes to sit in the car anyway," he said. "His caregiver keeps telling him that we're planning to get the car fixed soon. It's always news to him when she tells him that."
I thought this was a great example of a family putting a loved one's forgetfulness to good use.
My prescription for caregivers:
Never allow a person with even early dementia to judge his or her own ability to keep driving. If you're uncomfortable when your loved one is driving, pay attention to that instinct. During mild or early dementia, know that there's no way for the doctor to accurately evaluate driving safety. Although all states allow doctors to refer people with dementia for an on-the-road evaluation (in some states, this is even required, although often not enforced), most states also allow caregivers to report concerns directly to the state, sometimes even anonymously, which can lead to the person being asked by the state to come in for testing
Know that even if your loved one passes a test, driving ability will still worsen, sometimes quickly. So you'll still have to keep monitoring driving carefully and start on a plan for alternative transportation. (Social workers and counselors at your [local Agency on Aging] (https://www.caring.com/local) can help point you to resources in your area.)
Stick to your guns even if you encounter resistance. (And know you probably will.) After all, it's not just the safety of your loved one that's at stake; it's also the safety of everyone else on the road.
Safest of all is for a person to give up driving once a diagnosis of even mild Alzheimer's or other dementia has been made.
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