By Geri Adler, PhD, MSW
Dr. Geri Adler is Assistant Professor in the Graduate College of Social Work at the University of Houston. She has over twenty years of clinical experience working with individuals with Alzheimer’s disease and their families. A Hartford Geriatric Social Work Scholar, Dr. Adler’s funded research focuses on driving and dementia. She has multiple publications in this area including recent manuscripts in Dementia: The International Journal of Social Research and Practice, Traffic Injury & Prevention, The Gerontologist and Health and Social Work.
Q. Why is driving and dementia a concern?
Over five million Americans are estimated to have Alzheimer’s disease (AD) and related dementias and 30% to 50% of persons with dementia continue to drive. Although some individuals with mild dementia can drive safely, for almost all, driving will become impossible at some point as the disease progresses.
Research has found that drivers with dementia have a higher crash rate, become lost in familiar areas, and make more frequent errors in performance than other older drivers. In addition, because of poor judgment, lack of insight and a loss of reasoning ability some drivers with dementia may not even realize they having any problems. Therefore, individuals with dementia continue to drive when they are no longer able.
Being unable to drive is a serious loss of independence and mobility. It is not unusual for drivers with dementia to become upset, angry and even depressed when driving concerns are raised.
The sheer numbers of persons with dementia who continue to drive, the seriousness of the issue, and its effect on mobility, underscores the importance of addressing driving and dementia.
Q. What are some warning signs of driving problems?
It can be difficult to determine when a driver with dementia is no longer safe to drive. However, there are several warning signs or red flags that may indicate driving skills are declining and need to be evaluated.
Warning signs to watch for include:
- becoming lost in familiar areas,
- incorrect signaling,
- improper speed – driving too slow or too fast for conditions,
- driving the wrong direction on roadways,
- decreased understanding of traffic signs,
- confusing the break and gas pedals,
- reliance on a co-pilot,
- making poor or slow decisions while behind-the-wheel,
- moving violations, tickets or police warnings, and
- crashes or near misses.
Another indicator of problematic driving occurs when family members refuse to ride with the driver or do not allow others, such as grandchildren, to ride with driver.
Q. What are some ways to assess driving fitness and resources for driving decisions?
It is important to discuss driving concerns with a physician and to also have the individual with dementia’s driving evaluated. Many physicians are comfortable beginning the discussion about driving reduction and cessation and to start the driving assessment process. The physician may ask the driver and family questions about the frequency, distance, circumstances of travel, familiarity with roadways used, use of a co-pilot, and any recent crashes and episodes of getting lost. Family may also be asked if they have any concerns about their relative’s driving.
If there is any question about the individual’s ability to drive safety, he or she will benefit further from a formalized evaluation. Testing can be conducted by a certified driver rehabilitation specialist (CDRS), a professional trained in driver education and training, or the State Department of Public Safety. An assessment may include a knowledge test as well as a behind-the-wheel evaluation. There is usually a fee for an assessment completed by a CDRS. Unfortunately, Medicare and private insurance are unlikely to reimburse for this service.
If the evaluation shows that the individual with dementia is able to continue to drive safely, his or her performance must continue to be revisited. Because many dementias are progressive, ongoing management and discussions about driving are needed. Driving modifications may also be suggested such as limit the individual’s driving to off-peak or daylight hours, in familiar areas or in less complex driving environments.
If serious driving errors are apparent, the driver will be advised to stop driving. Discussions about “retirement” from driving must be handled sensitively. In order to be successful, family need to be supportive and participate in creating a workable transportation plan for their relative.
If a driver is reluctant to quit driving, different approaches can be considered to facilitate voluntary cessation. First, it is important to explore with the driver, his or her reasons for resistance. A conversation with a person whom the driver respects, such as a clergy or a police officer, may be able to persuade the driver to quit. Insurance ramifications are also important to consider. For some drivers, individual or group support can diminish the loss and provide opportunities to discuss concerns. For others, a prescription stating that the individual should no longer drive can add leverage.
If all fails authoritarian approaches are needed. In those situations, family members may need to disable the vehicle, move it to another location, hide or replace the keys, or even the sell the vehicle.
When an individual can no longer driver, resources for alternative transportation must be identified. Often friends and relatives can provide necessary transportation or can help to locate other options. Conversations with a social worker to identify community supports can be helpful, too. Finally, the person’s driver’s license should be replaced with an identification card.
Several helpful booklets and online resources, designed to help family, friends and caregivers of older drivers with driving discussions and decisions include:
- “At the Crossroads: A guide to Alzheimer’s disease dementia and driving” and “We need to talk: Family conversations with older drivers” are available through www.thehartford.com
- “When you are concerned” is another resource available at http://aging.state.ny.us/caring/concerned/handbook/pdf
- The Alzheimer’s Association (http://www.alz.org/living_with_alzheimers_driving.asp) has a fact sheet available on driving as well as discusses warning signs and tips for limiting driving.
- “Drivers 55 Plus: Check Your Own Performance” are available at http://www.seniordrivers.org/research/driver55.pdf
- The American Society on Aging’s DriveWell project (www.asaging.org/drivewell) promotes older driver safety and community mobility options.
- AARP’s Driver Safety Program is available at http://www.aarp.org/families/driver_safety/
- The “Physician’s Guide to Assessing & Counseling Older Drivers” (http://www.ama-assn.org/go/olderdrivers) provides information about assessment, legal and ethical responsibilities as well as state licensing requirements and reporting laws.
- To locate a Certified Driving Rehabilitation Specialist — www.aota.org/olderdriver or www.driver-ed.org or call at 1/800-290-2344