This blog is about a clinical update by Alan et al (2016) in the Evidence Based Mental Health journal, which provides a concise and clear overview of the issues surrounding driving in dementia.
Driving is an essential skill for many people and the loss of the ability to drive can be a major setback for anyone. Driving itself is a complex task that involves multiple cognitive domains such as attention, memory, planning and co-ordinating movements. As such, driving can become challenging after a diagnosis of dementia.
For patients with dementia, the loss of driving ability is one of the most significant losses experienced. The challenge for professionals working with dementia sufferers is to balance their desire to continue driving, with all its benefits, and safety concerns that arise as driving safely becomes more difficult.
In this paper, the authors summarise the latest evidence and recommendations to do with driving and dementia. They completed a literature search using PubMed and Google Scholar.
Driving can become challenging after a diagnosis of dementia.
What are the DVLA guidelines in relation to dementia and mild cognitive impairment?
Drivers with a diagnosis of dementia are required to inform the DVLA. In the case of mild cognitive impairment (MCI) the DVLA do not need to be informed unless there are concerns around driving. Please note – mild dementia is not the same as a diagnosis of ‘mild cognitive impairment’. Whether the stage of dementia is mild or not, the DVLA must be informed. In most cases, patients with dementia inform the DVLA themselves; however, in scenarios where the DVLA have not been informed by the patient the clinician has a responsibility to let them know about the patient’s diagnosis.
How good are clinicians at predicting driving risk?
It turns out – not very good. Clinical assessment of driving ability show only modest agreement with ‘on-road driving tests’. Clinician errors typically assess people as being fit to drive when the driving test unfortunately shows otherwise. Therefore, by itself a clinical assessment should not be used as the basis to make the decision about driving.
The authors go on to say, however, that the accuracy with which a clinician can predict driving performance can be increased by involving dementia specialists and including neuropsychological test results. It also seems that, although useful in combination with the above, information from family and friends is also not very predictive of the driving test results.
Clinical assessments are not an accurate way to measure driving safety.
Can cognitive tests predict driving ability?
Again – not really. The best tests are the ‘composite’ ones that include multiple domains of cognition. This is not surprising given the complex cognitive nature of driving. However, in isolation, they are not brilliant at predicting ‘on-road’ performance. The cut-off points relevant to driving are not established and so interpreting these results in the context of driving is difficult.
Screening tools like the MMSE and the MoCA, which are common and brief cognitive questionnaires used to get a quick overview of cognitive function, do not correlate well with driving performance and should not form the basis of a recommendation. That said, lower scores (<= 24 on MMSE and <= 18 on the MoCA) should alert clinicians to pursue a more detailed assessment of driving function and may be associated with increased driving risk.
So what is the best way of predicting driving performance?
The authors recommend that a combination approach is the best way of best assessing driving ability:
- Opinions from clinical experts
- Neuropsychological tests
- Collateral history
- Driving assessments (see below)
What factors determine the decision to stop driving?
In patients with moderate or severe dementia the decision to stop driving is often made quickly. However, in patients with mild dementia the discussion around stopping needs to be more detailed.
Some of the factors that may contribute are listed below:
- Patients may identify cognitive symptoms that result in them feeling less confident driving; impaired attention or getting lost for example
- There may be other non-dementia factors like visual impairment or impaired neck mobility that may contribute. Other significant medical co-morbidities like strokes can also be important
- Minor accidents should be viewed as warning signs and influence the decision to stop driving
- The type of dementia may also be very important. Frontotemporal dementia (FTD) for example can lead to personality change, disinhibition or poor insight into impairments. Patients with Lewy Body dementia on the other hand may have fluctuating levels of consciousness, hallucinations and poor mobility that may all impact on driving performance
- Depressive mood disorders may bias patients to stop driving when it may not be necessary.
The discussion around stopping driving can be difficult and should be handled with care. The recommendation to stop driving, and the reduced risk of an accidents, should be balanced against the role driving plays in the patient’s life. The loss of independence, impact on self-esteem and the increased support that patients will need should all be considered. While it may not be possible for the patient to continue driving, collaborative problem-solving with all parties involved may help minimise the impact.
The decision about when to stop driving should consider the negative impact that loss of independence will have on the patient.
What happens when the DVLA are informed?
As I mentioned above, all patients with a diagnosis of dementia are required to inform the DVLA. While they wait for an assessment they can continue to drive if there are no concerns and they may also want to attend a local driving assessment centre to collect evidence to support their application to the DVLA.
The DVLA will complete a medical, neuropsychological and driving assessment. The DVLA medical adviser will make the final decision about the patient’s suitability to drive taking into account all sources of evidence. Patients who can continue driving are required to attend annual reviews and will be given advice on safe driving. Tips include driving in the day time, using familiar routes and driving on quiet roads.
What happens at a driving assessment centre?
Clinicians can directly refer patients to Driving Mobility approved assessment centres for an independent assessment. These are not attached to the DVLA but they can provide reports and results from tests that may help the DVLA in deciding. There are 17 approved centres.
These assessments combine on-road tests, meeting with occupational therapists and office-based tests. They provide an impartial, valuable, opinion on a patient’s suitability to drive and can help contribute to the discussion about when a patient should stop driving. These ‘on the road’ assessments should be considered the gold standard in terms of assessment of driving function however access to these assessments is not always available for clinicians.
‘On the road’ assessments at approved centres should be considered the gold standard in testing driving function.
What happens when someone stops driving?
The authors of this review highlight that stopping someone from driving can be a major life event associated with a loss of independence, self-esteem and social isolation. These can have consequences on mental health, physical health and longer term risk of needing full time care and mortality. As such, these findings hammer home the importance of dealing sensitively and carefully with this issue.
The authors also highlight that in situations where a patient continues driving when told not to, this can place considerable stress on family members who may appreciate professional support.
Conclusions
In summary, this is a clearly written, well presented update on the issues around driving in dementia and I would recommend interested readers, especially clinicians, read the full open access article. The article also has the details of organisations that provide more information about this issue and I have linked a few below.
Getting a diagnosis of dementia does not mean immediate retirement from driving. However, driving is a complex cognitive task and will become more challenging as the condition progresses. As such, there are clear guidelines and assessment methodologies available to tackle this issue specifically. It is well worth clinicians ensuring that patients with dementia and their carers are regularly thinking about the best time to stop driving.
Clinicians should ensure that driving safety is a topic of conversation for patients with dementia and their carers.
Links
Primary paper
Allan CL, Behrman S, Baruch N, Ebmeier KP. (2016) Driving and dementia: a clinical update for mental health professionals. Evid Based Mental Health ebmental-2016-102485 Published Online First: 20 October 2016 doi:10.1136/eb-2016-102485
Other references
DVLA – https://www.gov.uk/dementia-and-driving
Alzheimer’s Society – https://www.alzheimers.org.uk/
Driving Mobility – http://www.drivingmobility.org.uk/
[…] A. (2017). Driving and dementia: when’s the best time to hang up those driving gloves? [Online]: The Mental Elf. January 5th […]