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Driving a motor vehicle is a complex activity that requires quick reactions; the ability to divide and maintain attention (for example, watching traffic light and pedestrians while keeping one’s foot on the gas pedal or brake); good judgment; an understanding and ability to recall the rules of the road; the ability to find a destination; and adequate eyesight and hearing. Driving also represents freedom, independence and mobility. Although driving is a privilege, some people view it as a right.

Alzheimer’s disease and related dementias cause changes that affect a person’s ability to drive a motor vehicle safely. However, a diagnosis of Alzheimer’s disease does not automatically mean that a person is incapable of driving. Some people may be capable of driving safely for some time after the diagnosis, depending on the timing of the diagnosis and the rate the disease progresses. However, eventually a person with Alzheimer’s disease must stop driving, as it will no longer be safe. There is currently no nationwide standardized testing to determine when someone with Alzheimer’s disease is unable to drive a motor vehicle safely.

The issues

For people with Alzheimer’s disease

Loss of independence, freedom and mobility:
Recognizing and admitting the loss of abilities needed to drive is difficult for some people, while others freely give up their licence. The loss of freedom to come and go as one pleases can have a devastating effect on a person. The person with Alzheimer’s disease may have been the only driver in the household. Also, many communities lack alternative forms of transportation; and, where alternative transportation is available, it may be expensive or inconvenient.

For family members and caregivers

Determining when driving is no longer safe:

When a person is unable to recognize or admit that driving abilities have been lost, family members and caregivers often have to address the issue. Their concerns may include the risk to the person, the risk to the public and the risk of liability in the event of an automobile accident.

Within families, there may be disagreement about when the person with Alzheimer’s disease should stop driving. Some family members may believe that the person should stop driving immediately upon diagnosis. Others may be inclined to overlook some risky driving behaviour in favour of maintaining the person’s sense of independence.

Family members and caregivers often find it difficult to suggest that the person with Alzheimer’s disease stop driving. They may fear that bringing attention to the person’s loss of abilities and the need to stop driving may create difficulties in the relationship.

For doctors:

Determining when driving is no longer safe:
Doctors are often approached to assist people with Alzheimer’s disease and their families in determining if a person can continue to drive. However, doctors:

• see people for a limited time during visits, not when they are behind the wheel;
• may not have proper training to assess driving abilities;
• must rely on information from individuals and family members that may not always be objective or reliable;
• may be concerned that telling people they must stop driving could harm the doctor/patient relationship.

Doctors are bound by law, in some provinces, and by professional ethics, to report medical conditions that could impair a person’s ability to drive. They also may be held liable if a person in their care who has Alzheimer’s disease is involved in an auto accident and they have not reported the person’s driving problems to provincial licensing authorities.

Preferred choices

When driving is recognized as dangerous:

Stop driving immediately

Driving must be stopped immediately if safety is at risk. Signs that a person’s driving abilities are declining include: slow response times, traffic violations, collisions, taking too much time to reach a destination or not reaching the destination at all.

When the person is still able to drive:

Plan ahead

Plan ahead for the time when driving must stop. This includes talking with the person with Alzheimer’s disease to find out when driving is needed most and why. For example, is it used for keeping medical appointments, shopping, entertainment, meeting with friends, or perhaps as a form of escape or relaxation? Once the needs have been identified, there should be a discussion of alternatives, such as public transit, services provided by community organizations, and transportation organized by family members and friends.

Driving assessment

Look into the availability of testing to assess the person’s driving abilities. This could be a driving simulation test and/or a road test conducted by someone with experience in assessing drivers with cognitive problems.
If this type of driving assessment is not available, enlist the help of a doctor to determine if and when the person is no longer able to drive. The doctor may ask the person and family members questions about:

• driving patterns (when and where the person drives);
• any differences noticed in driving skills;
• any unsafe or abnormal driving behaviour;
• traffic tickets (for going too slow, too fast, improper turns, failing to stop);
• crashes, fender benders or near-misses;
• instances where the driver has been lost;
• how comfortable the person or family members feel about the person’s driving abilities.

Ongoing monitoring

Throughout the course of the disease, the person’s driving ability needs to be monitored by the individual, family members, a doctor or other health-care professional, and appropriate actions taken.

When conflict arises

Reactions to driving restrictions may vary from immediate acceptance to strong resistance. Some people will recognize their failing abilities and limit their driving or stop driving on their own. Others will accept the decision more readily if it is discussed openly in a trusting environment. As well, the decision may be more acceptable if someone whom the person believes to be objective presents the information.

Some people may refuse to accept losing their driving privilege or simply forget that they are no longer able to drive. In these instances, family members should request that doctors or other members of the health-care team help them raise the issue. However, these discussions should not interfere with the provision of health care or support. This may happen if the person with Alzheimer’s disease becomes angry with the doctor and fails to return for future appointments.

If open discussion of the issue does not result in acceptance of the loss of driving privilege, then it may be necessary to use other means to prevent the person from driving, such as removing the keys to the vehicle.

For people with Alzheimer’s disease and their families, determining when driving is unsafe can be stressful. Talking to health-care professionals, or individuals and families in similar situations can provide information and support.

In closing...

The lives of people with Alzheimer’s disease should be as free and fulfilling as possible, but a totally risk-free life is not possible. Throughout the course of the disease, driving skills and abilities must be monitored. However, risks should never be assumed without an individual assessment and should not be exaggerated in order to remove driving privileges earlier than necessary. It must be recognized, as well, that people with Alzheimer’s disease who drive when not competent to do so create an unacceptable risk for themselves and others in the community.

Restricting or stopping driving may threaten a person’s independence and sense of freedom. Therefore, how and when to insist that a person stop driving is a difficult issue for people with Alzheimer’s disease, family members, doctors and other members of the health-care team. Public discussion of this issue will become crucial as more and more people are diagnosed with Alzheimer’s disease in Canada.
Contact us for information about provincial regulations for reporting potentially unfit drivers and the availability of driving assessment programs in Toronto.

Resources:
1. Determining Medical Fitness to Drive: A Guide for Physicians. Canadian Medical Association, May, 2000. (Addendum added February 1, 2005.)
2. Driving and Dementia Toolkit. The Dementia Network of Ottawa Carleton, 2001.

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