DRIVING AND DEMENTIA

KEY QUESTIONS

• Who decides when a person with a dementia should no longer drive?
• Is a diagnosis of Alzheimer Disease or a related dementia sufficient cause to rescind driving privileges?
• Should the person with dementia participate in making decisions regarding driving restrictions?

ETHICAL CONSIDERATIONS

Alzheimer Disease and related dementias cause changes in the brain that eventually affect a person's ability to drive safely. However, a diagnosis of dementia, in itself, does not automatically mean that a person is incapable of driving at that time. Some people may be capable of driving safely for some time after the diagnosis, depending on the timing of the diagnosis and the rate at which the disease progresses. However eventually, for safety reasons, a person with Alzheimer Disease or a related dementia must stop driving.

 

To date, there is no Canada-wide standardized testing protocol to determine when someone with Alzheimer Disease or a related disorder is unable to drive a motor vehicle safely. Hence, a suspicion or diagnosis of cognitive impairment  among the driving public often creates ethical dilemmas for affected individuals, their families, health professionals and legislators. Throughout North America and elsewhere,  the societal challenge has been to find a broadly acceptable balance between respect for individual rights and freedoms, and the clear need  to minimize potential risks to public safety.

 

In the United States, the  National Ethics Advisory Panel, which discussed this issue in depth in November 1998, recommended against mandatory reporting by physicians of a probable diagnosis of Alzheimer Disease.  The basis of this recommendation went beyond considerations related to personal privacy and patient confidentiality; the recommendation was also driven by the panel’s concern that mandatory reporting might dissuade licensed drivers, who might suspect a dementing illness in themselves, from seeking an accurate diagnosis and obtaining early treatment. Nevertheless, many North American jurisdictions, Ontario included, have already implemented mandatory physician reporting legislation.

         

THE LEGAL PERSPECTIVE IN ONTARIO

Physician’s Responsibility

• legally must report to the Ontario Ministry of Transportation a diagnosis of dementia in a patient
• above requirement supersedes ethical obligation with respect to patient confidentiality
• physicians in Ontario can/have been held liable for consequences of failing to report

Role of the Ontario Ministry of Transportation (MTO)

• reviews physician’s report; authorizes license suspensions if warranted
• informs patient and physician of MTO’s  decision

Additional Web Resource

• See: Ministry of Transportation: License Renewal Process for Drivers 80 and Over  http://www.mto.gov.on.ca/english/pubs/senior.htm

THE PATIENT’S PERSPECTIVE

A person who decides to stop driving, or whose driving privileges are threatened or revoked, can experience  a profound  sense of personal loss.  It is common for  such individuals to experience strong negative emotional reactions. These can  include strong denial of the need to stop driving, frustration, anger and clinical depression.

 Denial, frustration and outrage are reflected in the following quote from a newly-diagnosed individual with a dementing illness: “My kids had a meeting without me and decided they want me to stop driving; they’re making a big deal about nothing; I’ve driven longer than they’ve been alive.”  

THE FAMILY’S PERSPECTIVE AND ROLE

While some dementia patients willingly give up driving, many are unable to recognize and acknowledge  such a major loss of  freedom and mobility.  It then falls to the family, with the assistance and support of others such as the physician if necessary, to assess competence to drive. The family needs to  alert the physician of a potential problem,  and if the person is found incompetent to drive, must find ways to prevent driving.  At the same time, as Alzheimer Canada points out in its  Ethical Guidelines on Driving:, “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”.

If discussion with the affected individual does not bring about acceptance, the family needs to find effective ways to ensure that the patient does not drive. These can include strategies such as hiding or substituting keys; hiding or selling the car;  and disabling the vehicle.

SOME KEY CANADIAN STATISTICS AND RESEARCH FINDINGS

NB: Unless otherwise noted, the following information has been taken from a discussion paper:  Dementia & Driving Cessation, Dobbs, University of British Columbia 1998

• older drivers are the fastest growing segment of  the driving public in Canada
• within 20 years, 25% of all drivers will be 65 or older
• between 1979 and 1995  injuries and fatalities  among seniors increased  47%. At the same time injuries and fatalities in the under-65 age group decreased 8%
• when the amount of driving is factored in, older drivers have the highest crash rate of all adult age groups
• not aging itself, but medical conditions tend to account for crashes in the elderly: e.g. cardio-vascular disease; cognitive impairment; vision-related difficulties
• cognitive impairment is associated with more than a seven-fold increase in at-fault accidents, making this group an especially high risk population 
• over 70% of dementia caregivers have  reported that giving up driving was one of the most,  if not the most,  difficult aspects of the illness for the patient (Dobbs and Dobbs 1997)

• some early warning signs of  a possible dementia  in drivers include: incorrect signaling; confusion at exits; hitting curbs; delayed responses; getting lost in familiar places; parking problems; and minor dents/scrapes;
• drivers diagnosed with dementia are five-seven times as likely to have an accident than their same-age peers (from Dobbs, 1998 and U.S. and Australian studies)
• virtually all studies point to same conclusion: drivers with dementia need to take regular, on-road testing of skills

PROJECTIONS: LOCAL INCIDENCES OF DEMENTIA

Source: Dementia Projections for the Counties, Regional Municipalities and Districts of Ontario. Hopkins and Hopkins January 2002

Year                                       Total Pop. >65                      Est. dementia cases

HALTON

2004                                      50,500                                    4500

2014                                      77,000                                    7000

2024                                      112,000                                    10,500

 

HAMILTON

 

2004                                      74,000                                    7200

2014                                      88,000                                    9300

2024                                      114,000                                  11,135

 

 Notes:

·        All projections have been rounded to the nearest 500^th

·        According to the Ministry of Transportation, approx. 60% of Ontario seniors hold a valid driving license.

·        According to Alzheimer Canada, about1/13 Canadians > 65 have Alzheimer Disease or a related dementia.

·        For Canada-wide statistics, please go to Alzheimer Canada’s website, www.alzheimer.ca/english/disease/stats-people.htm

 

Additional Resources 

 

·        Should you require a media spokesperson or additional assistance on this or any dementia-related issue, please call us (905-529-7030); we’ll do our best to help.

·        The Alzheimer Society of Canada Ethical Guidelines  on Driving  http://www.alzheimer.ca/english/care/ethics-driving.htm.

·        Driving and Dementia Toolkit.  The Dementia Network of Ottawa Carleton, 2001    http://rgapottawa.com/dementia/english/default.asp

·        A comprehensive treatment of Driving and Dementia.  Although this is a U.S.-based site, most of the information on it is relevant to Canadians.  Highly recommended reading,  especially for families. Includes advice from other caregivers who had made driving decisions.    http://www.thehartford.com/alzheimers

·        Ministry of Transportation (Ontario) Home Page, http://www.mto.gov.on.ca/english/ 

·        Ministry of Transportation (Ontario) Seniors and Driving    http://www.mto.gov.on.ca/english/pubs/senior.htm 

·        “Aging Drivers –When is it time to take away the keys?”  Alzheimer Support website article, 2003.  Dr. Bonnie Dobbs, a researcher in Rehabilitation Medicine, University of Alberta.    http://www.alzheimersupport.com/library/showarticle.cfm/ID/1935

·        Driving and Dementia in Ontario:  A Quantitative Assessment of the Problem. Robert W. Hopkins PhD, Linda Kilik PhD, Duncan Day PhD, Catherine Rows RPN, Heidi Tseng BSc. The Canadian Journal of Psychiatry, Vol.  49  No7 July, 2004. http://alzheimer.interlynx.net/hopkins.pdf