Please Tell People with Alzheimer's Not to Drive ... published in reduced version as a Letter to the Editor

Ask any spouse of someone diagnosed with Alzheimer’s Disease (AD) what their toughest battle was, and I guarantee that most, if not all, will say it was about driving.  Taking away the car keys is, by far, the most common cause of conflict … and the most difficult hurdle to overcome … that I hear about in my actual support group and read about in my online support groups.  Why this driving issue causes so much stress and strife is an easy question to answer.  Driving is synonymous with independence … take away the AD patients’ car keys and you are robbing them of their independence to go and come wherever and whenever they want.  Insisting that AD patients stop driving is forcing acceptance of the ramifications of their disease when they may not be in an accepting mode.  Spouses saying “I can still drive” or “I’ll know when I can no longer drive safely” are the two most common refrains I hear in my support groups.  Of course, by definition when one is diagnosed with AD that patient is already suffering from some degree of cognitive, perceptual, and memory impairment that makes driving unsafe.  As the disease progresses, ability to drive safely will only get worse.  There will be impaired judgment and reasoning skills, impaired depth perception, and the inability to interpret the many visual cues and factors affecting one’s ability to drive safely … assessing road conditions, the effects of bad weather, heeding traffic signals, safely turning across oncoming traffic lanes, safe braking distance, etc.

In “Alzheimer’s: When to stop driving,” Mayo Clinic staff summarize the risks of driving with an AD diagnosis.  To answer the question of when the AD patient should stop driving, they provide this advice: “Ask yourself whether you’d feel safe riding in a vehicle driven by the person who has Alzheimer’s – or if you’d feel safe having your loved one drive your children or others.  If the answer is no, then you know it’s time for him or her to retire from driving.”  ^1.  

Whereas I concur completely with this advice, this does not solve the problem of getting the AD patient to actually “retire” from driving when driving is unsafe.  All too often, the AD patient will continue to insist that he or she can continue to drive safely despite what the caregiver or other loved ones say.  Sometimes, only a doctor will be able to convince a patient that it is time to stop driving.  Yet, too often doctors shy away from this responsibility.  And, sadly, doctors even have support for such a position from two highly respected organizations.

The American Academy of Neurology (AAN), states that the decision of whether or not to continue driving should be left to the patient in consultation with the doctor.  The AAN guideline issued in 2000 stated that patients should stop driving after a dementia diagnosis.  But the revised 2010 AAN guideline backs away from that categorical position.  Noting that “giving up driving is associated with depression and increased awareness of mortality,” the new guideline calls for doctors to implement the Clinicla Dementia Rating Scale to help determine when dementia patients should stop driving.  According to the guideline, this scale, which allows for input from the patient and caregiver, should help the doctor make a more informed decision of when to advise a patient to stop driving.  ^2.  

Similarly, the Alzheimer’s Association (AA) website has several pages that discuss when it is time for a person with AD to stop driving.  ”A diagnosis of Alzheimer’s is not a reason to take away driving privileges,” according to their Safety Center page.  ^3.   The AA website also provides a lengthy “Driving Assessment” position from their Georgia chapter that indicates that there should be an on-the-road driving assessment, or a test by an occupational therapist, to help determine when the AD patient should stop driving.  Noting warning signs and risk factors similar to those in the AAN guideline and on the Mayo Clinic website, the AA suggests that those risk factors should determine when it is time to stop driving.  ^4.

I find both the AAN and AA positions very troubling.  While it is true that  people with mild dementia may still be able to drive safely for a period of time, no one … no doctor, no occupational therapist, and certainly no patient or caregiver … can determine the exact time when that AD patient will no longer be able to drive safely.  Must we wait until a preventable tragedy occurs until those keys are taken away?  If everyone agrees that the AD patient’s skills and abilities are going to decline to make driving unsafe, why wait until that decline causes injury or death to the patient or innocent others?

In my opinion, a dementia or AD diagnosis should automatically mandate removal of a driver's license … if not immediately, then certainly within a period 3 to 6 months, at most.  Anyone diagnosed with AD already has, or will soon have, judgment and reasoning skills that are too impaired to continue to drive safely.  Once a person’s cognitive skills become impaired to the point of a doctor diagnosing probable Alzheimer’s, how can one reasonably argue that driving is still a safe activity for that person?  A car can be thought of as a weapon of limited destruction if an AD-impaired driver should injure or kill another driver or vehicle passenger, or an innocent pedestrian.  A car can also be considered a weapon of mass destruction if an AD-impaired driver crashes into a group of pedestrians, or crashes through a storefront window, or causes an accident with a fully loaded vehicle or bus that leads to multiple injuries or deaths.  The AAN had it right in 2000 … a dementia diagnosis should signal an end to safe driving.  Period!

In a handful of states, physicians are required to report names of patients diagnosed with Alzheimer’s to the Department of Motor Vehicles (DMV). The DMV is then responsible for determining whether that person should continue driving or not. But the DMV and doctors already know that, on any given day, a person with AD may be able to do well on a written test or even on a road evaluation … such is the nature of AD.  Just as an AD patient can score well on an MMSE given at noon but by 3 p.m. not even remember having taken that test, so can an AD patient fool a DMV examiner into thinking he or she can drive safely. 

Doctors should know better than to let such an important decision hinge upon a patient’s performance at one given time.  Doctors should know that multiple decisions and processing skills are needed each time someone gets behind the wheel of a car, and that AD-impaired drivers will have difficulty processing the information requiring them to driver safely.  If we know with certitude that a person diagnosed with AD is going to experience cognitive decline over time, why not stop that person from driving before a tragedy occurs?  Those 2010 AAN guidelines state that “a recent history of collisions or moving violations,” among other signs, “may indicate increased risk for driving.”  May indicate?  Must we wait until after a tragedy occurs before taking the keys away from an AD patient?

I think there really is only one indicator of when a person with AD should stop driving … and that is the AD diagnosis itself.  If someone has AD, that person should not be behind the wheel of a car.  In my AD spouse caregiver support group, we always ask this question of new members facing the driving issue, akin to the Mayo Clinic advice:  "Would you feel comfortable with your grandchildren in the car while your AD spouse is driving?"  Invariably, the answer from the spouse caregiver is no, but usually the spouse caregiver then relates something like this: “I agree with you but I just cannot get my spouse to give me the keys.  My spouse says, But the doctor never said that I had to stop driving, so it can’t be that serious; If I shouldn’t be driving anymore, the doctor would have said something to me.”

So I am saying this to all doctors treating patients for any kind of dementia, but especially for Alzheimer’s Disease:  Please, doctors … at the time of diagnosis or very shortly thereafter, please assume responsibility for telling your patients that they must stop driving.  Spouses and caregivers should not have to deal with this highly emotional decision without your help.  Yes, taking away the car keys also takes away independence from your patients.  And yes, taking away the car keys may even lead to depression in some of your patients.  And yes, some of your newly diagnosed patients could probably continue driving safely for quite some time.  But, you know that it is just a matter of time before your newly diagnosed patient loses the cognitive ability to drive safely … if that has not already happened … and your patient may not be scheduled to even see you again before this happens.  So, why wait until after a preventable tragedy occurs?  Let me put it one more way:  Imagine the lawsuit you and your patient could face if the estate of a mortally injured party sues, arguing that the doctor should have know better than to allow a person with diagnosed cognitive deficiencies to continue driving!  So, doctors … please tell Alzheimer’s patients not to drive!

1.  Mayo Clinic staff.  Alzheimers: When to stop driving.  Available at www.mayoclinic.com.  Accessed July 25, 2010.

2. Wesolowski, Kierstin.  New AAN Guideline on Assessing Driving Risk in Dementia Patients.  Neurology Today.  2010; 10 (8): 1, 12.

3. Safety Center.  Available at www.alz.org   Accessed July 25, 2011.

4. Driving Assessment.  Available at www.alz.org.  Accessed July 25, 2011.

Published in Journal of the American Geriatrics Society,  March, 2012, Vol. 60, No. 3, pp. 597-598.  Access at: http://onlinelibrary,wiley.com/doi.10.1111/j.1532-5415.2011.03857.x/full