Driving and Dementia
What specific driving abilities decline in older drivers, even ones without dementia?
Well for one, older drivers have declines in their physical ability, meaning that they have declines in their muscle strength, their coordination, their reach, and in their range of motion for their arms, legs, upper body, and neck. Some may lose consciousness periodically when having TIA’s (also known as mini strokes).
Secondly, older adults lose what is called their psychomotor ability. They lose the ability to respond quickly to something happening immediately in front of them like a dog running out in the street followed by a child chasing the dog. They may not be able to respond differently to different types of things happening to them — such as their car skidding or hydroplaning on a wet patch of road, after driving on dry roads just a second before that. In other words, their hand-eye and their foot-eye coordination can decline or slow down.
Additionally their visual ability declines just because they are older adults. They find it more difficult to differentiate things clearly under low light (night) and low-contrast (dusk) situations. It’s also harder for them to see objects in motion (like a child darting out into the street) and when there is glare and right after glare is gone. Also many people’s peripheral vision becomes blurry or dark and they can develop glaucoma, cataracts and macular degeneration.
How does dementia add to declining driving abilities?
Dementia causes perceptual ability to decline. Perceptual ability is the ability of the brain to correctly interpret and act on what a person sees and hears, for example detecting the actual speed and motion of other cars on the road. A cognitively impaired person could stop at a red light, then pull out into traffic going on the green light without realizing that those cars were entering the intersection. A person with dementia may not recognize the sound of a train whistle while they are crossing a railroad track. Sometimes the perceptual ability just slows down, meaning that the person does recognize what they see or hear but the recognition happens too slowly to react in enough time to avoid an accident. Some cognitively impaired people have hallucinations and react to things that are just not there, thus causing danger to themselves and other drivers.
In people with dementia, the ability to pay attention to things going on while driving lessens in several important ways. The person’s attention span is shortened. They may forget to properly react just seconds after seeing something that needs to be acted upon. They may not be able to share their attention between several different things happening at the same time and get confused as to which to respond to, or may not respond to anything that is going on. Also they may not be able to easily shift their attention from one set of circumstances to another, or just shift attention fast enough.
Certainly in people with Alzheimer’s and some others dementias their memory declines. At any given moment they may not be able to retrieve the memory of what to do when a situation arises. For example, remembering to allow the vehicle on your right to proceed first when both cars are stopped at an intersection simultaneously. Or remembering what a stop sign means.
Other cognitive abilities decrease as well. Declines in executive functions such as logic, decision making, self awareness, impulse control, and initiation of action can and do lead to dangerous situations. Even if the person performs adequately most of the time, you never know when they will have that moment of failure of executive function. The fluctuation in abilities can and does change from moment to moment.
Are there any ways to counteract these losses, to keep the person with dementia driving safely early in the disease?
Yes. Some things can be tried such as:
Going to an Occupational Therapist who specializes in assessing driving skills in the elderly is a start. After the therapist determines the deficits, they suggest ways to compensate for some of the deficits. Some methods involve vehicle control assists, and some involve training or retraining driving skills.
For cognitive deficits, sometimes Psychologists can train a person to help with mental processing of stimuli, which might lead to improved performance in driving skills for a short period of time.
Restricting the amount, times and locations of driving is another method. Some elderly drivers impose these restrictions on themselves, but for those who do not, the family needs to impose them — and monitor compliance on a routine basis (at least once every week or two).
Generally, experts agree that it is beneficial for people with dementia to be able to drive as long as they are not a danger to themselves or others. When they hang up the car keys they are in danger of losing their access to friends and family, to medical providers, to shopping and other services crucial to keeping them independent. Isolation leads to depression and other physical and mental issues.
What are some of the warning signs that driving behaviors can cause safety problems?
The American Academy of Neurology came out with recommendations and warning signs of unsafe driving on April 12th 2010 but I find the list issued by the Hartford Insurance Company in their brochure “We need to talk… Family conversations with older drivers” is more complete. It is free, and can be ordered at www.thehartford.com/talkwitholderdrivers.
They list the signs from the minor signs to very serious issues. Family members should observe (ride with) the person with dementia for a minimum once a week, and over a period of time. The person observing should keep notes so that changes in driving ability can be seen. The observer should look for a pattern of warning signs and for an increase in the frequency of occurrence of those signs. The signs are as follows:
A decrease in confidence while driving.
Difficulty turning to see when backing up.
Riding the brake.
Easily distracted while driving.
Other drivers often honking their horns.
Hitting curbs regularly.
Scraping or denting the car, mailbox or garage.
Increased agitation or irritation when driving.
Failure to notice important activity on the side of the road.
Failure to notice traffic signs.
Trouble navigating turns.
Driving at inappropriate speeds.
Not anticipating potential dangerous situations.
Using a “copilot”.
Bad judgment making left hand turns.
Delayed response to unexpected situations.
Moving into the wrong lane.
Difficulty maintaining lane position.
Confusion at exits.
Ticketed moving violations or warnings.
Getting lost in familiar places.
Failure to stop at stop sign or red light.
Confusing the gas and brake pedals.
Stopping in traffic for no apparent reason.
The rule of thumb is once you are nervous or uncomfortable riding with that person, the person needs to stop driving.
How do families broach the subject of stopping driving?
The most effective method is with several short conversations centering on health and safety. That way a pattern of open, calm, non-threatening dialogue has been started. There is no direct confrontation, no strain of asking them to change their driving behaviors. Opportunities to open discussion might be shortly after a car accident or near miss, or after seeing the doctor and new medicine has been prescribed for your family member.
Things that you can say to open dialogue might be:
“Have you talked to your doctor about the effects of your new medicine on your
“That was a close call yesterday. I worry about your safety on the road.”
“Driving isn’t what it used to be. There is so much more traffic nowadays, and people are driving more aggressively than ever. I read about road rage accidents and incidents in the paper all the time now”
“I worry about your getting lost.”
Of course, the comments should be appropriate to your loved one’s personal situation. Be prepared for negative reactions. After all, your loved one knows where these conversations are leading. They understand that a big portion of their independence is at risk. They know that they will be more dependent on family members and others and that they will have fewer social opportunities. They might become depressed or even angry at the thought of giving up their driving privileges, even if they secretly agree with the assessment of their driving ability.
Who should be the one to start these conversations?
A Harvard/MIT survey concluded that married drivers prefer to hear about driving concerns first from their spouses. Those living alone prefer to have these conversations with their doctor, their adult children or a close friend, in that order. Adults over the age of seventy-five allow their adult children to have more influence than younger seniors. Older drivers DO NOT want to have conversations with police officers on this subject. Would you?
How does a person prepare for these talks?
First, do your homework before you ask your loved one to restrict or stop driving.
Make sure that you have observed them behind the wheel a number of times over an extended period of time.
Have the knowledge. Learn the warning signs of driving problems and cite them in your discussion.
Speak to your family members’ doctor to see if they would be willing to help. Some doctors may take an active role in giving an opinion or writing a prescription to stop driving. Others may refer a concerned patient and their family to a driving rehabilitation therapist (OT) for assessment.
Have ready other options for transportation. Offer yourself or other family members to drive to doctor’s appointments, to the grocery store or for other errands, to social events, as your schedule allows. (If your loved one can still take public transportation find out what’s available to them. Many cities and towns have special buses for disabled adults. Prearranging for a regular pick up and drop off to the same location may work for awhile. Offer to pay for a taxi if your loved one can still handle that. Make sure the taxi driver knows not to let them off anywhere other than the designated location and watches them to ensure that they go in the door of the designated building. Private transportation is available as well. Look for companies offering rides for seniors. The same instructions would be given to the operator of the senior ride as are given to taxi drivers.
Be calm and supportive. Always let your loved one know that your concern is for their safety and well-being and that you love them. You might use some of the following direct appeals to your loved one.
“Even if you were not at fault in an accident, you could be seriously injured or die.”
“I know you would feel terrible if someone was hurt when you were driving.”
“I’m afraid to let the grandchildren ride with you”
“Let’s talk with your doctor about this.”
What if your family member refuses to stop driving?
Sometimes it takes more than just conversations. Maybe not renewing their driver’s license or canceling insurance will be enough. The State licensing authority can be notified in writing of your concern about the ability of your loved one with dementia’s ability to drive safely. Ask them to retest in all three areas: vision test, written test and driving test. Sometimes the prospect of being tested will make your loved one give up the keys voluntarily. Sometimes they can’t pass all the tests. Even if they do pass all the tests, you can ask that your loved one be tested again, say in 3 months or so. You may have to consider disabling the car, filing down the keys, or removing the car from their premises. These are drastic measures, and only to be taken when all other interventions have been tried and have failed. They probably will be very angry with you, but usually in time the anger fades. It’s really a small price to pay to keep your loved one safe and alive.
What dangers arise for families who do not address their loved ones with dementia’s declining driving skills?
The danger that always is cited first is that their loved one will get lost. People with dementia get lost driving every day. The longer into the disease they drive, the higher the chance that they will get lost, even driving to their self limited locations, such as the closest grocery store or drug store. Nonprofits such as the Alzheimer’s Association as well as a variety of corporations have systems for finding lost dementia patients. Technology can be used such as GPS or cellular tracking. They are good of course, but it is like closing the door after the house is already out of the barn. The real answer is for the family to be proactive and monitor their loved one with dementia’s driving skills and stop them from driving before they reach the point of getting lost.
Another danger to the person with dementia and the family is the much higher risk of liability from causing an accident — causing property damage, injury or even death. The family should check the limits of their loved one’s liability insurance, and increase the coverage as much as they can afford. Even then, there may not be enough coverage to protect the person from losing their income, home and retirement savings and other assets. If your loved one hits a bus full of people from the retirement home up the street, or a school bus full of children, will their insurance cover the costs from law suits that families of those injured or killed will file against them? I don’t think so.
One of these days, a judge somewhere will rule that the other family members (meaning adult children) are liable as accessories, if they knew that their loved one should not be driving, yet took no action to stop them. The likelihood of this ruling will rise with the number of people killed or injured by demented drivers. As more and more people enter older adulthood, and the epidemic of Alzheimer’s and other dementias continues, this result seems inevitable. When the ruling occurs, it will have an immediate impact on the income and assets of the family members who knew and did not take action. That would be devastating to all the family members affected.
By Carole Larkin MA, CMC, CAEd, DCP, QDCS, EICS is an expert in Alzheimer’s and related Dementias care. She has a Master’s of Applied Gerontology from the University of North Texas, is a Certified Alzheimer’s Educator, is a Dementia Care Practitioner, is a Qualified Dementia Care Specialist, and an Excellence in Care Specialist at the Alzheimer’s Foundation of America, as well as a Certified Trainer/Facilitator of the groundbreaking dementia care training tool, the Virtual Dementia Tour Experience She is a Certified Geriatric Care Manager who specializes in helping families with Alzheimer’s and related dementias issues. She consults with families telephonically nationwide on problems related to the Dementias. . Her company, ThirdAge Services LLC, is located in Dallas, TX, and her website is www.thirdageservices.com