Driving

Question 1

What are the 10 items on the 10-minute dementia and driving checklist?

Answer 1

1. Medications (alcohol, benzos, narcotics, neuroleptics, sedatives, anticholinergics, muscle relaxants, TCAs, antihistamines, antiemetics)
2. Physical inability to drive a car (medical/physical like MSK, weakness, cardiac “spells”)
3. Dementia type (LBD and FTD unsafe)
4. Functional impairment (>1 IADL, 1+ BADL)
5. Family concerns (feel unsafe, grandchild question)
6. Visuospatial (pentagons, clock)
7. Vision/visual fields (acuity, field of vision)
8. Trails (A unsafe >2 mins or 2+ errors, B safe <2 mins <2 errors, unsure 2-3 min or 2 errors, unsafe >3 mins or 3+ errors)
9. Ruler drop - dominant hand, thumb and first finger 1 inch apart, 12 inch ruler drop, normal is 6-9 inches, fail if hits the floor twice)
10. Judgement/insight - what would you do if you were driving and saw a ball roll on street? With your dx do you think at some point you will need to stop driving?

Question 2

If you determine driving to be safe when you should you reassess?

Answer 2

6-12 months

Question 3

If you determine driving to be uncertain what are the next steps?

Answer 3

If driving is only dementia related issue to address –> refer to comprehensive driving evaluation

If other issues requiring ax/tx or can’t afford on road test –> refer to local multidisciplinary dementia assessment site (OT, neuropsychological)

Question 4

3 office based tests to assess abilities/cognitive areas in someone with MNCD in whom you have concerns about driving

Answer 4

1. MOCA
2. MMSE (<20 likely unsafe to drive, 20-24 indeterminate)
3. RUDAS
4. Trails A/B
5. Ruler drop test

Question 5

10 questions to ask family about driving

Answer 5

1. Any recent accidents/damage
2. Any recent tickets
3. Near misses with vehicles/pedestrians
4. Getting lost while driving
5. Not following traffic signs/lights
6. Confusing gas and brake
7. Deferring right of way
8. Not observing during lane change/merge
9. Others honking
10. Needing co pilot

Question 6

What severity of dementia is driving CI?

Answer 6

Moderate to severe (impairment of 2 IADLs, or 1 BADL) should be reported automatically

Question 7

Ethical implications of driving competency

Answer 7

Beneficence/non maleficence - revoking can satisfy physician duty to society but may result in decreased social interactions, loss of self esteem, depression and social isolation
Autonomy - MD primary responsibility is to the patient including autonomy and respecting confidentiality when protecting public
Justice - overall goal to be fair to individual pt while satisfying responsibility to society

Question 8

Legal obligation with driving and dementia

Answer 8

MD have duty to report patients they believe to be unfit to drive
Supersedes duty with regard to confidentiality
Licensing authorities revoke, no MD
Generally protected from legal action when complying in good faith

Question 9

List TWO class ‘A’ evidence recommendations on fitness to drive in patients with dementia according to the CMA drivers guide (9.1 Edition).

Answer 9

1. Diagnosis of dementia alone is not sufficient to withdraw driving privileges.
2. People with dementia with progressive loss of 2 or more IADLs due to cognition (but no basic ADL loss) are at higher risk of driving impairment
3. No in-office test or battery of tests including global cognitive screens (e.g., MMSE, MoCA) has sufficient sensitivity or specificity to be used as a sole determinant of driving ability in all cases.

Question 10

List 4 recommendations, as part of the updated evidence informed guidelines: “An International Approach to Enhancing a National Guideline on Driving and Dementia” by Rapoport et al. in 2018, you might consider in your approach to driving in this older adult with cognitive impairment?

Answer 10

• Diagnosis of dementia alone is not sufficient to withdraw driving privileges
• No in-office test or battery of tests including global cognitive screens have sufficient sensitivity or specificity to be used as a sole determinant of driving ability in all cases
• People with dementia with progressive loss of two or more IADLs due to cognition (but no basic ADL loss) are at higher risk of driving impairment
• A formal assessment and ongoing monitoring of fitness to drive is recommended if the patients wishes to continue driving
• A clinician who has concerns but is uncertain whether a patient’s cognitive problems may adversely affect driving should refer the patient for a functional driving assessment
• Patients with prominent language impairment cannot be adequately screened with typical language-based tests and require a specialized assessment, functional assessment (ADLs, IADLs), and/or a formal driving assessment
• Caregivers are able to predict driving safety more accurately than can the patient themselves
• Conversation regarding eventual driving retirement from driving should be held as early as possible
• Driving cessation has been associated with social isolation, depression and other adverse health outcomes, and thus it is important to monitor for these problems longitudinally