As we watch the statistics on the prevalence of dementia increase from year to year, we have to consider the impact this has on all facets of life. One area that needs closer scrutiny is driving. Driving represents freedom and independence in a country where many goods and services are not within walking distance and a network of mass transportation varies wildly from city to city and state to state.
In the United States, 5.4 million people of all ages have dementia. As we age, the prevalence increases to one in eight persons age 65 and older and to nearly half of all persons age 85 and older (2011 Alzheimer’s Disease Fact & Figures, Alzheimer’s Association). Of the 38 million people age 65 and over living in the United States, 30 million are licensed drivers (National Highway Traffic Safety Administration, 2008). The automobile accounts for 90% of the trips made outside of the home (Collia, Sharp, & Geisbrecht, 2003). Due to our great dependence on automobiles in our society and the freedom and independence it represents, our focus of care for persons with dementia needs to include driving status.
Driving is a complex instrumental activity of daily living (IADL) that depends on numerous factors. The complex cognitive functions required for driving can be impaired by dementia even in the early stages due to the deterioration of the executive skills needed for driving, yet many, many persons in the early stages continue to drive. One of the functions affected is “way-finding.” Persons with dementia may become disoriented in early stages of dementia in unfamiliar environments and have difficulty finding their way.
As the disease progresses, drivers may start out driving and forget where they intend to go, not recognize or attend to their own familiar environment (neighborhood, streets, landmarks), and consequently become lost. If their problem-solving abilities are intact enough to ask for directions, they may not be able to implement those directions due to impaired short-term memory and a decreased ability to think abstractly. In the study Drivers With Dementia and Outcomes of Becoming Lost While Driving, the authors found that out of 207 reports of lost drivers with dementia over a 10-year period, 70 drivers were never found, 32 drivers were found dead, and 116 drivers were found alive.
Other cognitive functions that are affected as the disease progresses are attention, sequencing, judgment (knowledge of rules of the road), processing (reaction) time, problem solving (what to do when the unexpected happens), and visual perceptual skills (road sign recognition). In addition, many fit-to-drive assessments look for standard errors: Vehicle positioning (anterior-posterior), lane maintenance, speed regulation, yielding, signaling, adjustment to stimuli or traffic signs, and gap acceptance. Unfortunately, in the news we hear stories of elder drivers hitting and either injuring or killing bicyclists and pedestrians or themselves, and damaging property from making critical errors while driving. Studies examining driving assessment of drivers with dementia have supported that driving errors that are strongly predictive of crashes include: lane change with an unsafe gap, failure to stop completely at a stop sign, stopping over a stop bar, improper turning path, and stopping for no reason.
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As members of a community concerned about the health and well-being of persons with dementia, we can assist our local communities with the information we have regarding dementia and how the progression affects cognitive processes. Decisions of when it’s time to retire as a driver are difficult and require an interdisciplinary approach. Use of the Cognitive Disabilities Model could provide vital information to family and health-care professionals as to when it is time for the person to retire from driving because of the ability it has to assess functional cognition. This is a time when information provided by health-care professionals trained in the model could have a huge impact on the safety of persons driving with dementia and fellow drivers.
Resources for persons beginning the search for a driving assessment include:
Hospital-based programs, in both rehabilitation and acute-care hospitals
University-affiliated programs, often with connections to a medical center
State-operated facilities or programs established by the Department of Veterans Affairs
Independent, community-based businesses
Many web-based resources are available, such as the AAA Foundation for Traffic Safety, which aims to serve as a website portal for senior drivers, their families, researchers, and alternative transportation providers.
Offer your knowledge of the Cognitive Disabilities Model to persons with dementia, their families, care providers, health-care professionals, and public service agencies. Your input could provide someone with transportation independence without compromising safety.
The American Journal of Occupational Therapy, Vol. 64, No. 2, March/April 2010.
OT Practice, February 7, 2011.
Alzheimer’s Disease and Other Related Dementias State Plan, 2009.
2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s Association.