The inevitability of driving cessation in people with different types of dementia, regardless of type makes it essential to assess fitness to drive by conducting an in-office assessment at various stages of disease progression. This is important for the safety of people with dementia and the public. Given that a range of complex factors can affect driving ability, it’s important to gather information from different perspectives during the assessment. It is equally important that you base your decision on the sum of the findings, rather than just from a specific component of the assessment. In addition, after the assessment, you must follow legislative requirements for your province or territory regarding reporting unsafe driving. Learn what it means to use a comprehensive approach to inform your decision and follow these steps to conduct an in-office assessment.
An in-office assessment for fitness to drive cannot guarantee complete
accuracy in predicting unsafe driving. However, it can reveal issues
that may indicate that the person with dementia is no longer fit to
it’s important that you take an approach that considers the range of
factors that can affect driving ability. This requires gathering
information from different factors such as the type and severity of the
dementia, driving history, physical examination, and cognitive testing.
Then you should base your clinical decision on taking into consideration
the sum of your findings—not just on a specific component of the
Follow these steps to ensure that your clinical
decision is informed by the totality of your findings; in other words,
that you take a cumulative approach. You can also download and print this summary to refer to while assessing fitness to drive.
Other resources that include elements (although not validated), that you should consider in conducting a comprehensive assessment of fitness to drive are the Clinical
Assessment of Driving Related Skills (CADRes) and the Driving and Dementia Toolkit.
Document these aspects of the dementia diagnosis.
Assess the functional impact of dementia because as the disease progresses, functional abilities decline that may affect driving ability.
Basic ADLs = dressing, transfers/mobility, toileting, showering, grooming (e.g., shaving, brushing teeth, combing hair, applying make-up), eating
IADLs = work/volunteer-related activities, medication management, financial management, shopping, meal preparation, use of technology, housework, hobbies
Multiple medical and psychiatric conditions are common in older adults. Many of these conditions are associated with driving impairments, not only due to their symptoms, but also sometimes as a result of their treatments like medications/substances and adverse effects. Accordingly, document medical co-morbidities and medications/substances.
Document the person with dementia’s perception of their driving ability and more importantly, family/friend carer perceptions.
Ask if they have had any of the following driving incidents while keeping in mind that they may not realize or remember that their dementia is affecting their driving.
presence or absence of the person with dementia's concerns may
correlate poorly with on-road driving performance and outcomes. Therefore, it is
important to also take a history from a family/friend carer.
Use this patient questionnaire from the appendix of the article by Iverson and colleagues (2010) to help identify people with dementia who may be at increased risk for unsafe driving. Other driving incidents to consider in your assessment include:
Family/friend carer perceptions of the driving of the person with dementia may be more
accurate than those of the person with dementia due to their loss of insight. However, evidence shows that if family/friends raise concerns about the driving of a person they care for, it is often indicative of their fitness to drive, but if the family/friends have no concerns about their driving, it is not necessarily indicative of driving ability. Ideally, their input is based on having recently been in the car while the person with dementia was driving.
Ask about their experience and perceptions of the person with dementia’s driving ability.
Be mindful that some family members may be biased because they rely on the person with dementia to meet their transportation needs.
Conversely, others may hold ageist views that older adults are generally unsafe drivers.
They may be more forthcoming if you ask for their perspective while the person with dementia is not present.
Use this family or caregiver questionnaire from the appendix of the article by Iverson and colleagues (2010) to help identify people with dementia who may be at increased risk for unsafe driving. Other driving incidents to consider in your assessment include:
Use a general cognitive screening test to assess global cognition. Consider some of the cognitive tests listed below. However, keep in mind that no single test or battery of tests has sufficient sensitivity or specificity to solely determine unfit driving. Accordingly, include the cognitive examination findings as just one component of many for you to consider as part of a comprehensive assessment of fitness to drive. While conducting the examination, make sure that the person with dementia is wearing their glasses and/or hearing aids (as appropriate). Also, observe whether they are:
In addition, when interpreting the results for any cognitive test, make sure to take into account variables such as low formal education and history of poor performance on previous paper and pencil testing. Also, there are many other neuropsychological tests that are not included below. However, as previously mentioned, research has not found any test or test batteries sufficiently sensitive or specific on its own to accurately predict real-world driving. The key to informing your decision about the person with dementia's driving safety, is to combine information from the cognitive asessment with the other recommended aspects of the fitness to drive assessment.
Ask about different hypothetical driving scenarios. For example, ask questions like:
Assess for motor and sensory skills needed to operate a vehicle. For instance, assess whether issues exist that make operating a car difficult such as problems with vision or restrictions in neck mobility that may impair blind spot checking; motor and sensory skills that can impact the ability to maneuver the steering wheel or operate the brake and accelerator pedals.
Make your clinical decision regarding fitness to drive by reviewing the findings from steps 1-6. Consider the overall findings, not just one specific component of the assessment. Then use your clinical judgement to determine whether the person with dementia’s driving is safe, unsafe, or if you are uncertain about it. There is no magic answer, rather you must consider all your findings
from your assessment of their fitness to drive and then use your
clinical judgement to interpret whether the person with dementia’s
driving is safe, unsafe or uncertain.
Keep in mind
that if the person with dementia performs very poorly on testing with no
contributing factors—such as poor English fluency, limited formal education or
extreme anxiety—and there is a clear history that their cognitive impairment is
impacting instrumental and basic activities of daily living, the person with
dementia is not safe to drive.
Driving cessation is one of the significant major life transitions that
people go through later in life. Now that the time has come for
cessation, similar to disclosing bad news regarding other areas of
health care, how you tell the person with dementia and their
family/friend carers about cessation can significantly mitigate the
negative impact. Be empathetic regarding the many losses that driving may represent and be prepared
for strong emotional reactions, providing validation and support if
needed. Make sure that you allow enough time for the discussion. Try to
bring the family/friend carer into the discussion so that they can help
support the person with dementia after the appointment.
If the person with dementia continues to insist on driving:
If you think that the person with dementia is putting themselves or others in imminent danger:
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