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Intervention Approaches to Driving and Dementia.

by Geri Adler More than 4 million Americans are estimated to have Alzheimer's disease (AD) and related dementias, diseases that destroy memory, judgment, language skills, and the ability to perform routine activities (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). Dementia has a profound effect on millions more family members who must cope with their relative's progressive decline and increasing needs. Many issues must be addressed after a diagnosis of dementia has been made; however, one of the first and most difficult decisions involves driving. Although some drivers with mild dementia can drive safely, for most driving will at some point become impossible as the disease progresses. Gerontological social workers play a key role in addressing the complex care needs of older adults with dementia and their families. They use skills in assessment, counseling, group processes, and linkage and referral. Hence, social workers are trusted and relied on as families make decisions regarding life-sustaining treatment, finances, and long-term care planning. Because of their expertise, social workers are well suited to assist families in making decisions about driving and in coping with the consequences of those decisions. However, to best assist drivers with dementia and their families, social workers need to understand the effects of dementia on driving, be aware of their state's licensing requirements, recognize the challenges faced by families dealing with a driver with dementia, and consider their professional responsibilities. DEMENTIA AND DRIVING PERFORMANCE Dementias are characterized by progressive and irreversible cognitive, emotional, and social losses. AD is the most common cause of dementia (Tuokko, Tallman, Beattie, Cooper, & Weir, 1995). Dementia, even when mild, can impair the skills required to drive safely. Research has shown that drivers with dementia are at an increased risk of motor vehicle crashes (Tuokko et al.) and other adverse driving events, including becoming lost in familiar areas, driving in the wrong direction on roadways, failing to follow directional signs, and cutting across center lines (Wild & Cottrell, 2003). Furthermore, drivers with dementia are not always able to make appropriate decisions on their own about driving modification and cessation because of lack of insight, poor judgment, and a loss of reasoning ability (Wild & Cottrell). Much of the driving and dementia literature focuses on clinical and psychometric test performance. The Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) and neuropsychological testing batteries are most commonly referenced. Individually or together, they attempt to predict drivers at risk by comparing their scores to performance on road tests or to the rate of crash involvement. The MMSE is used to classify severity of cognitive impairment (Folstein et al., 1975). Its maximum score is 30 points, with scores of 24 or less indicating impairment and lower scores indicating greater dysfunction. Beyond the obvious conclusion that people who score poorly on the MMSE are less likely to drive, studies have been inconclusive (Fox, Bowdon, Bashford, & Smith, 1997; Shua-Haim & Gross, 1996). The MMSE focuses mainly on orientation and memory, missing other domains of cognitive functioning important to driving competence, mainly perception, attention, and motor skills. Neuropsychological tests document impairment as well, emphasizing specific areas of cognitive abilities. Research has suggested that tests measuring visual--spatial abilities, attention, and choice reaction time best correlate with on-road driving performance (Fitten et al., 1995). Nonetheless, results of neuropsychological tests have not been found to correlate sufficiently or consistently with other measures to detect unsafe drivers with dementia. Generally, neuropsychological tests measure a person's ability to perform unfamiliar, non-task-specific activities, whereas driving performance relies on task-specific, automatic processes that are learned through practice (Withaar, Brouwer, & van Zomeren, 2000). STATE RESPONSES Because valid and accepted standards of assessment are lacking, state Departments of Motor Vehicles (DMVs) remain the final judges of driver competence, determining the requirements and qualifications that applicants must meet to be licensed (Cobb & Coughlin, 1997).The purpose of driver licensing is to regulate and control drivers in the interest of public safety, yet the opportunity to drive is denied only to people with severe impairments or unmistakably inadequate skills. Once licensed, most people drive for decades without further evaluation for competence, even when cognitively impaired. A wide assortment of older driver relicensing rules and regulations typifies the nation's policy response. Few states have specific age-related restrictions. However, some have shortened licensing periods (Stamatiadis, Agent, & Ridgeway, 2003). Others require in-person renewals for drivers after a certain age or special tests at the time of renewal, such as vision testing (Cobb & Coughlin, 1997). A few states require older drivers to complete a knowledge test of traffic rules (Coley, 2001).

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Most states offer graduated licenses that permit individuals to continue to drive with restrictions that are based on their capabilities. Such licenses apply to any driver with health problems that might interfere with driving ability. Restrictions may limit the driver to a time of day, geographic region, or type of roadway (Retchin & Anapolle, 1993). Medical reports or examinations are generally not required unless specific circumstances indicate that a health condition might impair an individual's ability to drive safely. Most states have a medical review board available to review situations in which a driver may be medically unfit to operate a motor vehicle (Coley, 2001). Only in California are physicians required to report to the DMV individuals with chronic confusional states caused by AD and related disorders (Sterns, Sterns, Aizenberg, & Anapolle, 2001). FAMILY ROLE IN DRIVING DECISIONS Although research has shown that older adults with dementia want to make their own decisions about driving modification and cessation (Adler & Kuskowski, 2003), it is unrealistic to assume that such drivers will be able to make appropriate, timely, and safe driving decisions unaided as their competence declines. Drivers with dementia need their family's assistance. However, this responsibility can weigh heavily on families who, in the absence of accepted standards of assessment and comprehensive state regulations, must often rely on their own judgment to make decisions about driving. Driving is closely associated with an adult's personal identity and self-perceived roles in family and society (Adler, 1997). Driving affords status and other positive benefits, including independence, choice, spontaneity, and comfort. Older adults with dementia, already confronted with multiple losses, may view driving reduction and cessation as a concrete representation of declining function that further threatens their quality of life (Bahro, Silber, Box, & Sunderland, 1995). Interventions by family, sometimes in collaboration with professionals, are important to driving modification and cessation (Carr et al., 1991). However, long-standing family dynamics can complicate and interfere with discussions about declining driving skills. Family members may differ in their opinions about driving decisions. They may be uncertain regarding their relative's wishes and fear that the loss of driving privileges may lead to depression, anger, or isolation. Others may be unable or reluctant to assume greater responsibility for their relative's transportation needs. Families who rely on an older driver for transportation may be particularly reticent in discussing the matter (Adler, Rottunda, Rasmussen, & Kuskowski, 2000). Cottrell and Wild (1999) found a substantial time lag between a family's perception that their relative should stop driving and actual cessation, even when family members were aware of declining skills. PRACTICE GUIDELINES Answering the question of when to limit and stop driving remains difficult. While researchers debate the question, social workers and other professionals, individually or as teams, must determine how to best approach and resolve driving and dementia issues in their practices. To facilitate a smooth transition to a nondriving status, practice guidelines are needed. Guidelines based on the degree of disease severity, taking into account dementia's progressive nature and the developing concerns and priorities that arise as the disease unfolds, can provide a general framework for action. Driving Assessment Before any decisions about driving can be made, a comprehensive driving history is necessary. Such an evaluation can take place in a physician's or other professional's office, in a hospital room, or at an elderly person's home. It can be completed by a physician, a social worker, or other professional or conducted with a multidisciplinary team (Adler, 1997). A comprehensive driving history inquires about driving behaviors and includes questions regarding frequency, distance, circumstances of travel, familiarity with roadways used, and adverse events such as recent crashes and episodes of getting lost (Adler, 1997; Carr et al., 1991). Family members may be able to provide valuable information, especially if the driver is unaware of or is denying deficits. Completion of the MMSE and neuropsychological testing, ophthalmology and audiology consultations, and examination of current medications may further contribute to decisions about driving. In some communities, driver rehabilitation programs may be available to evaluate driving skills. Mild Dementia Practice Guidelines Early in the disease, cognitive deficits are generally mild and MMSE scores are usually in the high 20s. Clients and families are eager for education and information about the disease and its long-term management. Material about driving should be presented and discussed in an ongoing manner with clients and their families as part of dementia instruction. Discussing driving early in the disease allows clients and families to investigate available transportation options and make choices in a measured, reasoned manner. It is preferable to approach the issue of driving with client and family together as well as separately. Clients' judgment and cognition are at their peak, and it is important to involve them in planning for their own care. Delaying driving discussions

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only means that the client will be less able to participate in his or her own care planning once cognition has declined. Although there may be no concerns at this early juncture, a baseline driving assessment is necessary. Frequently, drivers with dementia self-regulate their behaviors to avoid perceived high-risk situations. Driving at off-peak hours, during daylight, or in familiar areas may decrease their exposure to and risk of a crash or another adverse event. Voluntary restraint on driving can facilitate a gradual withdrawal from driving as declines continue. With a chronic illness such as AD, long-term relationships are crucial to the well-being of the person with the disease and his or her family. Social workers and other professionals must not only offer support and guidance to the family, but also attend to the needs of the driver. An older adult's reaction to driving suggestions depends on his or her level of insight and relationship with the practitioner. It is important to get to know the client as an individual and to make recommendations on the basis of his or her unique set of circumstances. Concepts must be presented in a thoughtful and easily understood manner. Short-term counseling can assist some elderly people in gaining insight into their driving while enhancing feelings of autonomy and selfdetermination (Bahro et al., 1995). Forming a trusting relationship may be critical to compliance with driving recommendations. Social workers must bear in mind that men have a strong identification with driving and may be particularly reluctant to accept driving curtailment or cessation. Spouses, other family, and friends should be encouraged to gradually assume greater responsibility for providing' transportation. In addition, taxicabs and other transit alternatives could begin to be used. Such activities have a twofold purpose: to ease the transition to a nondriving status and to increase the familiarity with transportation options. Although some drivers with dementia can continue to drive safely after the onset of symptoms (Fox et al., 1997; Hunt et al., 1997), the progressive nature of many dementias makes it necessary to re-evaluate abilities at regular intervals (Adler, 1997). Periodic assessment along with discussions about driving means that families and social workers could more confidently act on and honor the elderly person's wishes as decisions about driving are made during the course of the disease. Moderate Dementia Practice Guidelines As clients move from mild to moderate dementia, their MMSE scores drop into the teens and deficits become more pronounced. Many will have adjusted their driving activities in light of declining skills, although self-restriction is limited to the extent to which drivers are aware of their deficits. Driving performance must continue to be revisited, with ongoing discussions about further modifications and eventual cessation. If reasonable, social workers should encourage drivers to adapt their driving behaviors to maximize the period during which they can drive safely, such as discontinuing night driving and avoiding unfamiliar areas. During the transition from driver to nondriver, emotional as well as practical issues related to driving arise (Adler, 1997). Social workers can identify ways for elderly clients to maintain their current lifestyle without driving. Individual or group support can diminish the loss and provide opportunities to discuss concerns. Sources of transportation services in the client's community can be provided as well as information about housing alternatives that might have their own transit services. If risk factors for unsafe driving are identified, further evaluation is recommended, except if the driver indicates that he or she will discontinue driving. A report should be filed with the DMV for re-examination unless the driver prefers to be first examined by a driver rehabilitation specialist. Regulations vary among states, but most allow physicians, other professionals, relatives, and concerned citizens to refer drivers for re-examination (Stamatiadis et al., 2003). Reports are generally confidential, although they can be released if required by court order (Sterns et al., 2001). Often support and input from family, physicians, and the DMV are needed for restrictions to be successful. Evidence of declining cognition or patterns of unsafe driving followed by a discussion of risk and insurance ramifications can sometimes persuade the driver to quit (Odenheimer, 1993). Meeting with an authority figure or someone the driver admires is another approach. Physicians, attorneys, police officers, or pastors are excellent choices (Carr et al., 1991). For others, written instructions available for easy reminders can reinforce the message that the client can no longer drive (Carr et al.). A minority of drivers will insist they can drive and resist any recommendations that they stop. As last-resort efforts, disabling the car, hiding the keys, moving the car to another location, or selling the vehicle may be necessary (Odenheimer). Following re-evaluation by the DMV, a follow-up call should be made to the client and family. In most cases, families assume the elderly person's transportation needs if the elderly individual's driver's license is revoked. Social workers can offer additional information about transportation and housing resources and provide suggestions to gain support of other family and friends. The inability to drive puts elderly drivers at a greater risk of social isolation and may necessitate major life changes, such as relocating. Because the driver's license is one of the most basic means of identification, efforts should be made to assist the client in acquiring an alternative form of identification. Severe Dementia Practice Guidelines In the later stages of dementia, MMSE scores fall into the mid-teens and lower. Cognitive declines continue, with pronounced changes in judgment, language, and visual-spatial skills. Physical changes occur, too, and with these the ability to live

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independently declines. It is unlikely that such severely impaired individuals will still be driving. However, if they are, family support and influence become especially important, particularly if the driver is resistant to stopping (O'Neill, 1997). In such situations, it is often necessary to notify the DMV as well as to remove or disable the car. Again, transportation alternatives and suggestions for management should be identified. At this stage of the disease, transit options such as taxis, buses, and even some senior transportation programs are impractical. Social workers must address the special needs of the client with dementia and may need to be creative in identifying appropriate resources. During the course of the professional relationship, social workers must document their discussions and recommendations about driving. Physicians have been held liable for not warning patients of the dangers of medications that may interfere with the safe operation of a motor vehicle or that a medical condition could contribute to a crash (Retchin & Anapolle, 1993). It is not an impossible leap that social workers in the course of their practice may find themselves involved in lawsuits and be questioned about whether they could have predicted or prevented a crash by a driver with dementia. CONCLUSION Almost all drivers with dementia will eventually need to stop driving. Social workers are in an ideal position to assist clients and their families with driving decisions. Ongoing assessment to identify drivers at risk, providing emotional support, and helping to identify alternatives to driving are all within the social worker's purview. By developing expertise, social workers can provide other staff with information about their state's licensing practices, their requisite responsibilities, and sources of assistance when they encounter problematic older drivers. Increased awareness, education, and support can encourage discussions about driving. Successful interventions will require that older drivers, their families, social workers, and other professionals work together in developing a comprehensive plan for driving cessation that is in the best interest of the individual as well as public safety. Original manuscript received November 10, 2003 Final revision received June 8, 2004 Accepted July 14, 2004 REFERENCES Adler, G. (1997). Driving and dementia: Dilemmas and decisions. Geriatrics, 52(Suppl. 2), S26-S29. Adler, G., & Kuskowski, M. (2003). Driving habits and cessation in older men with dementia. Alzheimer Disease and Associated Disorders, 17, 68-71. Adler, G., Rottunda, S., Rasmussen, K., & Kuskowski, M. (2000). Caregivers dependent upon drivers with dementia. Journal of Clinical Geropsychology, 6, 83-90. Bahro, M., Silber, E., Box, P., & Sunderland, T. (1995). Giving up driving in Alzheimer's disease: An integrative therapeutic approach. International Journal of Geriatric Psychiatry, 10, 871-874. Carr, D., Schmader, K., Bergman, C., Simon, T. C., Jackson, T.W., Haviland, S., & O'Brien, J. (1991). A multidisciplinary approach in the evaluation of demented drivers referred to geriatric assessment centers. Journal of the American Geriatric Society, 39, 1132-1136. Cobb, R.W., & Coughlin, J. F. (1997). Regulating older drivers: How are the states coping? Journal of Aging and Social Policy, 9(4), 71-87. Coley, M. (2001). Older driver relicensing laws: The state of the states. Public Policy and Aging Report, 11(4), 3-10. Cottrell, V., & Wild, K. (1999). Longitudinal study of self-imposed driving restrictions and deficit awareness in patients with Alzheimer disease. Alzheimer Disease and Associated Disorders, 13, 151-156. Fitten, L. J., Perryman, K. M., Wilkinson, C. J., Roderick, J. L., Burns, M. M., Pachana, N., Mervis, R., Malmgren, R., Siembieda, D. W., & Ganzell, S. (1995). Alzheimer and vascular dementias: A prospective road and laboratory study. JAMA, 273, 1360-1365. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.

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Fox, G. K., Bowden, S. C., Bashford, G. M., & Smith, D. S. (1997). Alzheimer's disease and driving: Prediction and assessment of driving performance. Journal of the American Geriatric Society, 45, 949-953. Hebert, L. E., Scherr, P.A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003).Alzheimer disease in the US population: Prevalence estimates using the 2000 census. Archives of Neurology, 60, 1119-1122. Hunt, L. A., Murphy, C. F., Carr, D., Duchek, J. M., Buckles, V., & Morris, J. C. (1997). Environmental cueing may effect performance on a road test for drivers with dementia of the Alzheimer type. Alzheimer Disease and Associated Disorders, 11 (Suppl. 1), 13-16. Odenheimer, G. L. (1993). Dementia and the older driver. Clinics in Geriatric Medicine, 9(2), 349-364. O'Neill, D. (1997). Predicting and coping with the consequences of stopping driving. Alzheimer Disease and Associated Disorders, 11(Suppl. 1), 70-72. Retchin, S. M., & Anapolle, J. (1993). An overview of the older driver. Clinics in Geriatric Medicine, 9(2), 279-296. Shua-Haim, J. R., & Gross, J. S. (1996). The "co-pilot" driver syndrome. Journal of the American Geriatric Society, 44, 815817. Stamatiadis, N., Agent, K. R., & Ridgeway, M. (2003). Driver license renewal for the elderly: A case study. Journal of Applied Gerontology, 22, 42-56. Sterns, H., Sterns, R., Aizenberg, R., & Anapolle, J. (2001). Family and friends concerned about an older driver: Final report (DOT HS 809 307). Washington, DC: National Highway Traffic Safety Administration. Tuokko, H., Tallman, K., Beattie, B. L., Cooper, P., & Weir, J. (1995). An examination of driving records in a dementia clinic. Journals of Gerontology: Psychological Sciences and Social Sciences, 50B, S173-S181. Wild, K., & Cottrell, V. (2003). Identifying driving impairment in Alzheimer disease: A comparison of self and observer reports versus driving evaluation. Alzheimer Disease and Associated Disorders, 17, 27-34. Withaar, F. K., Brouwer, W. H., & van Zomeren, A. H. (2000). Fitness to drive in older adults with cognitive impairment. Journal of the International Neuropsychological Society, 6, 480-490. Geri Adler, PhD, MSW, is assistant professor, Graduate College of Social Work, University of Houston, 237 Social Work Building, Houston, TX 77204-4013; e-mail: gladler@uh.edu.
Questia, a part of Gale, Cengage Learning. www.questia.com Publication Information: Article Title: Intervention Approaches to Driving and Dementia. Contributors: Geri Adler - author. Journal Title: Health and Social Work. Volume: 32. Issue: 1. Publication Year: 2007. Page Number: 75+. COPYRIGHT 2007 National Association of Social Workers; COPYRIGHT 2007 Gale Group This material is protected by copyright and, with the exception of fair use, may not be further copied, distributed or transmitted in any form or by any means.

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