Dementia, Aging and Driving: Managing Risks of Older Adult Drivers
By Pamela D Wilson CSA, CG, MS, BS/BA
“God almighty, those poor people. Poor, poor, tragic people. And what a tragic ending to their outing, and I contributed to it, which is just almost more than I can figure out,” said George Russell Weller after his car stopped after veering out of control for nearly 1,000 feet leaving 10 people dead and more than 60 injured on July 16, 2003 in Santa Monica, California.1 He also reported that “something” smashed into his windshield and he had no idea what “it” was; “it” was the body of an innocent human bystander colliding with his car.
Three years later, on October 20, 2006, Weller was found guilty of 10 counts of vehicular manslaughter. He was ordered to pay $107,100 in fines and restitution and was sentenced to five years’ felony probation. As of May 22, 2008 the City of Santa Monica had paid out $21 million to settle dozens of civil lawsuits stemming from the case. 2
This presents a picture of what might happen when an older adult with multiple health conditions or a diagnosis of dementia continues to drive a motor vehicle. Very different from the humorous and heartfelt movie, Driving Ms. Daisy, (click player below for a trip down memory lane) older adults who choose not to give up the car keys have the potential of seriously harming themselves, other drivers or pedestrians.
As the result of a panel formed by The American Academy of Neurology, of neurologists, a neuropsychologist, and an occupational therapist, recommendations were made regarding the identification of cognitive impairment and individuals who may be at higher risk for unsafe driving.3 Concerns exist by family members over taking away the keys due to expected negative reactions from a parent who feels he or she has the ability to drive safely. Doctors as well as other healthcare and aging professionals working with older adults also hesitate to recommend taking away the keys as this may open them to potential civil litigation.
“I’ve been driving safely for the past 90 years.” This is a common statement made by many of my clients diagnosed with memory loss who believe they are as safe driving today as they were 50 years ago. According to research conducted by the American Academy of Neurology, a patient’s self-rating of safe driving is established as not useful for determining that the patient is save to drive. Additionally, a history of a crash is possibly more useful in identifying individuals at risk for subsequent crashes than a diagnosis of mild dementia alone. 3
The act of giving up the car keys is perceived by older adults as the final “nail in the coffin” ending independence and the ability to come and go as one desires. Isolation from social situations, friends and activities is proven to have a negative impact on older adults, resulting in depression, further declines in physical abilities and increasing memory loss due to less frequent interpersonal interaction and physical activity. It is for this reason that many professionals hesitate to recommend to individuals and family members that the car keys should be taken away.
Many professionals, attempting to be supportive, recommend driving tests through the Department of Motor Vehicles who usually only require a paper test, not a driving test. I am able to cite a situation where I took a client, for whom I was appointed guardian, to the DMV. She failed the initial test and was served by a DMV employee who clearly felt empathetic due to my client’s age and the fact that she was a “sweet little old lady” whose driving privileges should not be revoked. The DMV employee allowed a second attempt to pass the exam.
My client stood next to another individual taking the test who allowed her to cheat. Concerned that she would be granted a new license, my client’s conservator, an attorney also present, spoke to the DMV employee to explain the background: a diagnosis of advanced Alzheimer’s disease including previous multiple car accidents. Only after this explanation, and after failing the second test, was my client’s driver’s license revoked.
Some communities offer special driving exams for memory impaired individuals that feature a driving simulation and an actual driving assessment. These exams, requiring a doctor’s order, include testing of reflexes and other aspects not included in regular DMV testing. The availability of this test offers a method for individuals, who believe their driving abilities to be intact, to prove that they are safe drivers.
There are differing opinions on types of tests that indicate an individual may be unsafe to drive. Some studies suggest that an MMSE (Mini Mental State Examination) score of 24 or less is a starting point to question driving ability. Other studies support neuropsychological testing that includes tests of executive function, visual retention, memory and other aspects are useful but may not be totally accurate.
According to the AAN, a more appropriate measure called CDR-1 indicates that patients are at a substantially higher risk for unsafe driving and should strongly consider discontinuing driving or at the very least, discuss and prepare for driving cessation within a set period of time. Drivers with a CDR-1 designation were more likely to be judged unsafe on a 6 month follow up if driving was not discontinued immediately.3
Descriptions supporting the CDR-1 measure include the following. If one or more of these aspects exist, discussions and a plan for driving cessation should be put into place:
- Inability to remember recent events that interferes with performing everyday activities
- Moderate difficulty with day, time and place orientation
- Moderate difficulty responding to problems
- Difficulty functioning in community situations i.e. work, shopping, volunteer activities or in social groups
- Abandonment of prior hobbies and interests that may now seem “complicated”, absence of completing normal household activities and chores
- Reminding for activities of personal hygiene, dressing, maintaining personal effects like keys etc.
Because of the absence of professional guidance regarding driving, family members should take responsibility for discussions surrounding driver safety. While taking away the keys will likely result in an emotional battle of wills if a memory impaired individual is adamant about continuing to drive, the consequences of not taking away the keys may be life changing as in the situation of George Russell Walker.
Many communities have public transportation opportunities available. In the state of Colorado, Access-A-Ride is one of the most common transportation options along with other local city and county specific transportation. For individuals living in assisted living communities, transportation is provided. Many in home care agencies also provide incidental transportation to medical appointments, for shopping and for errands.
While giving up the car keys may be viewed as the “end of the road”, adults who choose to do so willingly are exhibiting wisdom and concern not only for their well-being but also for the well-being of others.
1 Spano, John. (2006) Trial in Market Crash Set to Begin. Los Angeles Times, 9/4/2006.
2 George Russell Walker, Wikipedia
3 Iverson, D.J., M.D., et al. Practice Parameter Update: Evaluation and Management of Driving Risk in Dementia. Neurology 2020: 74: 1-9.
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©2014 Pamela D. Wilson, All Rights Reserved.