Physician's Guide to Assessing and Counseling Older Drivers-Chapter 9-Section 4: Neurologic Diseases

10. Sleep disorders

Narcolepsy
Sleep apnea

11. Stroke
12. Tourette’s syndrome
13. Traumatic brain injury
14. Vertigo

Dementia deserves a special emphasis in this section because it presents a significant challenge to driving safety. With progressive dementia, patients ultimately lose the ability to drive safely and the ability to be aware of this. Therefore, dementia patients may be more likely than drivers with visual or motor deficits (who tend to self-restrict their driving to accommodate their declining abilities) to drive even when it is highly unsafe for them to be on the road. It becomes the responsibility of family members and other caregivers to protect the safety of these patients by enforcing driving cessation.

While it is optimal to initiate discussions of driving safety with the patient and family members before driving becomes unsafe, dementia is too often undetected and undiagnosed until late in the course of the disease. Initially, family members and physicians may assume that the patient’s decline in cognitive function is a part of the “normal” aging process. Physicians may also hesitate to screen for and diagnose dementia because they erroneously believe that it is futile—in other words, that nothing can be done to improve the patient’s situation or slow the progression of the disease. In addition, physicians may be concerned about the amount of time required to effectively diagnose dementia and educate patients and their families.¹³

Despite these barriers, physicians are encouraged to be alert to the signs and symptoms of dementia and to pursue an early diagnosis. Early diagnosis is the first step to promoting the driving safety of dementia patients. The second step is intervention, which includes medications to slow the course of the disease, counseling to prepare the patient and family for eventual driving cessation, and serial assessment of the patient’s driving abilities. When assessment shows that driving may pose a significant safety risk to the patient, driving cessation is a necessary third step. With early planning, patients and their families can make a more seamless transition from ‘driving’ to ‘non-driving’ status.

Section 4: Neurologic Diseases

¹³ Valcour VG, Masaki KH, Curb JD, Blanchette PL. The detection of dementia in the primary care setting. Archives of Internal Medicine. 2000;160:2964-2968.

¹⁴ Alzheimer’s Association. Position statement: Driving. Adopted by the Alzheimer’s Association Board of Directors, October 2001. Available at: http://www.alz.org/aboutus/ positionstatements/overview.htm. Accessed January 9, 2003.

¹⁵ Patterson CJS, Gauthier S, Bergman H, et al. The recognition, assessment and management of denenting disorders: conclusions from the Canadian Consensus Conference on Dementia. Canadian Medical Association Journal. 1999;160(12suppl):S1-S15.

¹⁶ Carr DB, Duchek J, Morris JC. Characteristics of motor vehicle crashes with dementia of the Alzheimer type. Journal of the American Geriatrics Society. 2000;48(1):18-22.

¹⁷ Zesiewicz TA, Cimino CR, Malek AR, et al. Driving safety in Parkinson’s disease. Neurology. 2002;59:1787-1788.

¹⁸ American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. Consensus statements, sample statutory provisions, and model regulations regarding driver licensing and epilepsy. Epilepsia. 1994;35(3):696-705.

¹⁹ Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540-545.

Brain tumor	Driving recommendations should be based on the type of tumor; location; rate of growth; type of treatment; presence of seizures; and presence of cognitive or perceptual impairments. Due to the progressive nature of some tumors, the physician may need to evaluate the patient’s fitness to drive serially. See also the stroke recommendations in Section 3. If the patient experiences seizure(s), see also the seizure recommendations in this section.
Dementia	The following recommendations are adapted from the Alzheimer’s Association’s Position Statement on Driving¹⁴ and recommendations of the Canadian Consensus Conference on Dementia.¹⁵ A diagnosis of dementia is not, on its own, a sufficient reason to withdraw driving privileges. A significant number of drivers with dementia are found to be competent to drive in the early stages of their illness.¹⁶ Therefore, the determining factor in withdrawing driving privileges should be the individual’s driving ability. When the individual poses a serious risk to self or others, driving privileges must be withheld. Physicians should consider the risks associated with driving for all of their patients with dementia, and they are encouraged to address the issue of driving safety with these patients and their families. When appropriate, patients should be included in decisions about current or future driving restrictions and cessation; otherwise, physicians and families must decide in the best interests of the patient whose decision-making capacity is impaired. Physicians are recommended to perform a focused medical assessment that includes history of driving difficulty from a family member or caregiver and an evaluation of cognitive abilities, including memory, attention, judgement, and visuospatial abilities. Physicians should be aware that patients with progressive dementia require serial assessment, and they should familiarize themselves with their state reporting laws and procedures for dementia (if any). (See Chapter 8 for a state-by-state reference list of reporting laws.) If there is concern that an individual with dementia has impaired driving ability, and the individual would like to continue driving, a formal assessment of driving skills should be administered. One type of assessment is an on-road driving assessment performed by a driver rehabilitation specialist. Such an assessment should lead to specific recommendations, consistent with state laws and regulations, as to whether the individual is safe to drive. Physicians should encourage patients with progressive dementia to plan early for eventual cessation of driving privileges by developing alternative transportation options. The patient should be encouraged to coordinate these efforts with their family members and caregivers, and to seek assistance (as needed) from their local area agency on aging.
Migraine and other recurrent headache syndromes	Patients with recurrent severe headaches should be cautioned against driving when experiencing neurologic manifestations (eg, visual disturbances or dizziness), when distracted by pain, and while on any barbiturate, narcotic, or narcotic-like analgesic. (See Section 5 for further recommendations regarding narcotic analgesics.)
Movement disorders	If the physician elicits complaints of interference with driving tasks or is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for a driver evaluation (including on-road assessment) is recommended.
Multiple sclerosis	Driving recommendations should be based on the types of symptoms and level of symptom involvement. Physicians should be alert to deficits that are subtle but have a strong potential to impair driving performance (eg, muscle weakness, sensory loss, fatigue, cognitive or perceptual deficits, symptoms of optic neuritis). A driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist may be useful in determining the patient’s safety to drive. Serial evaluations may be required as the patient’s symptoms evolve or progress.
Paraplegia/quadriplegia	Referral to a driver rehabilitation specialist is necessary if the patient wishes to resume driving or requires vehicle modifications to accommodate him/her as a passenger. The specialist can recommend an appropriate vehicle and prescribe adaptive devices (such as low-resistance power steering and hand controls) and train the patient in their use. In addition, the specialist can assist the patient with access to the vehicle, including opening and closing car doors, transfer to the car seat, and independent wheelchair stowage, through vehicle adaptations and training. Driving should be restricted until the patient demonstrates safe driving ability in the adapted vehicle.
Parkinson’s disease	Patients with advanced Parkinson’s disease may be at increased risk for motor vehicle crashes due to both motor and cognitive dysfunction.¹⁷ Physicians should base their driving recommendations on the level of motor and cognitive symptom involvement, patient’s response to treatment, and presence and extent of any medication side effects. (See Section 5 for specific recommendations on antiparkinsonian medications.) Serial physical and cognitive evaluations are recommended every six to twelve months due to the progressive nature of the disease. If the physician is concerned that dementia and/or motor impairments may affect the patient’s driving skills, a driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist may be useful in determining the patient’s fitness to drive. See also the dementia recommendations in this section.
Peripheral neuropathy	Lower extremity deficits in sensation and proprioception may be exceedingly dangerous for driving, as the driver may be unable to control the foot pedals or may confuse the accelerator with the brake pedal. If deficits in sensation and proprioception are identified, referral to a driver rehabilitation specialist is recommended. The specialist may prescribe vehicle adaptive devices (eg, hand controls in place of the foot pedals) and train the patient in their use.
Seizure disorder	The seizure disorder recommendation below is adapted from the Consensus Statements on Driver Licensing in Epilepsy crafted and agreed on by the American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America in March 1992.¹⁸ Please note that these recommendations are subject to each particular state’s licensing requirements and reporting laws. A patient with seizure disorder should not drive until he/she has been seizure-free for three months. This three-month interval may be lengthened or shortened based on the following favorable and unfavorable modifiers: Favorable modifiers Patient experiences only simple partial seizures that do not interfere with consciousness and/or motor control Seizures have consistent and prolonged aura There is an established pattern of pure nocturnal seizures Seizures occurred during medically directed medication changes Seizures were secondary to acute metabolic or toxic states that are not likely to recur Seizures were caused by sleep deprivation Seizures were related to reversible acute illness Unfavorable modifiers Noncompliance with medication or medical visits and/or lack of credibility Alcohol and/or drug abuse in the past three months Increased number of seizures in the past year Prior bad driving record Structural brain lesion Noncorrectable brain functional or metabolic condition Frequent seizures after seizure-free interval Prior crashes due to seizures in the past five years
*Single unprovoked seizure*	The patient should not drive until he/she has been seizure-free for three months. This time period may be shortened with physician approval. Predictors of recurrent seizures that may preclude shortening of this time period include: The seizure was focal in origin Focal or neurologic deficits predated the seizure The seizure was associated with chronic diffuse brain dysfunction The patient has a family history positive for epilepsy Generalized spike waves or focal spikes are present on EEG recordings
*Withdrawal or change of anticonvulsant therapy*	The patient should temporarily cease driving during the time of medication withdrawal or change due to the risk of recurrent seizure and potential medication side effects that may impair driving ability. If there is significant risk of recurrent seizure during medication withdrawal or change, the patient should cease driving during this time and for at least three months thereafter. If the patient experiences a seizure after medication withdrawal or change, he/she should not drive for one month after resuming a previously-effective medication regimen. Alternatively, the patient may resume driving after three months if he/she refuses to resume this medication regimen but is seizure-free during this time period.
Sleep Disorders
*Narcolepsy*	The patient should cease driving upon diagnosis. The patient may resume driving upon treatment when he/she no longer suffers excessive daytime drowsiness or cataplexy. Physicians may consider using scoring tools such as the Epworth Sleepiness Scale¹⁹ to assess the patient’s level of daytime drowsiness.
*Sleep apnea*	See Section 11.
Stroke	See Section 3.
Tourette’s syndrome	In evaluating the patient’s fitness to drive, the physician should consider any comorbid disorders (including attention deficit hyperactivity disorder, learning disabilities, and anxiety disorder) in addition to the patient’s motor tics. (For specific recommendations regarding these disorders, see Section 6). If the physician is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for driver evaluation (including on-road assessment) is recommended. Physicians should be aware that certain medications used in the treatment of Tourette’s syndrome have the potential to impair driving performance. (See Section 5 for more information on medication side effects.)
Traumatic brain injury	Patients should not drive until symptoms have stabilized or resolved. For patients whose symptoms resolve, driving may resume following medical assessment and, if deemed necessary by the physician, driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist. Patients with residual neurological or cognitive deficits should be assessed and managed as described under the dementia recommendations in this section. If the patient experiences seizure(s), see the seizure recommendations in this section.
Vertigo	Vertigo and the medications commonly used to treat vertigo have a significant potential to impair driving skills. For acute vertigo, the patient should cease driving until symptoms have fully resolved. Under no circumstances should the patient drive to seek medical attention. Patients with a chronic vertiginous disorder are strongly recommended to undergo driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist prior to resuming driving.