Driving is seen as a practical necessity for most Americans as well as a symbol of independence. It is little wonder that few people will easily give it up. Yet for individuals with Alzheimer's disease, operating a motor vehicle can pose serious increased risks to themselves and others. The decision of when to stop driving is one that Alzheimer's disease patients and their families often face. This article provides some guidelines for approaching this sensitive issue.

Age And Accident Risk
Among drivers overall, 16 to 19 year-olds have the highest accident risk, at 28.6 motor vehicle accidents per million vehicle miles traveled (MVA/MVMT). For 40 to 45 year-olds, the rate drops to 3.7 MVA/MVMT, less than one seventh that of teens. For the 80 to 85 age group, the figure is 15.1; for those over 85, it is 38.8. But older drivers also log far fewer miles on average than younger drivers-just 2615 miles per year for those 80 to 84, as compared with 13,000 for the 40 to 44 year-old group.

Statistics like these have led most experts to conclude that age alone is not reason enough to impose restrictions on someone's driving, since accident rates among the elderly are less than rates tolerated by society among other age groups.

Mentally competent seniors typically limit their own driving to reduce their risk. Common adaptations are to take shorter trips, use familiar routes, avoid night driving and rely more heavily on friends and relatives for transportation.

Alzheimer's Disease Poses a Special Problem
Because Alzheimer's diseases affects judgment, patients often do not recognize indications of increased driving risk and therefore may not voluntarily limit or discontinue their driving. Overall, patients with Alzheimer's disease continue to drive an average of 2.5 years after diagnosis. When is it time to stop?

The American Academy of Neurology (AAN) published recommendations on this issue in 2000, based on an exhaustive review of scientific studies. They found that for patients with mild Alzheimer's (slight memory loss, impairment in problem solving and difficulty with time relationships), the accident rate was higher than that of age-matched controls but comparable to that of 16 to 19 year-olds. For this group, the AAN recommended driving performance testing by a qualified examiner and re-evaluation every 6 months. Patients with more advanced Alzheimer's, according to the AAN, have a substantially higher risk of accidents and driving errors, such that cessation of driving should be strongly considered.

Clues to Impaired Driving
Statistics are fine, but for an individual driver with Alzheimer's disease the practical question is, "Are their indications of impaired driving ability?" Concerned family members need to create non-threatening opportunities to observe driving behavior, and make careful note of warning signs. The Hartford Financial Services Group, Inc., the MIT Age Lab and Connecticut Community Care, Inc. have developed the following checklist:

• Incorrect signaling.
• Trouble navigating turns.
• Moving into a wrong lane.
• Confusion at exits.
• Parking inappropriately.
• Hitting curbs.
• Driving at inappropriate speeds.
• Delayed responses to unexpected situations.
• Not anticipating dangerous situations.
• Increased agitation or irritation when driving.
• Scrapes or dents on car, garage or mailbox.
• Getting lost in familiar places
• Near misses.
• Ticketed moving violations or warnings.
• Car accident.
• Confusing brake and gas pedals.
• Stopping in traffic for no apparent reason.

Approaching Driving Impairment in a Loved One with Alzheimer's
If some of the warning signs on the foregoing checklist are present, family members and caregivers must address the problem driving. Experience shows that no two cases are alike, and that there is no single best approach. The following "road map" may help. Employing several of these strategies together is usually most effective:

• Begin intervening early, when signs of impairment are not yet critical.
• Try to make driving cessation a gradual transition.
• Understand the practical needs that driving meets for the patient, and provide alternatives to driving that meet these needs.
• Have others drive the patient to appointments, shopping, church or social functions. Use taxi services or public transportation, if available, for patients with mild Alzheimer's who are accustomed to such services.
• Arrange for services to be provided in the home which would otherwise require driving. Examples include home delivery of groceries and medications and the use of errand services.
• Enlist help. No one family member should be forced to shoulder the entire load. Consider involving a professional such as a geriatric care manager, social worker or elder law attorney.
• Talk to the patient's physician, whose expertise can help guide the process and whose recommendations may carry greater weight with the patient.
• If necessary, take the keys or remove or disable the car.
• Don't decide that you can safely control the risks by riding as a passenger when the patient drives. This may simply prolong a bad situation.

Reporting Impaired Drivers to State Motor Vehicle Departments
Most state laws call for investigating the driving performance of individuals reported to state motor vehicle departments as potentially unsafe drivers. Virginia law, for example, states that if the Department of Motor Vehicles (DMV) has good reason to believe that a driver is unfit to operate a motor vehicle safely, it may require that the driver submit to an examination of his or her driving competency. As part of its examination, the DMV may require a physician's written assessment.

Upon written request, the DMV must provide its reasons for the examination. However, the law stipulates that the DMV shall not reveal its reasons if its source is a relative or friend, or a treating physician. After its examination, the DMV may take whatever action it deems necessary, including revocation of the driver's license.

What this means is that reporting to the DMV is an important option if a patient with Alzheimer's will not otherwise accept appropriate restrictions. There are pitfalls, however. Cognitive function in Alzheimer's patients may fluctuate, so that an examination on a good day may miss risky driving behaviors, yet lead a patient to feel justified in continuing to drive. In addition, despite the protection of anonymity, suspicion and resentment can result. By addressing the problem early and using less drastic approaches, driving can be safely stopped without causing ill feelings.

Where to Get More Information:
The Hartford has an excellent website on this topic. A brochure entitled At the Crossroads: A Guide to Alzheimer's Disease, Dementia and Driving can be obtained via download or mail.
The Virginia Department of Motor Vehicles provides information on how to report a possibly impaired driver.

January, 2003