Tips on assessing driving risk, understanding your responsibilities and when to get an OT involved…

GPs are often called on to decide whether patients with dementia are fit to get behind the wheel, but the issue is highly complex and there is a lack of objective data about driving behaviour and skills on which to base decisions, says Professor Kaarin Anstey, director of the NHMRC Dementia Centre for Research Collaboration, the UNSW Ageing Futures Institute, and co-deputy director of the ARC Centre of Excellence in Population Ageing Research.

“Driving skills are impacted by so many factors, some of which are part of normal ageing and some are related to disease,” she says.

Here is some advice for dealing with an issue affecting a growing number of Australians.

1. A dementia diagnosis does not always exclude people from driving

This is a common misconception, but “being given a diagnosis of dementia doesn’t automatically mean you can no longer drive,” says Victorian GP Dr Marita Long, Honorary Medical Advisor for Dementia Australia and cohost of the Dementia in Practice podcast.

The Austroads Assessing Fitness to Drive guidelines state that while dementia symptoms are associated with a moderately high collision risk compared to that for matched controls, the “evidence does not suggest that all people with dementia symptoms should have their licences revoked or restricted.”

Those with preclinical dementia, which is increasingly being discovered due to advances in diagnostic technology, are considered fit to drive under the updated 2022 guidelines.

Additionally, the guidelines note that mild cognitive impairment does not significantly impair driving abilities, though if multiple cognitive domains (e.g. visuospatial, attention and executive functions) are impacted, an assessment may be appropriate.

Once someone has a dementia diagnosis, the guidelines say they must move to a conditional license if they are to keep driving, Professor Anstey says.

For a conditional licence to be issued, the treating professional must provide the driver licensing authority with:

• details of which medical criteria are not met
• evidence of the medical criteria that are met
• the proposed conditions and monitoring requirements of the licence.

While many people continue to drive in the early stage of dementia, there are some circumstances where it is not safe, Professor Anstey says, such as when there is impaired decision-making and insight or visual disturbance.

The Austroads guidelines list factors to consider, such as:

• Driving history: Have they had recent accidents or near misses, or been referred for assessment by police or other authority?
• Vision and hearing: Can they see things directly in front of them and off to the sides? Can they hear oncoming traffic, horns, sirens etc?
• Reaction time, coordination and other physical abilities: Can they turn, stop or accelerate quickly? Have they become clumsy or has poor coordination affected their walking? Do they have trouble using their hands and feet when following motor instructions?
• Basic skills that impact driving: e.g. can they understand road signs and traffic lights, stay in the correct lane, tell left from right etc.
• Cognitive abilities, alertness, perception: Are they aware and cognisant of what is happening around them? Do they experience hallucinations or delusions? Do they get lost on familiar routes? Do they stay calm when multiple things are happening at once?
• Insight: Do they understand/acknowledge how dementia impacts them?

2. Regular assessment is crucial

At some point, all patients with dementia will need to hang up the car keys for good, and regular monitoring is crucial for determining when this time has come.

Useful assessment tools

While there is no single test that can determine when someone’s driving days are done, we shouldn’t rely solely on MMSE scores, Dr Long says.

You can use various tests to guide the decision, with or without cognitive assessment scores, she says. These include the:

• Trail Making Test (Parts A and B) – this two-minute video shows you how to do it.
• Clock Drawing Test – watch this 1.5-minute video for instructions.
• Intersecting pentagons test

Dr Long also suggests asking others who know the person if they would drive with them.

3. Refer for an OT assessment if unsure

If there is any uncertainty about a person’s fitness to drive, they should be referred for an occupational therapy assessment, Professor Anstey says.

“OTs are trained to assess driving and their assessment takes a lot of time which GPs just don’t have,” she says.

This involves a  “comprehensive battery of assessments” both in and out of the car, says OT driving assessor Matt Underwood in a podcast episode for Dementia Training Australia. This includes a detailed medical and driving history, visual screening, physical screening to assess muscle strength, sensory function, balance, coordination, reaction time and mobility, cognitive screening using  DriveSafe DriveAware and more.

To minimise anxiety, Underwood recommends explaining that it’s not necessarily a pass/fail exam, since many patients will have the opportunity to participate in a series of driver rehabilitation lessons to see if they can incorporate strategies that would bring their driving skills up to a threshold deemed to be safe.

“Sometimes it’s really clear-cut either way if someone’s fit or not fit. When someone presents in a grey area… that is often a trigger to make a recommendation of a driver rehab program,” Underwood says.

This would typically consist of five to 10 lessons with an instructor to target issues seen in the OT driving assessment, he explains.

The OT assessor may also recommend licence restrictions such as only driving during daylight hours or within specific geographical areas.

Dr Long says OT assessments are the gold standard and while they can be expensive, you can explain they are a necessary cost associated with driving, just like insurance and registration.

You may also want to get an opinion from a geriatrician, she adds.

4. You or your patient will need to notify the relevant authority

Once someone can no longer hold an unconditional licence, the relevant authority must be notified. In some states and territories this responsibility falls to the doctor and in others to the patient (or their carer).

Dementia Australia  ‘Driving and dementia’ webpage has links to state and territory licensing authorities.

If it is the patent’s responsibility to make the notification but you’re concerned they haven’t  done it, Dr Long suggests seeking advice from your medical defence organisation.

Patients will also need to notify their insurance company.

5. Older people won’t always know it’s time to give up their license

Professor Anstey says older people commonly think they will know when it is time to cease driving—but evidence suggests otherwise.

“We have assessed over 1000 drivers using on-road tests and found that they are not good at evaluating how well they drive,” she says.

“Hence we don’t think that people can always tell when they are becoming unsafe.”

Dr Long suggests starting the discussion early and framing it around scenarios like, “How would you/they feel if at the end of their driving career they caused a serious accident when they have had such a good driving record?”

It can be helpful to offer tips like not driving at night, when sick, after a bad night’s sleep, or in unfamiliar places, she says.

Some people are more than happy to stop driving once they look at other options, such as transport with family, friends or a community transport service, she adds.

Government-subsidised taxi schemes are another option and can be cheaper than keeping a car. Check your state or territory transport authority for details.

Useful resources

• Dementia | Austroads
• Forward with dementia – checklist of signs that may suggest someone should stop driving.
• Dementia Australia: Driving and dementia – a consumer-facing resource with information on warning signs that it’s time to stop driving, how to broach these conversations, and driving alternatives.
• Dementia Training Australia – Podcast episode about OT driving assessments and how OTs can assist the GP and the person living with dementia.
• Article in Canadian Family Physician on managing driving safety concerns in general practice.