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Clinicians often face a gap in assessing driving safety in older adults with neurocognitive disorders due to the lack of evidence-based tests and discomfort with the topic. This issue is compounded by a reluctance to address driving concerns, whether from clinicians, patients, or caregivers. Effective evaluation is crucial as these patients are at higher risk of accidents. In addition, improved patient education and counseling are necessary, supported by an interprofessional healthcare team, to address driving safety concerns and maintain independence while mitigating risks. Enhancing awareness and communication about driving fitness can help bridge this practice gap. Objectives: Identify key signs of cognitive decline and driving impairment in older adults to ensure timely evaluation and intervention. Implement a multidisciplinary approach to driving evaluations, involving healthcare professionals, social workers, and family caregivers. Select appropriate tools and tests to evaluate driving fitness in older adults and ensure their effective use in clinical practice. Collaborate with an interprofessional healthcare team to develop a personalized plan for managing driving safety in older adults and transitioning them to alternative transportation options. Access free multiple choice questions on this topic.

Cognitive decline can be described as a gradual or sudden loss of thinking abilities such as learning, paying attention and remembering past events/details.This is more commonly seen in the older adults with dementia.[1] When taking care of patients with dementia (PWD), it is important to assess the patient’s fitness to drive. Patients with dementia have a 2-8x increased risk of motor vehicle accidents compared to similarly aged drivers without dementia, yet many are never counseled on driving safety.[2] Driving safety assessment is a sensitive discussion that is often delayed or forgone altogether because of physician reluctance, patient refusal, or caretaker preference. Physicians often are not formally trained on how to conduct these conversations and seldom do not conduct the assessment. Driving is integral to a patient’s independence, so discussions of driving fitness may be met with emotional resistance, and patients may not recognize or admit their deficits.[3] The true extent of driving impairment may be minimized by caretakers who either do not want to admit the progression of their loved one’s disease or do not want to take on additional driving responsibilities.[4] Despite these barriers, driver safety assessment is an important public health and medicolegal issue and should be familiar to all healthcare professionals. See Driving Screening Flowchart below:

Given the high emotional stakes with discussing and determining driving privileges, it is better to begin this discussion early in the course of dementia before overt impairment is noted.[4] This allows patients to anticipate the impact of driving restrictions while still having insight without immediately taking away their sense of control. Maintaining control is a key factor in a patient’s self esteem, and loss of control in everyday tasks is often associated with psychological decline.[9] Instead, the clinician and caregivers should focus the discussion on transitioning to safe transport and becoming a safe passenger.[4] Avoiding the language of “withdraw,” “take away,” and “loss of privilege” can aid in effective patient communication without making the patient feel victimized or at fault. After providing the driving fitness assessment, patients and families may need help complying with this new transition at home. Clinicians may suggest social resources or safer public transportation options.[17] Patients may continue to attempt driving despite their families’ warnings, and at this point, the patient's safety must be prioritized. Caregivers should be advised to avoid discussions that remind the patient of what they can no longer do. In some cases, families may need to park the car away from easy access or hide the car keys. Directly confronting the patient with repeated threats will likely increase a patient’s confusion and compromise safety at home. Instead, families should be encouraged to de-escalate by changing the topic of discussion discussion topic or distracting the patient until they are less focused on driving.[4] Patients and families may benefit from participating in driving cessation groups in the community to aid the transition.

After providing the driving fitness assessment, patients and families may need help complying with this new transition at home. Clinicians may suggest social resources or safer public transportation options.[17] Patients may continue to attempt driving despite their families’ warnings, and at this point, the patient's safety must be prioritized. Caregivers should be advised to avoid discussions that remind the patient of what they can no longer do. In some cases, families may need to park the car away from easy access or hide the car keys. Directly confronting the patient with repeated threats will likely increase a patient’s confusion and compromise safety at home. Instead, families should be encouraged to de-escalate by changing the topic of discussion discussion topic or distracting the patient until they are less focused on driving.[4] Patients and families may benefit from participating in driving cessation groups in the community to aid the transition. In summary, patients with dementia are at increased risk of driving impairment and their fitness to drive should be evaluated in all patients with neurocognitive disorders. There is no single objective scale or test to determine driving fitness, so this decision should involve a multidisciplinary assessment. It is prudent to begin screening for driving impairment as soon as the clinician obtains a history of driving accidents/citations or significant changes in driving patterns. This should be followed with a thorough evaluation of the patient’s medications and physical exam. If patients have high-risk features of cognitive decline on screening, they should be further evaluated with neuropsychological testing and the clinical dementia severity scale (Level 1A evidence).

In summary, patients with dementia are at increased risk of driving impairment and their fitness to drive should be evaluated in all patients with neurocognitive disorders. There is no single objective scale or test to determine driving fitness, so this decision should involve a multidisciplinary assessment. It is prudent to begin screening for driving impairment as soon as the clinician obtains a history of driving accidents/citations or significant changes in driving patterns. This should be followed with a thorough evaluation of the patient’s medications and physical exam. If patients have high-risk features of cognitive decline on screening, they should be further evaluated with neuropsychological testing and the clinical dementia severity scale (Level 1A evidence). Due to the complexity of CDR scoring, clinicians in a busy practice may consider utilizing the MMSE or MoCA as an alternative. They should consider the lack of Level 1A evidence supporting their use in assessing driving ability. The next step in any safety assessment can include referring the patient to a certified occupational therapist or a driving rehabilitation specialist to assess on-the-road driving abilities. Using this stepwise diagnostic approach may provide a comprehensive evaluation of the patient and driving safety. After a patient has been deemed unfit to drive, it is the clinician’s responsibility to share this information sensitively with the older adult and ensure that the patients and caregivers are well-supported in this important transition. Additionally it is important that this information has also been well documented so other team members involved in the patients care are informed and aware.