Mental Health

New Guidelines on Driving Risk in Dementia Presented

April 13, 2010 (Toronto, Ontario) — New recommendations are encouraging clinicians to identify mild dementia patients who are at risk for unsafe driving without restricting those who may still be able to commute safely.

Recent studies show that as many as 76% of patients with mild dementia are still able to pass an on-road driving test, report guideline authors presenting here at the American Academy of Neurology 62nd Annual Meeting.

“We want to preserve autonomy when appropriate,” lead author Donald Iverson, MD, from Humboldt Neurological Medical Group in Eureka, California, told reporters attending a press conference. “Loss of driving privileges can result in worsening depression, which can also shorten life expectancy,” he noted.

The new guidelines are less stringent than previous recommendations, published a decade ago, which tended to encourage patients to cease driving. The update is also published in Neurology and now available online.

April 13, 2010 (Toronto, Ontario) — New recommendations are encouraging clinicians to identify mild dementia patients who are at risk for unsafe driving without restricting those who may still be able to commute safely.

Recent studies show that as many as 76% of patients with mild dementia are still able to pass an on-road driving test, report guideline authors presenting here at the American Academy of Neurology 62nd Annual Meeting.

“We want to preserve autonomy when appropriate,” lead author Donald Iverson, MD, from Humboldt Neurological Medical Group in Eureka, California, told reporters attending a press conference. “Loss of driving privileges can result in worsening depression, which can also shorten life expectancy,” he noted.

The new guidelines are less stringent than previous recommendations, published a decade ago, which tended to encourage patients to cease driving. The update is also published in Neurology and now available online.

Dr. Iverson pointed out that although some patients can continue to drive safely for a time, nearly all will eventually have to give up their car keys. The new guidelines recommend the Clinical Dementia Rating scale to identify those at increased risk.

During an interview, Dr. Iverson said the Mini-Mental State Examination (MMSE) was not as clinically useful. Although patients with scores of 24 or less are typically considered at increased risk of unsafe driving, guideline authors found the evidence for this was weak.

“I would hate for neurologists to check the MMSE and see it is less than 25 and think the patient is good to go,” he said. Dr. Iverson pointed out the scores are more useful when driving history and additional testing are taken into account.

Also not useful, he warns, is a patient’s self-rating of driving ability. Patients may report safe driving practices that are not substantiated by later testing.

In contrast, he says that a caregiver’s assessment of a patient’s deteriorating driving skills was predictive of declining road safety.

Also useful in identifying unsafe driving were the following:

  • Reports of fewer miles driven;
  • Collisions;
  • Moving violations;
  • Avoiding certain driving situations, such as at night or in the rain; and
  • Aggressive or impulsive personality traits.

Dr. Iverson also pointed out that clinicians should remain informed of local laws because some states require that physicians report any medical conditions that may influence driving safety.

Asked by Medscape Neurology to comment, David Knopman, MD, from the Mayo Clinic in Rochester, Minnesota, said the recommendations are evidence based and fully justified. “The limitation is they are based only on facts and do not include clinical opinion.”

Evidence based and fully justified.

Dr. Knopman says he agrees with using the Clinical Dementia Rating scale over the MMSE. “It is a research instrument, but including direct interview and family input, it represents clinical judgment and offers a much more accurate view of a patient.”

The guideline authors suggest that patients with mild dementia who continue to drive should be reassessed at 6-month intervals. Additional medical conditions — especially visual defects or mobility impairments — may also be problematic.

“I feel the physician should take the lead on reversing driving privileges,” Dr. Knopman added. “Families have to live with the patient every day and losing this mark of independence can be devastating for people. If someone needs to be the bad guy, it should be the physician.”

Dr. Donald Iverson has disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 62nd Annual Meeting. Presented April 12, 2010.

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Allison Gandey

Allison Gandey is a journalist for Medscape. She is the former science affairs analyst for the Canadian Medical Association Journal. Allison, who has a master of journalism specializing in science from Carleton University, has edited a variety of medical association publications and has worked in radio and television. She can be contacted at [email protected]

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Medscape Medical News © 2010 Medscape, LLC

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