As physicians, our primary goal is to positively impact our patients’ lives. Whether or not we succeed depends on many factors, but when we do make a significant improvement, it’s always a success worth celebrating. Today, as a geriatrician, I feel that impact more deeply than usual. It wasn’t just about treating a patient; it was about making a decision that could save lives—not only my patient’s but also the lives of others.
The Challenge of Assessing Driving in Older Adults
One of the most challenging yet essential parts of being a geriatrician is assessing the driving abilities of older adults, especially those with cognitive decline. Today, I was reminded just how vital this responsibility is.
A few years ago, I recommended to a patient’s power of attorney (POA) that her family member should stop driving due to progressing memory problems. At the time, the POA was unsure whether it was time to take away her family member’s keys. But after my recommendation, she found the strength to make that difficult decision. Later, the family told me that this was one of the most valuable and necessary recommendations they had received. The POA even shared an incident where the patient almost hit someone while they were in the process of taking the car away. Situations like these highlight the grave risks at play—not just for the patient but for others on the road as well.
The Risk of Driving with Cognitive Decline
Patients with cognitive impairment eventually lose the cognitive and physical abilities needed for safe driving. Identifying the right time to stop driving is critical. But it’s a tough conversation to have. It’s often met with resistance, emotional turmoil, and the challenge of balancing a patient’s independence with the need for safety.
Cognitive decline isn’t the only reason older adults may need to stop driving. Other factors can include:
- Vision impairment: Difficulty seeing or recognizing road signs and hazards can make driving unsafe.
- Physical limitations: Conditions like arthritis can slow reaction times or limit mobility.
- Medication side effects: Some medications, especially those affecting the brain or causing drowsiness, can impair driving abilities.
Screening for Driving Impairment Secondary to Cognitive Impairment
When I screen for signs of driving impairment related to cognitive issues, I look for certain red flags in history, including:
- Small fender benders or dents on the car: These could signal poor judgment or slowed reaction times.
- Parking difficulties: Struggling to park or navigate tight spaces can be a warning sign.
- Getting lost in familiar places is often a red flag for cognitive decline.
- Reliance on passengers: Constantly asking for help with navigation or directions suggests impaired driving skills.
It’s essential to remember that these issues only indicate a problem if they suggest a pattern, mainly when they occur multiple times and are associated with memory concerns. Isolated incidents may or may not point to driving impairment. However, when I notice recurring signs that suggest driving issues, I take a deeper look into the patient’s cognitive function ( many patients have undiagnosed memory problems), vision, physical limitations, and medication side effects.
A cognitive screening test, such as the analog clock drawing test, can sometimes provide the first clue that there are concerns about driving abilities. Any difficulties with visuospatial orientation can point to driving problems.
Trail-making tests are another valuable tool to assess driving skills. Combined with the patient’s history, these tests often provide enough evidence to confirm suspected impairments. However, in some cases, we may need more detailed assessments from occupational therapy or driving rehabilitation specialists. A one-on-one, behind-the-wheel evaluation may be necessary to fully understand how well the patient can handle driving demands.
The Emotional Toll: Family and Autonomy
Once we’ve determined that a patient’s driving abilities are impaired, the next challenge is ensuring that they will not drive.
Some older adults limit their driving naturally, choosing to avoid nighttime driving or busy roads. Others stop driving when they recognize their own limitations. But for some, especially if cognitive decline is involved and if they don’t have insight into their limitations, the emotional impact of stopping driving is enormous. It’s common to see frustration, confusion, or resistance.
In these cases, family members and physicians must work together to ensure the patient’s safety and dignity. Families must work closely with an experienced geriatrician to develop a tailored care plan. There is no one-size-fits-all solution, and each case requires a thoughtful, individualized approach.
One of the more challenging aspects of this process for families is dealing with the logistics of taking away the car keys, removing the car, and finding alternative transportation. As physicians, we must notify the Department of Motor Vehicles (DMV) to ensure the patient does not continue driving.
A Holistic Approach: Balancing Safety and Dignity
Ultimately, driving impairment later in life might be caused by developing physical or cognitive limitations, and managing it in older adults requires a holistic approach. It’s not just about diagnosing medical conditions; it’s about understanding the decision’s emotional, psychological, and social impacts. As a geriatrician, my role goes beyond diagnosis and treatment. It’s about helping patients, their families, and caregivers navigate these tough decisions with empathy and understanding.
It’s never easy to tell someone they can no longer drive. But when we make that decision, we’re not just protecting the patient—we’re protecting everyone they encounter on the road.
Making a difference in my patients’ lives isn’t just about treating symptoms; it’s about ensuring their safety—and the safety of others. Sometimes, that means having difficult conversations about risks they may not even see themselves. Today, I was reminded just how profound the impact of that responsibility can be.
Trail making test: https://www.safemobilityfl.com/pdfs/CliniciansGuide/Trail Making Test 4th Edition.pdf
