Question: Can my client with dementia drive?

When should I consider a driving evaluation for my client with dementia and when should I be talking about driving retirement?

Dementia is a tough disease. It changes as it progresses. Understanding a client’s stage of dementia can be helpful for understanding how to intervene. I like to use the Global Deterioration Scale (GDS) that rates clients with dementia from 0 – no dementia to 7 – severe. No matter the rating scale you use, most look at dementia on a scale of none to mild to moderate to severe.

Knowing your client’s stage of dementia is important for knowing what to do when it comes to driving. We know client’s with severe dementia should not driving. But what about those client’s with mild or moderate dementia?

What we use to do….

When I started in driving rehab (over 15 years ago), we had very little research to guide us on when we should or shouldn’t see a client with dementia for a driving evaluation. As a result, I saw a range of clients dementia, some of whom I knew should not be driving.

To see and evaluate everyone was the industry standard and we believed to be best practice. The mindset was, the best way to determine fitness to drive, was to see the client drive. While this is true for the majority of clients – I still have non-dementia clients who will surprise me and do well in the car – we have come to find out that the driving evaluation for clients with dementia is not always needed. The mindset was also, maybe this would help the client understand the need to retire from driving. However, in my experience, most clients lacked the insight to understand how their driving behaviors were unsafe. As a result the driving evaluation caused more angst.

What I use to do…

I think it is important to note that while I was providing a driving evaluations for persons with dementia, it was often a modified version. For safety reasons, I would start in an empty parking lot,  focus on basic driving maneuvers, and then have the client find the parking lot exit. For many, because of dementia related visual perceptual and executive functioning changes, they were unable to do this successfully.

What is interesting is that sometimes, because driving can be an exceptionally overlearned behavior, I would take someone with dementia for a drive and see no errors. But I knew, they were really not safe to continue. As a result, many times, I felt conflicted. I questioned myself, “Was completing the driving evaluation, really the best strategy for every client with dementia?”

What we do now…

Thankfully, the early 2000’s brought a nice influx of research focused on driving & dementia. While many contributed, much of the work was completed by Dr. David Carr, Dr. Peggy Barco OTD, and Dr. Linda Hunt, PhD, OTR/L, FAOTA. This research opened up best practice ideas to include the approach that NOT every client with dementia requires an in car driving evaluation, AND in fact our clinical testing can accurately guide our decision.

Much of their work has lead to the AOTA Evidenced Based Consensus Statements. These statements include a section specifically on dementia. I am posting this resource and strongly encourage you use this to help guide your own practice.

These statements clearly reinforce the following,

• “An individual with moderate to severe dementia should not drive.”
• “Those with very mild or mild dementia may be appropriately referred for further testing when risk factors for unsafe driving are present.”

My own practice…

I follow this in my own practice. I like to use a combination of assessments & tools to first stage a client’s dementia and then make a decision on whether or not the behind the wheel evaluation will be completed. I encourage you continue to explore options, however I personally have found a lot of good success with the Brief Cognitive Assessment Tool (BCAT). The BCAT is a challenging executive functioning test. It is scored on a scale of 0-50. There is a small annual fee or individual use fee for this test, however this BCAT system comes with training AND a computerized, evidenced based report that provides an indication of MCI versus dementia. AND fingers crossed, I am extremely hopeful that the BCAT will be looking at the correlation between the BCAT and on the road driving performance. This research could really give us another, very good indicator, to support decision at the primary occupational therapists’ level.

Resource Follow Up:

• The Evidence-Based Consensus Statements for Driving and Community Mobility is a FREE resource available through the National Highway Traffic Safety Administration Gaps & Pathways Project, and can be found on the AOTA’s website: AOTA>Practice>Productive Aging>Driving & Community Mobility>Gaps and Pathways.
• OT Spectrum of Driving Services is another helpful resource to guide OT practice
• OT DRIVE is a helpful model for guidance decision making
• Driving Pathways by Diagnosis sheets
• Explore these resources and other education thru Adaptive Mobility’s online courses.
• Learn more about the Brief Cognitive Assessment Tool.