Dementia is a challenging condition that presents with many variations and can be staged or categorized using several different rating scales. I was personally trained on 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.
When I started practiced as an occupational therapy driver rehab specialist (over 15 years ago), we had very little research or evidence based practice to guide us on when we should or shouldn’t see the client with dementia for a behind a wheel driving evaluation. As a result, I saw many clients, who I already knew should not be driving for a driving evaluation. This 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 – even if all of our clinical testing was indicating otherwise. 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 later have come to find out that the driving evaluation for clients with dementia is not necessarily needed. The mindset was also, maybe this would help the client understand the need to retire from driving. However, truthfully, because of the stage of dementia, most clients lacked the insight to understand how their driving behaviors were unsafe.
With the unsafe driving behaviors and concerns, I think it is important to not that while I was providing a behind the wheel driving evaluation, it was often a modified version. For safety reasons, I would start the client in an empty parking lot, work on allowing the client to get comfortable with the car, focused on some basic driving maneuvers and then would ask the client to problem solve how to exit the parking lot. 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 driving evaluation and see no errors. But I knew, they were really not safe to continue.
As a result, many times, I felt conflicted. Was completing the behind the wheel evaluation, really the best strategy for every client with dementia?
Thankfully, in early 2000s, we saw a nice influx of research – mainly completed by Dr. David Carr, Dr. Peggy Barco OTD, Dr. Linda Hunt, PhD, OTR/L, FAOTA – all focused-on dementia and driving. This research opened up best practice ideas to include the approach that NOT every client with dementia required a behind the wheel evaluation, AND in fact our clinical testing could and should guide some of our decision.
Much of their work has lead to the 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. “
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.
I personally like to use the Evidence-Based Consensus Statements for Driving & Community Mobility, OT Spectrum of Driving Services, and Driving Pathways by Diagnosis sheets, to guide my clinical reasoning process and ensure I am identifying the potential to return to driving and addressing all pertinent performance skills. You can attend a FREE online training that reviews these foundation resources thru our education site https://adaptivemobility.mykajabi.com/store/ZSz22fQZ
In addition, let me throw this out there, if you ever want to talk thru a case, I am more than happy to chat privately via messenger or phone. Sometimes it is helpful to talk thru a case and partner with a driver rehabilitation specialist who has the additional training to further understand the application of assessments for driving.