Safe Driving for Patients With Dementia: Keys to Better Discussions at Every Stage

Primary care clinicians are often asked to assess older patients' fitness to drive but may feel underprepared for these assessments.¹ When patients have a dementia diagnosis, the guidelines are seemingly straightforward: Those with moderate or severe dementia should no longer drive.^2,3 But putting the guidelines into practice can still be challenging. For patients with mild cognitive impairment or early-stage dementia, the guidelines allow them to drive, but as many as one in three may still fail a behind-the-wheel driving test.⁴ Those patients may benefit most from in-depth assessment and counseling about their driving safety. In the later stages of dementia, patients are less likely to have insight into their driving ability and may not remember past conversations about driving cessation.

Navigating these complex conversations starts with gathering focused information about the patient's dementia stage, type, and impact on driving and then applying four key considerations when discussing driving safety.

Physicians can quickly and effectively determine a patient's stage of dementia at each encounter by assessing functional independence and how this has changed over time. These determinations rely on the patient's ability to perform the following:

• Activities of daily living (ADLs), which include managing basic physical needs such as personal hygiene, toileting, eating, and dressing,
• Instrumental activities of daily living (IADLs), which require more advanced skills and support overall well-being such as managing finances, managing medications, preparing meals, and cleaning the home.

When asking about functional dependence, it's important to distinguish between changes due to cognitive impairment as opposed to other factors such as mood, personality, or a physical limitation. In general, if a patient has functional dependence in one or more ADLs due to cognitive impairment, they will also show functional dependence in their IADLs. A patient who is functionally dependent on others for at least one IADL has at least mild dementia, which warrants a conversation about driving safety. A patient who is functionally dependent on others for at least one ADL (often starting with difficulty choosing appropriate clothes or going through their personal hygiene steps when they bathe/shower) has at least moderate dementia, and guidelines state you should recommend they no longer drive.