The Question of Driving

Washington DC

When I was a family doctor in a small town, one of the most difficult tasks was telling an elderly or seriously ill person that his driving was no longer safe and he would have to give up his license.  In our culture, losing one’s driving privileges is a significant blow to the ego, especially for men.

As I was driving this past Saturday, I had a disturbing experience.  Every three or four months I drive 3½ hours to southern Virginia and 3½ hours back to Washington to visit my friend Jens Soering, who has served 26 years of a life sentence for a crime that I believe he didn’t commit.  It’s a long trip and I have to get up much earlier than usual and, since I don’t sleep well anyway, I don’t get much sleep. 

What I noticed was difficulty following the thread of conversation on National Public Radio while simultaneously paying attention to my driving.  I couldn’t follow any concept that required concentration.  It seemed that I could only pay attention to one thing at a time, either the driving or the radio.  I was concerned that if I tried to pay enough attention to the radio to understand, I wouldn’t be able to drive as well.

I didn’t have the same trouble driving back to DC that afternoon, so I assumed my trouble had just been my tiredness from too little sleep, but it got me to thinking about driving in the face of my diagnosis.  Ordinarily, I feel no deterioration in my driving ability compared with my skills before my Alzheimer’s diagnosis (but, as we’ll see below, it turns out that my own rating of safety doesn’t mean much).  My neurologist—using the nationally recognized neurology standards—isn’t concerned.  But if I did have a serious accident that was judged my fault, would I be risking my insurance company refusing to cover me?  Or even that I would face criminal charges for negligence?  I could just imagine myself in a court room as the prosecutor intoned: “Dr Hilfiker you knew you were cognitively impaired and yet you put yourself behind the wheel of a car.  What can you say to this family of the little girl who died as a result?”  OK, a little melodramatic but you get the point.

Should I be driving?  It’s obviously an important question, but it doesn’t feel like a particularly powerful emotional issue for me (we’ll see about that when it’s time to stop, of course).  In practice it will certainly be difficult for Marja and me.  Even though we don’t have a car and can get around Washington quite well with a combination of good public transportation and our bikes, it will still mean that Marja will have to drive those short trips around the city (for which we borrow friends’ cars) and the occasional long trips in rental cars to places we can’t get to by public transportation.  I’ve always done most of the driving; Marja doesn’t enjoy it and becomes anxious and tense while driving, so it will be an adjustment for her.  But we’ll deal with it.

Should I be driving? 

I emailed my neurologist to get advice and he wrote back essentially advising me not to worry about it, yet. 

He wrote that the American Academy of Neurology has published guidelines for auto safety for people with Alzheimer’s (http://www.neurology.org/content/74/16/1316.full.html).  (The following a bit technical but stay with me.) 

There are six useful factors to consider in determining how safe a person is driving.  The most important is the Clinical Dementia Rating scale, which requires a professional neurological exam (but the criteria can be found at http://www.neurology.org/content/74/16/1316/T1.expansion.html)

The other five can supplement the dementia rating:

1. a caregiver's rating of a patient's driving ability as marginal or unsafe
2. a history of crashes or traffic citations in the last five years
3. the patient deliberately reducing driving mileage or avoiding driving in certain situations
4. a Mini-Mental State Examination score of 24 or less and
5. aggressive or impulsive personality characteristics. 

 As I mentioned above, research indicates that your own rating of your safe driving ability isn’t correlated with the results of an on-road-driving-test. 

 (Note: This same webpage says that insurance companies and licensing agents have a demerit point system based only on previous crashes or citations, but I couldn’t find a description of the exact criteria.)

I was a little surprised that the implication on the Academy’s website was that any person who can pass an on-road-driving-test is judged safe, which seems a little loose to me.  I would think that the biggest issue in safe driving would be distractibility, and I doubt a routine driving test would measure that very well.

My neurologist believes my dementia score to be essentially zero, so, according to the criteria, I can still consider myself safe to drive, which fits with my subjective conclusion.  But I know it’s only a matter of time.  Alzheimer’s is a disease of constant losses.  Losing one’s driver’s license is, in our culture, a highly symbolic event.  I only hope I have the grace to accept that loss when it comes.