Safety Principles
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Basics
Guaranteeing safety for patients with dementia is often a struggle
for caregivers – trying to balance keeping the individual
safe but allowing them to continue to be as independent as possible.
There are no right answers and not all strategies work in all situations.
It is most important to try to evaluate if a particular behavior
or situation is going to be dangerous for the person with dementia.
Often behaviors can be irritating or annoying; for example, pacing
in the house or repeating questions, but these can hardly be considered
dangerous. On the other hand, operating firearms or even a household
stove can be dangerous if the individual no longer has the ability
to make good decisions. Seek professional help to try to define
what situations might be considered dangerous or what strengths
the individual still has that can be maximized to encourage continued independence.
Driving
Driving is a significant indicator
of independence and often a source of self-esteem for patients.
The decision to stop driving due to dementia is often a difficult
one for patients and families as well as a frequent source of disagreement.
In the early stages, people with dementia may have no impairment
in their driving skills.
Regular Driving Tests Recommended
However, as the disease progresses people may get lost, make poor
decisions on the road or actually forget those skills involved
in operating a vehicle. Because of this, it is recommended that
these patients have regular driving tests to monitor the effects
of the disease on driving ability. In California, it is required
by law that physicians report patients diagnosed with dementia
to the Department of Motor Vehicles so this monitoring can occur.
Driving Impairment
Individuals with Alzheimer’s
disease or related disorders become progressively impaired in their
ability to drive. Such symptoms like memory loss, disorientation
and changes in visual and spatial perception can result in patients
getting lost, forgetting the “rules of the road”, or having slowed reaction times. While patients
with early dementia may not seem to have these problems, eventually
motor coordination, powers of concentration, and exercise of appropriate
judgment may become affected by the disease. Furthermore, driving
performance is likely to worsen during times of crisis at all levels
of impairment.
Clinicians Required to Report
A state mandate requires that clinicians submit a confidential
report to the county health department when individuals are diagnosed
as having Alzheimer’s disease and related disorders. The
health department forwards this information to the Department of
Motor Vehicles (DMV). DMV then determines whether patients have
the capacity to continue driving safely. Physicians who do not
follow this procedure may be subjected to disciplinary action,
and/or be liable if patients are involved in auto accidents.
The California Department of Motor Vehicles' Policy
Although policy implementation varies statewide, here is the official procedure
once a report is received by the state.
Friend, relative or clinician reports the person
A computer search is conducted to locate the patient’s name,
verify that he/she has a license, and examine the driving record.
A notice of re-examination will be mailed to the person that was
reported. The notice tells the person that in the interest of his/her
personal safety and the safety of others on the road, the DMV has
determined it necessary to review the person’s driving qualification.
If a clear diagnosis of moderate or advanced Alzheimer’s
disease or dementia is made, the person’s driving privilege
is suspended or revoked.
Review of Medical Information
The reported person will be sent a Driver Medical Evaluation form, along with
the Notice of Re-Examination. The person is requested to have the
physician most familiar with his/her medical history complete
the form. The person is informed that the Driver
Medical Evaluation must be returned to DMV within 20 days or the driving privilege
will automatically be suspended. The person is also informed that
failure to appear at the scheduled reexamination will result in
suspension of the driving privilege.
The Reexamination Interview
The reported person will be given a written knowledge test on the rules of the road
prior to the re-examination interview. The re-examination interview
will be held if the person passes the knowledge test. If the person
does not pass the written test, the person’s
driving privilege is suspended or revoked.
The re-examination interview gives the person the opportunity
to discuss his/her medical condition with a DMV representative
for the purpose of establishing the person’s ability to safely
operate a motor vehicle. The DMV representative will ask questions
to determine memory deterioration, awareness, orientation, attention,
and judgment. The representative will observe the person’s
coordination and adaptation to the environment.
Additional Tests
The DMV representative interviewing
the reported individual will determine if the person should be
given a driving test. This decision is based on the information
provided by the reported person, medical documentation, and the
results of the written examination. A driving test is not given
if the evidence indicates that the reported individual may be unable
to safely operate a motor vehicle. If this is the case, the driving
privilege is suspended or revoked.
The Driving Test
The driving test given to individuals
reported with dementia takes 30-45 minutes. The examiner will be
looking for the person’s
ability to concentrate, recall multiple instructions, execute them
safely, and possibly find a location that should be familiar to
the person (church, doctor, pharmacy, home, store, etc) and the
examiner will be watching for signs of mental confusion, perceptual
misjudgment, and/or impulsiveness.
The DMV Decision
At the conclusion of the driving test, the examiner will document the person’s areas of
strengths and weaknesses. The interviewer will review the results
of the driving test. These results, in combination with the
medical documentation, the reported person testimony, and any
testimony of witnesses accompanying the reported person, lead
to the licensing decision. If the evidence shows the reported
person is able to safely operate a motor vehicle,
he/she will be allowed to continue to drive. The driver will
get a written notice about 2-3 weeks after the testing.
It is not uncommon for patients and their family to have differing
opinions on the patient’s driving ability. Some patients
insist on continuing to drive even when their licenses are revoked.
This would have obvious legal implications for the patient and
family in the unfortunate event of an accident or legal violation.
Because of the potential danger to patients and to others on the
road, it may be necessary for family members to prevent patients
from having access to the vehicle. For example, the car may need
to be “disabled”, sold, or moved to an unknown location,
or the keys taken away. The letter from the attending physician
recommending against continued driving may also be shown to the
patient.
Some patients are aware of having difficulty with driving and
are relieved when they are told to stop. However, having to give
up driving is likely to be upsetting. Emotional support may help
patients adjust to this significant loss of independence and ability.
It will be important to make other transportation arrangements
so that patients’ mobility and activity levels are not
unduly restricted.
The DMV can provide California identification card to those patients
who will no longer have a driver’s license.
Patient and families who have question or want further information
can call their local DMV for the number of their Regional Driver
Safety Office or visit the DMV
website.
Laws around driving and patients with Alzheimer’s Disease
or other dementia are subject to change. There are resources available
to help guide caregivers in determining when discontinuation
of driving needs to occur.
For more detailed information:
Emergency Plan
Caregivers play a pivotal role in the coordination of the care of their loved
ones with dementia. It is for just this reason that it is so important
that a “back up” caregiver be identified
in the event something happens to the primary caregiver. In this
situation an individual needs to have access to information about
the patient to plan for their care and allow their services to
continue as smoothly as possible. For this reason, consider having
someone else with access to your home and important papers. Try
to have someone else knowledgeable about the patient’s care
and available to health care providers to consult about medical
needs. Finally, discuss a “chain of command” should
the primary caregiver need to be relieved of their responsibility
either temporarily or permanently. It is always much more difficult
to make these arrangements in the event of a crisis or emergency.
Some tools to help plan are available below.
For more detailed information:
References
Reuben DB, St George P. Driving and dementia — California’s approach to a medical and policy dilemma. West J Med 1996;164:111-121.
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