Driving and Alzheimer’s disease

By Carole Larkin and Max Wallack of the Alzheimer’s Reading Room

Carole Larkin is a geriatric care manager who specializes in dementia in the Dallas — Ft.Worth area. One of the routine issues she addresses with her clients and their families is:

When does a person with dementia need to stop driving and how to tell them to stop driving in a respectful and considerate manner.

The following is part one of a two part series where Carole discusses her many experiences in dealing with this difficult problem – Driving and Alzheimer’s disease.

Max Wallack conducted the interview.

Today, we are going to talk about driving and dementia.

Hi Carole!

Hi Max.

Max: What specific driving abilities decline in older drivers, even ones without dementia?

Carole: Well for one, older drivers have declines in their physical ability, meaning that they have declines in their muscle strength, their coordination, their reach, and in their range of motion for their arms, legs, upper body, and neck. Some may lose consciousness periodically when having TIA’s (also known as mini strokes).

Secondly, older adults lose what is called their psychomotor ability. They lose the ability to respond quickly to something happening immediately in front of them like a dog running out in the street followed by a child chasing the dog. They may not be able to respond differently to different types of things happening to them — such as their car skidding or hydroplaning on a wet patch of road, after driving on dry roads just a second before that. In other words, their hand-eye and their foot-eye coordination can decline or slow down.

Additionally their visual ability declines just because they are older adults. They find it more difficult to differentiate things clearly under low light (night) and low-contrast (dusk) situations. It’s also harder for them to see objects in motion (like a child darting out into the street) and when there is glare and right after glare is gone. Also many people’s peripheral vision becomes blurry or dark and they can develop glaucoma, cataracts and macular degeneration.

Max: How does dementia add to declining driving abilities?

Carole: Dementia causes perceptual ability to decline. Perceptual ability is the ability of the brain to correctly interpret and act on what a person sees and hears, for example detecting the actual speed and motion of other cars on the road. A cognitively impaired person could stop at a red light, then pull out into traffic going on the green light without realizing that those cars were entering the intersection. A person with dementia may not recognize the sound of a train whistle while they are crossing a railroad track. Sometimes the perceptual ability just slows down, meaning that the person does recognize what they see or hear but the recognition happens too slowly to react in enough time to avoid an accident. Some cognitively impaired people have hallucinations and react to things that are just not there, thus causing danger to themselves and other drivers.

In people with dementia, the ability to pay attention to things going on while driving lessens in several important ways. The person’s attention span is shortened. They may forget to properly react just seconds after seeing something that needs to be acted upon. They may not be able to share their attention between several different things happening at the same time and get confused as to which to respond to, or may not respond to anything that is going on. Also they may not be able to easily shift their attention from one set of circumstances to another, or just shift attention fast enough.

Certainly in people with Alzheimer’s and some others dementias their memory declines. At any given moment they may not be able to retrieve the memory of what to do when a situation arises. For example, remembering to allow the vehicle on your right to proceed first when both cars are stopped at an intersection simultaneously. Or remembering what a stop sign means.

Other cognitive abilities decrease as well. Declines in executive functions such as logic, decision making, self awareness, impulse control, and initiation of action can and do lead to dangerous situations. Even if the person performs adequately most of the time, you never know when they will have that moment of failure of executive function. The fluctuation in abilities can and does change from moment to moment.

Max: Are there any ways to counteract these losses, to keep the person with dementia driving safely early in the disease?

Carole: Yes. Some things can be tried such as:

Going to an Occupational Therapist who specializes in assessing driving skills in the elderly is a start. After the therapist determines the deficits, they suggest ways to compensate for some of the deficits. Some methods involve vehicle control assists, and some involve training or retraining driving skills.

For cognitive deficits, sometimes Psychologists can train a person to help with mental processing of stimuli, which might lead to improved performance in driving skills for a short period of time.

Restricting the amount, times and locations of driving is another method. Some elderly drivers impose these restrictions on themselves, but for those who do not, the family needs to impose them — and monitor compliance on a routine basis (at least once every week or two).

Generally, experts agree that it is beneficial for people with dementia to be able to drive as long as they are not a danger to themselves or others. When they hang up the car keys they are in danger of losing their access to friends and family, to medical providers, to shopping and other services crucial to keeping them independent. Isolation leads to depression and other physical and mental issues.

Max: What are some of the warning signs that driving behaviors can cause safety problems?

Carole: The American Academy of Neurology came out with recommendations and warning signs of unsafe driving on April 12th 2010 but I find the list issued by the Hartford Insurance Company in their brochure “We need to talk… Family conversations with older drivers” is more complete. It is free, and can be ordered at www.thehartford.com/talkwitholderdrivers.

They list the signs from the minor signs to very serious issues. Family members should observe (ride with) the person with dementia for a minimum once a week, and over a period of time. The person observing should keep notes so that changes in driving ability can be seen.

The observer should look for a pattern of warning signs and for an increase in the frequency of occurrence of those signs. The signs are as follows:

• A decrease in confidence while driving.
• Difficulty turning to see when backing up.
• Riding the brake.
• Easily distracted while driving.
• Other drivers often honking their horns.
• Incorrect signaling.
• Parking inappropriately.
• Hitting curbs regularly.
• Scraping or denting the car, mailbox or garage.
• Increased agitation or irritation when driving.
• Failure to notice traffic signs.
• Trouble navigating turns.
• Driving at inappropriate speeds.
• Not anticipating potential dangerous situations.
• Using a “copilot”.
• Bad judgment making left hand turns.
• Delayed response to unexpected situations.
• Moving into the wrong lane.
• Difficulty maintaining lane position.
• Confusion at exits.
• Ticketed moving violations or warnings.
• Getting lost in familiar places.
• Car accident.
• Failure to stop at stop sign or red light.
• Confusing the gas and brake pedals.
• Stopping in traffic for no apparent reason.

Carole Larkin MAG, CMC, DCP, EICS is a geriatric care manager who specializes in helping families with Alzheimer’s and related dementia issues. She also trains caregivers in home care companies, assisted living, memory care, and nursing home communities in dementia specific techniques for best care of dementia sufferers. ThirdAge Services LLC, is located in Dallas, TX.

Max Wallack is a student at Boston University. His great grandmother, Gertrude, suffered from Alzheimer’s disease. Max is the founder of PUZZLES TO REMEMBER. Puzzles To Remember has already distributed 40,406 puzzles to over 2778 Alzheimer’s caregiving facilities in all 50 states and around the world. With our help, many similar programs are being launched in Portugal, Australia, and elsewhere. All donations are tax deductible.