At some point, all people with dementia must stop driving due to the impact of cognitive impairment on skills critical for safe driving – but when is the right time, and how should this sensitive matter be best approached?

Flinders University researchers have investigated the reactions of people with dementia and mild cognitive impairment (MCI), in the hope of finding a process that best supports the person with dementia.

“Our aim was to obtain insights into the needs and experiences of older people with dementia or MCI regarding their health professionals’ management of driving cessation,” says Flinders University PhD student Claire Spargo, who led the research with colleagues from Flinders’ College of Nursing and Health Sciences.

In Australia, people with dementia cannot hold an unconditional licence, but may qualify for a conditional licence which is subject to at least an annual review. Health professionals assess a person’s fitness to drive, advise the person about the potential impact of their medical condition on driving capabilities and, under mandatory reporting laws, must notify the driver licensing authority if they believe the driver may present a danger to the public.

However, what happens if cognitive impairment deteriorates significantly? Family members must often assume decision-making roles, despite many saying they feel unprepared, lack expertise and fear blame, particularly when the individual lacks insight into cognitive impairment, and strongly identifies as a driver.

A family member’s willingness to raise concerns may also be constrained by their limited capacity to provide alternative transport, or reliance on the individual for their own mobility.

Family members say they often receive conflicting advice from health professionals about a person’s suitability to continue driving, or that driving cessation is only considered after someone in the family raises concerns.

To help find a solution that will address this delicate situation, the researchers interviewed 12 people aged 65 years or older with dementia or mild cognitive impairment (MCI). The findings highlight a need for structured and comprehensive communication by health professionals over several phases leading up to driving cessation, followed by improved support for people with dementia and their families. The four phases are:

• Prepare the person before driving is unsafe: There is great value from health professionals initiating early and ongoing discussions with people and their families about driving cessation. A collaborative decision-making approach should involve an Advance Driving Directive to document the person’s preferences for future decision-making about their fitness to drive, including their preferred decision-makers – a GP or medical specialist, with input from family or a friend. A memory or cognitive clinic can provide formal assessment if there is no existing diagnosis, and if the cause of the cognitive impairment is likely progressive, the health professional should advise the person that driving cessation will be necessary in future. Support early planning to ease the transition to not driving, such as developing new routines and using alternative transport.

• Navigate fitness-to-drive decisions: Provide people with information and choices about their options, such as pursuing practical assessment or relinquishing their licence. Involve the family in discussions, if the person wishes. Apply shared decision-making that supports meaningful patient involvement in driving safety discussions, while retaining responsibility as health professionals for the decision-making of fitness to drive recommendations
• Deliver a recommendation to discontinue driving: Use simple, straightforward language, while showing compassion. Emphasise safety as the central concern, highlighting that the recommendation was made to protect the person as well as others in the community. Acknowledge the person’s personal connection to driving, and recognise both the challenges and benefits associated with not driving.
• Adjust to life without driving: People may feel a loss of independence and loneliness after they stop driving, so practical and emotional support should begin with connecting the person to such services as CarFreeMe for counselling and practical assistance about transport planning and social support. Support and guidance should also be offered to family members who have to manage the practical, social and emotional outcomes of changed driving status.

“We have noted that offers of support from a clinician who recommended discontinuation of driving may not always be welcomed, and that engaging another health professional or service may be preferred to support this phase,” says Ms Spargo.

The researchers hope the findings will guide the design of tools and resources to support health professionals manage driving safety concerns more effectively with people who dementia or MCI, and their families.

The research – “Insights from Older People With Dementia and Mild Cognitive Impairment on the Management of Driving Cessation by Health Professionals: A Qualitative Study”, by Claire Spargo, Kate Laver, Zoe Adey-Wakeling, Angela Berndt and Stacey George – has been published by Australasian Journal on Ageing.
DOI: 10.1111/ajag.70215

• International Day of Older Persons is celebrated globally on 1 October each year. Established by the United Nations in 1990, the day recognises the contributions older people make to society and raises awareness of the need to challenge ageism, prejudice and discrimination.