Growing Road Hazard: Drivers With Dementia

The woman, a 65-year-old former psychologist diagnosed as having Alzheimer’s disease, was not always able to understand traffic signs. But her physician thought that she could probably still drive, so long as she stayed in her own familiar neighborhood and used her car for such simple activities as grocery shopping and going to church.

One day, she risked a trip downtown. Lost, confused and disoriented, she misinterpreted a red light and drove straight into a busy intersection.

Fortunately, she escaped unharmed and did not hurt anybody else. But new studies have begun to show that people with dementia caused by such illnesses as Alzheimer’s, advanced Parkinson’s disease, multiple strokes and even AIDS are becoming an increasing--and only recently recognized--hazard on the roads.

Major Safety Issue

“It’s a public safety issue of major proportions,” said Geri Hall, a gerontology clinical nursing specialist at the University of Iowa Hospitals and Clinics who is conducting a study on driving and dementia. “It’s as big an issue as drunk drivers, except it just hasn’t had the same publicity.”

About 12% of Americans--more than 16 million--are now 65 years old or older, a figure that is expected to rise to at least 17% within the next 40 years, experts say. Statistics long have shown that as individuals age, they lose many of the cognitive and physical abilities of their earlier years. Eyesight, hearing and reflexes often begin to deteriorate.

And, although they typically drive far fewer miles than they did when they were younger, the accident rate of elderly drivers per miles driven is second only to that of the very youngest and most inexperienced drivers between 16 and 18.

There is considerable debate over what to do about it. Although many experts believe that people with dementia should not be allowed to drive, they recognize that the loss of driving privileges can be devastating.

“The biggest day in your life is when you get a car and the worst is when they take it away,” said Hall, who chairs Iowa’s task force on Alzheimer’s. “Nobody wants to make grandpa stop driving. But these people have the potential for causing tragedies.”

Judgment Impaired

It is the estimated 2.5 million Americans with progressive dementing illnesses who pose the greatest danger on the roads because their judgment is often seriously impaired, experts say.

“It’s like putting a toddler behind the wheel,” Hall said. “People who have normal changes of aging, theoretically, have insight into their condition. If they’re going blind because of cataracts, hopefully they’ll stop driving. But in many cases, Alzheimer’s patients are not aware of their deficits. Or if they are aware, they aren’t able to act upon it in a reasonable way.”

“These people have difficulty interpreting traffic signs,” said Linda Hunt, an occupational therapist at Washington University School of Medicine in St. Louis who is also studying the problem. “I had one man who saw a green arrow for a left-hand turn--all he saw was green and he went straight. A policeman saw him and stopped him. When he realized there was something wrong with the man, he escorted him home.”

Hall said that Alzheimer’s, as it progresses, produces “changes in how the brain perceives what you see and hear. If you have an Alzheimer’s patient copy a stop sign, you often get something totally distorted. It’s not that their eyes aren’t working--it’s that the brain is not comprehending things in the same way it used to.

“Alzheimer’s patients can be driving in a place that is totally familiar and then something happens in a split second--a squirrel runs across the road--and they’re lost,” she added. “They don’t know where they are and they don’t know how to get home.”

Slow Drivers

Dr. Larry E. Tune, director of the dementia research clinic at Johns Hopkins School of Medicine in Baltimore, said that the number of accident-related deaths linked to demented drivers is probably less than that caused by drunken driving because “the elderly typically drive so slowly.” But the problem is still serious, he said, and has not been adequately addressed.

“The frequency rate (of accidents) is frightening, no question about that, and it’s unappreciated, no question about that,” he said. “There are probably fewer fatalities than with drunk drivers, but, proportionately, probably as many general accidents.”

Dangerous Patterns

Recent research confirms dangerous driving patterns among this patient population.

Tune recently studied 53 Alzheimer’s patients who drove and found that 30% of them had been involved in at least one accident since their illness began, and that 11%--although not directly involved in accidents--were reported by their care-givers to have caused them. He said that 44% of them routinely got lost while driving and that 75% consistently drove below the speed limits.

Another study, released last December and conducted by Dr. Robert P. Friedland, chief of the section on brain aging and dementia at the federal government’s National Institute on Aging, compared 30 Alzheimer’s patients with 20 healthy people of the same age.

Driving Deteriorates

Friedland and his colleagues found that 47% of the Alzheimer’s patients had been involved in at least one car crash in the previous five years, compared to only 10% of the healthy persons. Further, 77% of the Alzheimer’s patients had suffered a marked deterioration in their driving performance.

Also, the study showed, 63% of the patients had stopped driving--although only 42% of them had stopped driving before they had become involved in an accident.

“These data suggest that the occurrence of driving crashes in patients with dementia of the Alzheimer type is an important public health problem,” he wrote.

California requires that a diagnosis of Alzheimer’s--as well as other disorders characterized by seizures, lapses of consciousness or marked confusion--be reported to motor vehicle authorities. A hearing is conducted to consider whether an individual’s license should be revoked. California transportation and Highway Patrol officials said that the law’s impact on traffic accidents and fatalities has never been studied and thus cannot be measured.

But some medical specialists fear that the threat of losing a license may keep patients from seeking treatment, particularly if they are suffering from other forms of dementia that are treatable or reversible. Also, because Alzheimer’s is often difficult to diagnose, an inaccurate call “could wrongly deprive a patient of mobility,” Tune said.

Hunt wonders whether “maybe in the early stages (of disease) they should be allowed to drive on a limited basis, rather than taking their independence away.” But she added: “My concern is how this is ever going to be regulated--I don’t know.”

Many experts have urged families to get involved in ways to keep their impaired relatives from driving. But this approach does not always work.

“Families often can’t get control,” Hall said. “We’ve had some families hide the keys or the distributor cap, even sell the car. One man nearly broke his wife’s arm trying to get his keys back. She had quite a bit of soft tissue damage.”

Nevertheless, Tune--saying that “there is a gentler way to approach this”--believes that, if families and physicians become involved as soon as the illness is diagnosed, they can prepare for the time when it will be too risky for the impaired individual to drive. Laws to regulate their driving may not be necessary, he said.

First, he said, physicians need to be aware of the potential of a driving problem “and ask about it.” Then, he said, families need to devise ways of “picking up the slack” to make the transition with a minimum of inconvenience.

Time for Wife to Learn

“In that generation, it’s very common for the man to be the only one who ever drove,” he said. “Maybe the wife needs to go out and learn how to drive. If I tell her now, when her husband is only mildly impaired, she can go out and learn. Also, if you’re given enough time, you can set up rides, etc., and pare down the need to drive.”

He added: “We’ve got this population that doesn’t want to give up its rights and I don’t blame them. Most of the time, they are waiting for something to happen before they give up driving--that was the message in Dr. Friedland’s study. Most of the time, it’s a trivial accident, but not always. We’ve had people die.”

Because most of these diseases are progressive, families can be aware that a problem is coming and do something about it. “You can take care of it now in a smooth way,” Tune said. “Or wait until something happens and pay later.”