Psychiatric Bulletin (2005) 29: 372-373. doi: 10.1192/pb.29.10.372
© 2005 The Royal College of Psychiatrists
Psychiatric Bulletin (2005) 29: 372-373
© 2005 The Royal College of Psychiatrists
Audit of clinicians’ approach to patients’ driving status in a dementia day hospital setting
Philip Baker, Senior House Officer in Psychiatry
Chase Farm Hospital, The Ridgeway, Enfield EN2 8JL, e-mail:
philip.baker{at}doctors.org.uk
Tim Rogers, Senior House Officer in Psychiatry
Chase Farm Hospital, Enfield
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
To examine whether driving is discussed with patients attending a
specialist day hospital for dementia and whether appropriate action is taken.
Patients’ notes were reviewed for evidence of such discussion. A
questionnaire was implemented before the audit was repeated 6 months
later.
RESULTS
During the first cycle 44 patients’ notes were assessed and 38 were
assessed on repeat audit. The documentation of discussions regarding driving
increased from 23 to 95% of notes following implementation of the
questionnaire.
CLINICAL IMPLICATIONS
By discussing driving status, important legal, insurance and safety issues
can be addressed. Routine use of a simple questionnaire dramatically improved
the likelihood of such discussion. These findings apply for all conditions
requiring Driver and Vehicle Licensing Agency notification.
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Introduction
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In patients who have been given a diagnosis of dementia, the issue of
driving is of vital importance. For many people, being able to drive is
crucial for their independence. In the UK the law requires anyone who has been
given a diagnosis of dementia to inform the medical branch of the Driver and
Vehicle Licensing Agency (DVLA; Driver and
Vehicle Licensing Agency, 2004). Failure to do so can result in a
fine of £1000 and will also be likely to invalidate insurance. Many
drivers with early dementia will have their licence renewed by the DVLA,
although other people may be deemed unsafe to drive. The evidence regarding
the safety of driving in dementia suggests that people with dementia do have a
higher risk of being involved in an accident
(Carr, 1997), although this
finding has not been universal (Trobe
et al, 1996). Subcategorisation of drivers with dementia
has shown patients to be at significantly increased risk only at the more
severe end of the spectrum (Dubinsky et
al, 2000).
Professionals treating people with dementia should consider the issue of
driving and are in a unique position to inform patients of their legal
responsibilities. In the service in which the authors were working there was
the perception that this issue might in some cases be unintentionally
overlooked. This has the potential to leave issues of risk and safety
unaddressed and also raises important legal considerations. We decided to
perform an audit to investigate this in a day hospital specialising in the
assessment and treatment of people with dementia.
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Method
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We considered the gold standard to be that the issue of driving is
discussed with all patients given a diagnosis of dementia. Those who are still
driving should be advised that they must inform the DVLA of their medical
condition. Within a reasonable period, which we set as 1 month, patients
should be interviewed again to ensure that they have acted on the advice
given. In exceptional circumstances, where the patient has refused to inform
the DVLA and continues to drive, the consultant psychiatrist should decide
whether to inform the DVLA against the patient’s wishes, and this
decision should be documented.
The notes of all patients attending the Elms Day Hospital in Enfield during
January 2004 were thoroughly reviewed, looking for evidence that the issue of
driving had been discussed. In cases where this had been documented, we looked
for evidence of what advice had been given to the patient regarding informing
the DVLA of his or her condition. We then assessed whether this advice had
been followed up within 1 month.
Following the evaluation of these results, we presented our findings to
staff at the day hospital and then implemented an audit questionnaire for
staff to use when admitting patients. This questionnaire was constructed after
consultation with the various professionals working within the hospital, so
that it was quick and easy to complete. Any member of the multidisciplinary
team could complete the questionnaire, which would then be signed and inserted
into the front of the patient’s medical notes
(Fig. 1). It was also suggested
that patients who had been advised to contact the DVLA should be given a
factsheet detailing the issues. The leaflet designed by the Alzheimer’s
Society was used (Alzheimer’s
Society, 2000). We repeated the audit in November 2004; all new
patients admitted since April 2004 were included, representing a 6-month
period. The same gold standard was applied to these patients.
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Fig. 1. Questionnaire used in the audit (DVLA, Driver and Vehicle Licensing
Agency; RMO, responsible medical officer).
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Results
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Forty-four patients were attending the Elms Day Hospital during January
2004 when the first cycle of audit was undertaken. Of these patients, 41 had a
diagnosis of dementia, one had a diagnosis of isolated memory impairment and
two had other conditions leading to social impairment. All 44 patients were
included in the study, as under DVLA rules all should inform the medical
branch of their condition. The notes of 34 (77%) of these patients had no
documented evidence of any discussion relating to driving. The remaining ten
patients (23%) had clear evidence of driving status recorded: four patients
(9%) were no longer driving and six (14%) were still driving when the issue
had been discussed. All of the six patients known to be still driving had been
advised to contact the DVLA, but this was only followed up in two cases to
ensure that it had been done.
Six months after the questionnaire was implemented we performed the second
audit cycle, including all patients who had been admitted to the Elms during
the 6-month period. The same gold standard was applied. During this period 38
patients were admitted, all of whom had a diagnosis of dementia.
Questionnaires were found in all of the patients’ notes. In 36 (95%) of
the cases there was evidence (from the questionnaire) that driving had been
discussed. In the other two cases, questionnaires were filed in the notes but
had not been completed; there was no documentation elsewhere in these notes
that driving had been discussed. Of the 36 patients whose driving status had
been documented, 33 (92%) were not driving and no further action was taken.
One patient had decided to sell her car after the issue was discussed with her
and she had had access to relevant support and information. The other two
patients were advised to contact the DVLA. The issue was discussed within 1
month, at which point they confirmed that they had contacted the DVLA medical
branch.
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Discussion
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The results demonstrate that prior to implementation of the questionnaire
the issue of driving was discussed only sporadically. Appropriate advice was
given when patients were found to be driving, however. The issue was only
discussed again in a minority of these cases. Following the implementation of
the audit questionnaire, the vast majority of patients had had the issue of
driving discussed with them. Only a small minority of patients were found to
be driving, and in these cases appropriate advice, action and follow-up were
provided. This ensured that the patient’s insurance would not be
invalidated by non-disclosure of medical conditions and also allowed the DVLA
medical branch to assess the situation and the appropriateness of a driving
licence remaining valid. As a result, the safety of the patient and of the
wider public is being better monitored, and legal issues have been
addressed.
Following this audit, there is now a plan to implement the audit
questionnaire in other dementia services that operate within the trust. It is
hoped that this will prove particularly useful in the memory assessment
services, where the patients tend to have milder disease and are more likely
to be driving. Feedback from staff indicated that the questionnaire was a
useful tool and easy to use.
The implications of this audit apply across many fields within psychiatry
(and indeed other medical specialties). The DVLA requires drivers to inform
them of many mental illnesses and all mental illnesses that have necessitated
admission to hospital (Driver and Vehicle
Licensing Agency, 2004). In the same way as for those with
dementia, non-disclosure of the condition to the DVLA could result in a fine
and insurance being invalidated. Contrary to many people’s perceptions,
only a minority of patients are likely to have their licences revoked after
contacting the DVLA. Use of this questionnaire can provide documentation in
the notes that appropriate advice has been provided to patients, and it is a
simple, cheap and effective measure.
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References
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ALZHEIMER’S SOCIETY (2000) Alzheimer’s
SocietyAdvice Sheet: Driving and Dementia
(http://www.alzheimers.org.uk/After_diagnosis/Driving_and_travelling/info_driving.htm).
CARR, D. B. (1997) Motor vehicle crashes and drivers
with DAT. Alzheimer Disease and Associated Disorders,
2 (suppl.1), 38
-41.
DRIVER AND VEHICLE LICENSING AGENCY (2004)
At a Glance Guide to the Current Medical Standards of Fitness to
Drive. Swansea: Department of Transport.
DUBINSKY, R. M., STEIN, A. C. & LYONS, K. (2000)
Practice parameter: risk of driving and Alzheimer’s disease (an
evidence-based review): report of the quality standards subcommittee of the
American Academy of Neurology. Neurology,
54, 2205
-2211.[Abstract/Free Full Text]
TROBE, J. D., WALLER, P. F., COOK-FLANNAGAN, C. A., et al
(1996) Crashes and violations among drivers with Alzheimer
disease. Archives of Neurology,
53, 411
-416.[Abstract]
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Abstract
Introduction
