Hostname: page-component-7c8c6479df-p566r Total loading time: 0 Render date: 2024-03-29T07:27:40.450Z Has data issue: false hasContentIssue false

Driving in Somerset

Published online by Cambridge University Press:  02 January 2018

Stefan Jan Kolowski
Affiliation:
Taunton Community Psychiatric Unit, Cheddon Road, Taunton TA2 7AU
Jackie Rossiter
Affiliation:
Taunton Community Psychiatric Unit, Cheddon Road, Taunton TA2 7AU
Rights & Permissions [Opens in a new window]

Abstract

Aims and Methods

The number of drivers on our roads with dementia is likely to increase as the elderly population grows. We performed a retrospective analysis of patients referred to our Memory Clinic in Taunton who were still driving despite a high suspicion of dementia.

Results

Twenty per cent of the patients were still driving at the time of their assessment. Ten per cent had a diagnosis of Alzheimer's disease and 10% mild cognitive impairment. The patients and/or carers stated that the patient had not been told to stop driving and none of the referral letters documented any advice about driving.

Clinical Implications

Referrers should advise all patients with possible dementia to refrain from driving until assessment by a specialist team is completed. They should be informed of the risk of medico-legal consequences if they continue to drive.

Type
Original Papers
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © 2000, The Royal College of Psychiatrists

The new millennium has seen the number of people aged 65 years and over grow to be about 423 million, nearly half of whom live in developing countries (World Health Organization, 1993). As Alzheimer's disease increases exponentially with age, dementia will become more common (Reference Evans, Funkenstein and AlbertEvans et al, 1989).

Many studies reveal an increased motor vehicle accident (MVA) rate for drivers with dementia compared with those without dementia (Reference Gilley, Wilson and BennettGilley et al, 1991; Reference Logsdon, Teri and LarsonLogsdon et al, 1992;Reference Friedland, Koss and KumarFriedland et al, 1998). Although 50% of the former stop driving within three years of onset of dementia the risk of an MVA increases with the duration of driving after onset, especially for male drivers (Reference CarrCarr, 1997).

In a Finnish study of men over 70 years old who had stopped driving the most frequently stated reason for stopping driving was deterioration in health (Hakamies-Blomqvist & Wahtstrom, 1998). However, only 6.9% of the ex-drivers had received professional advice to stop driving. In one study, drivers who scored in the lowest 10% on specific cognitive testing were found to be 1.5 times more likely to experience MVAs than those drivers in the highest 10% (Reference Stutts, Stewart and MartellStutts et al, 1998).

The Driving and Vehicle Licensing Agency (DVLA) guidelines for medical practitioners (DVLA, 1998) state:

“It is extremely difficult to assess driving ability in those with dementia. Those who have poor short-term memory, disorientation, lack of insight and judgement are almost certainly not fit to drive. Disorders of attention are important. In early dementia when sufficient skills may be retained, a formal driving assessment may be necessary”.

The DVLA Medical Advice Unit suggests that people with a suspicion of dementia should stop driving until a diagnosis of dementia is excluded.

Aims

The aims of our study were to find out how many patients referred to our Dementia Memory Clinic were still driving at time of assessment despite having cognitive impairment and how many of these were advised to stop by their referrers until assessment had been completed (in accordance with the DVLA Medical Unit's advice).

The study

In a retrospective analysis, the notes of all new referrals to the Dementia Clinic at Pyrland House Old Age Psychiatry Unit, Taunton and a satellite clinic at the district general hospital between June 1998 and May 1999 were scrutinised.

All of those still driving were classified using the ICD-10 (World Health Organization, 1992) and according to results on psychometric testing using Mini-Mental State Examination (Reference Bleecker, Bolla-Wilson and KawasBleecker et al, 1988) and Cambridge Cognitive Examination of the Elderly (CAMCOG) (Reference Hupper, Brayne and GillHupper et al, 1995) assessment scores. Carers were contacted and referral letters scrutinised to see if any advice concerning driving had been given.

Findings

A total of 84 cases were referred to the clinic. Seventeen (20%) patients were still driving at the time of the assessment (5 female, 12 male).

Of the 17, using the above mentioned criteria, the diagnoses were: seven with dementia in Alzheimer's disease with late onset (two female, five male); one with dementia in Alzheimer's disease of a mixed type (male); one patient was found to have no actual cognitive impairment (female); and eight had a mild cognitive disorder (two female, one male).

Of the eight patients in the mild cognitive disorder group CAMCOG scores ranged from 82-101 out of 106 (cut-off for dementia being 80 with up to a 10-point variation for age, socio-economic status and education (Reference Hupper, Brayne and GillHupper et al, 1995)). These variables were not assessed in the study.

Regarding referral letters: one could not be found, two were referrals from general physicians and 14 were from general practitioners.

Although two letters mentioned that the patient was still driving none mentioned that they had advised them to stop driving.

Discussion

This simple study illustrates that when doctors (usually general practitioners) refer a patient with a likely diagnosis of dementia to the Memory Clinic in Taunton they do not document in the letter to the clinic that they have told the patient to refrain from driving until dementia is excluded (admittedly the referring doctor could have documented this in his or her notes and the patient may forget or ignore the advice). In our opinion, if no documentation exists then medico-legal liability may become an issue should an MVA occur.

Our study showed that eight (almost 10%) of the referred patients who were still driving were probably unsafe to do so, as they had a definitive diagnosis of dementia. The group with mild cognitive disorders (almost 10%) showed quite a large variation in CAMCOG scores - these patients we found difficult to decide on how to advise. Storandt & Hill (Reference Storandt and Hill1989) showed that it is difficult to decide who has normal ageing and who has early dementia. Further investigation of the DVLA guidelines and the DVLA medical advice made the following clearer:

  1. (a) Where there is a suspicion of dementia the person should be advised to stop driving until assessment by a psychogeriatric team is completed. We suggest that this advice should be documented.

  2. (b) All patients diagnosed as having dementia should be told to stop driving and to inform the DVLA. If they disagree that they are unsafe they should ask for a driving assessment from the DVLA, but they should still be advised not to drive until the DVLA has completed its assessment. If the patient passes this assessment then the DVLA may award a time-limited driving licence which may be renewable every six months or so, for example, pending further assessments.

  3. (c) All cases that fall into ICD-10 mild cognitive disorder should be assessed to see if they only have age-related memory loss with no other significant areas of cognitive deficit. If this is the case then the psychogeriatric team does not have to advise them to inform the DVLA. However, these patients should undergo a periodic review as their cognitive performance may deteriorate further.

The group with mild cognitive disorder who show cognitive losses in areas other than memory and/or those who have loss of normal daily living skills should be advised in the same way as those with dementia.

The latest General Medical Council guidelines state that it is the doctor's job to inform the patient that the DVLA needs to be informed and that they should refrain from driving pending the DVLA assessment. If they continue to drive then the doctor should tell them that he or she has no choice but to inform the DVLA.

References

Bleecker, M. L., Bolla-Wilson, K., Kawas, C., et al (1988) Age-specific norms for the Mini-Mental State Exam. Neurology, 38, 15651568.CrossRefGoogle ScholarPubMed
Carr, D. B. (1997) Motor vehicle crashes and drivers with Alzheimer's dementia. Alzheimer's Disease and Associated Disorders, 11 (suppl. 1) 3841.CrossRefGoogle Scholar
Driving and Vehicle Licensing Agency (1998) Ata Glance Guide to Medical Standards of Fitness to Drive. Swansea: Drivers Medical Unit, DVLA.Google Scholar
Evans, D. A., Funkenstein, H. H., Albert, M. S., et al (1989) Prevalence of Alzheimer's disease in a community population of older adults. Journal of the American Medical Association, 262, 25512556.Google Scholar
Friedland, P. P., Koss, E., Kumar, A., et al (1998) Motor vehicle crashes in dementia of the Alzheimer type. Annals of Neurology, 24, 782–778.Google Scholar
Gilley, D. W., Wilson, P. S., Bennett, D. A., et al (1991) Cessation of driving and unsafe motor vehicle operation by dementia patients. Archives of International Medicine, 151, 941946.CrossRefGoogle ScholarPubMed
Hakamies-Blomqvist, L. & Wahlstrom, B. (1998) Why do older drivers give up driving? Accident Analysis and Prevention, 30, 305312.CrossRefGoogle ScholarPubMed
Hupper, F. A., Brayne, C., Gill, C., et al (1995) CAMCOG – A concise neuropsychological test to assist dementia diagnosis: Socio-demographic determinants in an elderly population sample. British Journal of Clinical Psychology, 34, 529541.CrossRefGoogle Scholar
Logsdon, P. G., Teri, L., Larson, E. B. (1992) Driving and Alzheimer's disease. Journal of Geriatric Internal Medicine, 7, 583588.Google Scholar
Storandt, M. & Hill, R. D. (1989) Very mild senile dementia of the Alzheimer type 2. Psychometric test performance. Archives of Neurology, 46, 383386.CrossRefGoogle Scholar
Stutts, J. C., Stewart, J. R. S. Martell, C. (1998) Cognitive test performance and crash risk in an older driving population. Accident Analysis and Prevention, 30, 337346.Google Scholar
World Health Organization (1992) The Tenth Revision of the International Classification of Diseases and Related Disorders (ICD–10). Geneva: WHO.Google Scholar
World Health Organization (1993) Implementation of the Global Strategy for Health for All by the Year 2000, Second Evaluation; and Eighth Report on the World Health Situation. Geneva: WHO.Google Scholar
Submit a response

eLetters

No eLetters have been published for this article.