I often hear, “It’s ok for my family member to drive, even though he has dementia (or Alzheimer’s). He doesn’t go far. He only goes to local places, like Walmart and church.”
Maybe. Maybe not.
A State Trooper with Dementia Awareness
My son, Mark, is a Florida State Trooper. He spends his entire 12-hour shift on the roads, highways, and interstates that lay inside of Manatee County. Not too long after he graduated from the academy Mark encountered his first Silver Alert. Silver alerts indicate that a vulnerable older adult may be in some sort of danger. Mark recognized the car and license plate of a 75-year-old man who had been reported missing four days earlier. The man lived in the Orlando area and was driving to Tampa, a 130-mile and easy 2-hour drive. When the gentleman failed to arrive at his destination for Thanksgiving dinner, worried relatives called police. When Mark located the man, he was driving around Sarasota, about 2 hours south of Tampa.
When Mark approached the missing man, he jumped out of his car and began screaming at my son: “Why are you pulling me over? I’m driving the speed limit!” Mark calmly responded, “Sir, your family is worried about you. They have been looking for you.” Mark had already decided to treat this man as if he were cognitively impaired unless he found evidence to the contrary.
The man stopped yelling and seemed confused. Mark continued to speak quietly and gently to the man. Mark convinced him to leave his car and wait in the police cruiser, “May as well use up my gas instead of yours. It’s your tax money.” Mark convinced the man to let the paramedics check him out—he was fine. The fast-food receipts indicated that missing man had been driving the same 50-mile loop for the last 3 days. No one had a clue where he had been sleeping during the 4-day period. While waiting for the man’s relatives, Mark answered the same 3 question-loop for 90 minutes: why did Mark pull him over (“Your family was worried.”), when can he be allowed to drive back home (“Your family is on their way, you are in Sarasota, sir.”) and what was he doing in Sarasota (“I think you got turned around because of the construction.”). There was no construction in the immediate area but Mark figured out that blaming construction was a good move. Mark was using the “enter their reality” technique.
A couple of days later, Mark was summoned to the captain’s office. Mark was greeted by his captain, lieutenant, and sergeant. They had watched the dash- and cruiser-cams; the lieutenant got right to the point: “Son, I know they don’t teach this at the academy. I’ve never seen a trooper handle a person with obvious dementia so well. Where did you learn this?”
“From my mom,” Mark responded.
“Shit, I’m so sorry!” blurted out the captain. “I didn’t know she had Alzheimer’s!”
Without missing a beat, my smartass son responded, “She hasn’t been diagnosed yet.” He then explained my work and introduced them to my blog and podcast. I now have a growing group of podcast fans from all over Florida!
Driving Ability Cannot Be Based on Diagnosis/Staging Alone
Driving is a tricky and sensitive topic. One person with mild cognitive impairment may be fine driving locally, during the day, in good weather, and avoiding interstates. Another person with mild cognitive impairment may be dangerously impulsive and easily angered—and have no business behind the wheel. To be fair, anyone who is very impulsive and easily angered should not be driving, regardless of cognitive abilities! But I digress…
Driving involves several types of brain activities. These activities have to work together. A problem in one area can jeopardize the whole process.
Driving and Procedural Memory
Driving definitely relies on procedural memory. Procedural memory can be thought of as “auto pilot” memory. It is the memorization of all of the steps to do something. We create procedural memory by doing a specific task daily or multiple times a day over decades. Over time, the procedural memory becomes automatic. A great example is learning to tie shoelaces. I remember teaching each of my 3 children how to tie their shoes. It took hours. Each child would face the task of tying their shoelaces with deadly seriousness and evidence of concentration. Over time, it became easier and easier. By the time they entered the first grade, tying shoelaces had become a procedural memory which meant they used very little brain power to complete the task.
Procedural memory acts like brain “autopilot”. This frees up the brain’s energy to focus on other activities, like planning (“what should I pull out for dinner tonight?”) and problem-solving (“how do I keep the dog from eating the cat turds?”). If we had to concentrate on brushing our teeth, wiping our butts after pooping, dressing ourselves, making coffee, feeding the cats, feeding the dog, tossing laundry in the washer, emptying the dishwasher–we would be exhausted 20 minutes after getting up in the morning. Instead, thanks to procedural memory, I can do all of the above almost simultaneously (except for the poop part…that’s just gross!)
All of us rely on procedural memory when we drive familiar routes. Ever have the experience of arriving at your destination and realizing you have no idea how you got there? Because your mind was preoccupied with something else during the drive? Or my personal favorite, have you found yourself halfway to work on a Sunday morning instead of heading to the park–because you were daydreaming or talking and you went on “autopilot” instead of paying attention to making that right to go south (the park) instead of that left to head north (towards the job)? If so, thank your procedural memory!!
Beyond Procedural Memory
When something sudden or unusual occurs during the drive, other brain parts jump in. A crash up ahead? Ok, I’ll jump off the exit ramp and reroute my drive. I may have to retrieve old memories from my previous experiences of taking this route. Or, if I’ve never used this detour, I have to bring in my working memory to “hold onto” the general direction I need to travel in order to arrive at my destination. I also have to engage my concentration and visual-spatial brain parts because I have to generate the “map” of the detour into my conscious mind, plan the route, and implement it–all the while maneuvering around the other 100 drivers with the same idea. My procedural memory continues to run in the background because I’m using the procedural memory to handle the basic mechanics of driving (start/stop, turn, use turn signal).
If I have any brain problems in any of these important areas–working memory, concentration, attention, retrieval, and visual-spatial–I lose my ability to successfully arrive at my destination in spite of a detour. I may keep going around in circles. I may forget my destination and have no idea where I am going–which causes anxiety and slows down retrieval, attention, and concentration. I may fail to react quickly to debris in the road, or I may over-react and change lanes, hitting the vehicle next to me.
Now that I’ve explained how driving involves a “dance” between procedural memory and other parts of the brain, I want you to think about the person living with dementia. Do they have short-term memory problems? Problems with road rage or impulsivity? Problems knowing the day of the week? The month? The year? Any of these problems are a red flag that their ability to drive needs further evaluation.
7 Important Questions
1. Getting lost in familiar places?
A “yes” response to this question is a definite NO, the person should not be driving.
2. Any recent accidents or “near-misses”?
3. Any new damage showing up on the car?
Positive responses these questions require more investigation for PATTERNS of recent accidents or near-misses, as well as consistent new damage on the car. When thinking about recent accidents or near-misses, was the person living with dementia at fault? Did time of day or weather play a factor? Sometimes people living with dementia have to restrict their driving to daytime only and avoid driving during busy times, on interstates, and during bad weather.
4. Sudden pattern of traffic violations?
A family member became concerned after her husband received 3 speeding tickets in the mail within a month. He had driven for 40 years with zero speeding tickets–and he often drove all over the country as part of his business. The sudden flood of traffic violations was highly unusual for her husband. She took him to get evaluated and sadly, he received a dementia diagnosis.
The scary part is that these tickets are probably the tip of the iceberg. These tickets represent OBSERVED problems, like failing to stop at a stop sign, speeding, running a red light, or driving the wrong way down a one-way street.
5. Any impulsive or “road rage” behaviors?
When I talk about impulsivity and road rage, I’m talking about frequent issues. I’ve had experiences with persons with frontal lobe problems who became overly aggressive and literally tried to run another driver off of the road because the other driver “wasn’t driving fast enough” or “changed lanes without signaling so they had to be taught a lesson.” I also recognize that a “yes” to road rage would apply to many people without a dementia diagnosis having their licenses revoked–no argument here!
A person with a diagnosis of Alzheimer’s or another dementia can exhibit impulsivity or road rage, too.
6. Would you feel comfortable riding as a passenger if the person with dementia were driving?
7. Would you feel comfortable having your child or grandchild as a passenger if the person with dementia were driving?
A “no” response to either of these questions is a definite NO THE PERSON SHOULD NOT BE DRIVING. Again, you could make the argument that any driver, regardless of cognitive abilities, getting a “no” to either question has no business behind the wheel of a car!!
What if there seems to be no driving issues right now?
The safest approach is to limit driving to local, well-known places that the person has driven to for years (supermarket, barber shop, hair salon, church). It may also be a good idea to avoid busy highways and interstates and to drive only during daylight and in good weather. Someone should regularly ride as a passenger to make sure the driving is still OK.
If you have questions or concerns about whether or not a person with dementia should be driving, talk to your primary care provider, a clinician EXPERIENCED WITH DEMENTIA CARE (physician, nurse practitioner, physician’s assistant), or even local law enforcement. Find out if there are occupational therapists in your health care system or community who provide driving evaluations.
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Dr. Rita Jablonski
Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.