Intervention Approaches to Driving and Dementia

More than 4 million Americans are estimated to have Alzheimer's disease (AD) and related dementias, diseases that destroy memory, judgment, language skills, and the ability to perform routine activities (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). Dementia has a profound effect on millions more family members who must cope with their relative's progressive decline and increasing needs. Many issues must be addressed after a diagnosis of dementia has been made; however, one of the first and most difficult decisions involves driving. Although some drivers with mild dementia can drive safely, for most driving will at some point become impossible as the disease progresses. Gerontological social workers play a key role in addressing the complex care needs of older adults with dementia and their families. They use skills in assessment, counseling, group processes, and linkage and referral. Hence, social workers are trusted and relied on as families make decisions regarding life-sustaining treatment, finances, and long-term care planning. Because of their expertise, social workers are well suited to assist families in making decisions about driving and in coping with the consequences of those decisions. However, to best assist drivers with dementia and their families, social workers need to understand the effects of dementia on driving, be aware of their state's licensing requirements, recognize the challenges faced by families dealing with a driver with dementia, and consider their professional responsibilities. DEMENTIA AND DRIVING PERFORMANCE Dementias are characterized by progressive and irreversible cognitive, emotional, and social losses. AD is the most common cause of dementia (Tuokko, Tallman, Beattie, Cooper, & Weir, 1995). Dementia, even when mild, can impair the skills required to drive safely. Research has shown that drivers with dementia are at an increased risk of motor vehicle crashes (Tuokko et al.) and other adverse driving events, including becoming lost in familiar areas, driving in the wrong direction on roadways, failing to follow directional signs, and cutting across center lines (Wild & Cottrell, 2003). Furthermore, drivers with dementia are not always able to make appropriate decisions on their own about driving modification and cessation because of lack of insight, poor judgment, and a loss of reasoning ability (Wild & Cottrell). Much of the driving and dementia literature focuses on clinical and psychometric test performance. The Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) and neuropsychological testing batteries are most commonly referenced. Individually or together, they attempt to predict drivers at risk by comparing their scores to performance on road tests or to the rate of crash involvement. The MMSE is used to classify severity of cognitive impairment (Folstein et al., 1975). Its maximum score is 30 points, with scores of 24 or less indicating impairment and lower scores indicating greater dysfunction. Beyond the obvious conclusion that people who score poorly on the MMSE are less likely to drive, studies have been inconclusive (Fox, Bowdon, Bashford, & Smith, 1997; Shua-Haim & Gross, 1996). The MMSE focuses mainly on orientation and memory, missing other domains of cognitive functioning important to driving competence, mainly perception, attention, and motor skills. Neuropsychological tests document impairment as well, emphasizing specific areas of cognitive abilities. Research has suggested that tests measuring visual--spatial abilities, attention, and choice reaction time best correlate with on-road driving performance (Fitten et al., 1995). Nonetheless, results of neuropsychological tests have not been found to correlate sufficiently or consistently with other measures to detect unsafe drivers with dementia. Generally, neuropsychological tests measure a person's ability to perform unfamiliar, non-task-specific activities, whereas driving performance relies on task-specific, automatic processes that are learned through practice (Withaar, Brouwer, & van Zomeren, 2000). …