Introduction
Assessment
Stopping driving in the interim, persuading, breaking confidentiality
After informing the DVLA
Who to call for advice?
Conclusion
References

Introduction

There are 850,000 people in the UK with dementia,1 many of whom are still driving. The loss of this independence, especially in rural areas can have an impact on their well-being but this has to be counterbalanced by the safety of the person and the safety of others. There are mental abilities necessary for driving safely, which usually deteriorate in dementia, such as attention, concentration, visuospatial skills, problem-solving skills, judgement, decision-making, reaction and processing skills.2

Law

Dementia itself does not stop people driving but the law states anyone who has an illness such as dementia that could affect their driving has to inform the DVLA (or risk a fine up to £1000) through CG1 form or Declaration of Surrender for Medical Reasons.3 Fortunately in our experience many older patients innately obey the law and do so, we also advise them to notify their insurance company to avoid a claim being refused as they were not told.

Assessment

Assessing driving ability in people with dementia is a serious challenge. Licensing decisions made by the DVLA are usually based on medical reports. A license may be given on an annual basis for review or up to a maximum three years, when dementia progression is slow and people retain sufficient skills. There are varied presentations and rates of progression of dementia, however impaired short-term memory, disorientation, and lack of insight and judgement almost undoubtedly mean no fitness to drive. If there are any doubts, a formal driving assessment may be required.4

According to the Alzheimer’s Society the assessment is different from a driving test and focuses on how dementia overall influences a person’s driving to evaluate whether it is still possible to drive safely and stay in comfort on the road.5

The driving evaluation can take approximately two hours and is performed by two specialists: an occupational therapist and an advanced driving instructor. It covers the steps below:

  1. An interview covering medical and driving history, followed by a brief mental ability pen-and-paper test.
  2. Time of reaction and strength of the limbs on a static tackle for steering, braking and eyesight.
  3. Driving on the public road in a dual-braking car (pedals on both passenger’s and driver’s sides) with the advanced driving instructor as a front passenger and the occupational therapist as an observer to check for safety.
  4. Findings of the staff at the end of the assessment at the centre – comments, suggestions for techniques and improvements to continue driving with more safety and confidence. If the person is found not to be safe to drive, other alternatives will be given and someone else will have to drive the person home. Where DVLA/DVA have asked for the assessment, a report will be submitted directly to them by the centre.5

The Rookwood Driving Battery (RDB) and Dementia Drivers’ Screening Assessment (DDSA) are neuropsychological batteries designed to assist in this process. Another tests are The Hayling and Brixton Tests measuring symptoms of the dysexecutive syndrome: response suppression, response initiation and rule attainment.6

The RDB consists of 12 tests:

  1. Visual Object and Space Perception: Incomplete Letters, Position Discrimination and Cube Analysis (shape perception and visuospatial abilities)
  2. Letter Cancellation: Target numbers and Percentage errors
  3. Weigl Sorting Task (abstract thinking)
  4. Behavioural Assessment of the Dysexecutive Syndrome (BADS): Key Search, Action Programme and the Rule Shift (executive function)
  5. Copying hand movements, Gestures and Use of Objects (praxis)
  6. Tapping and Sequencing (rule-bound praxis skills)
  7. Modified Token Test (ability to follow instructions)
  8. Letter cancellation with a distractor task: Threes (divided attention).7

The Dementia Drivers’ Screening Assessment includes the following tests:

  1. Mini Mental State Examination
  2. Stroke Drivers’ Screening Assessment (SDSA) Dot cancellation (12 lines): time, errors and false positives; SDSA Square Matrices Directions and SDSA Road Sign Recognition
  3. Salford Objective Recognition Test (SORT): immediate and delayed recognition of words
  4. Stroop Color and Word Test (Victoria version): discrepancy between colour–words time and non-colour–words time
  5. Visual Object and Space Perception (VOSP): Incomplete Letters
  6. Behavioural Assessment of the Dysexecutive Syndrome (BADS): Rule Shift and Key Search
  7. Adult Memory and Information Processing Battery (AMIPB) Information Processing.7

Stopping driving in the interim, persuading, breaking confidentiality

Not informing DVLA/DVA puts the person at risk of a fine and prosecution, as well as the danger of driving without insurance and possibly having an accident. In these circumstances, the doctor should try to persuade the person to stop driving and to notify DVLA/DVA (or get their permission to let the family do this). People suffering from dementia should also inform their insurance provider as driving without at least third-party cover is a criminal offence.8

As trust is essential in doctor patient relationship doctors owe a duty of confidentiality, therefore medical professionals should remind the patients their legal responsibility to inform the appropriate agency. Doctors should disclose relevant medical information to the licensing agency if a patient is incapable of understanding doctor’s advice or if they believe the person's continued driving poses a serious risk to public.9

If persuading to inform the DVLA/DVA and/or stop driving when appropriate do not work, doctors do not need the person's permission to reveal necessary information to the agency, but they should tell the patients afterwards in writing that they have done it. This is frequently difficult for both parties.8,9

After informing the DVLA

Possible outcomes from the DVLA:10

Alternatives and benefits to be discussed

Doctors may show options to their patients such as starting to use public transportation or taxis. Using local NHS transport service for hospital appointments can be advised. Another way can be seeking help from family or close friends as well as joining organised trips or excursions. Patients can solve the problem of driving to do the shopping through online delivery.

When not driving patients experience less stress due to remembering the way or finding routes as well as searching for parking space and managing traffic or busy routes. They save money on petrol, insurance, taxes and parking fees. The most important benefit is that patients suffering from dementia preserve safety of others an self.10

What the DVLA do

The Driver and Vehicle Licensing Agency (DVLA) is an executive agency sponsored by the Department for Transport. DVLA is responsible for driver and vehicle registration and licensing in Great Britain. They have multiple duties including recording driver endorsements, disqualifications and medical conditions.11

Who to call for advice

Families and carers can seek advice calling Alzheimer's Society's National Dementia Helpline on 0300 222 1122 or discuss online with others on forum, Talking Point.12

Doctors can contact DVLA’s medical advisers on 01792 782 337 or at medadviser@dvla.gsi.gov.uk, and the DVA on 0800 200 7861.13

Conclusion

Dementia is a serious condition affecting patients, their families, neighbourhood or even the public. Medical professionals and various organizations have significant contribution in helping to cope with the impairment. Functioning can vary, therefore regular monitoring is vital for the safety of the patient and the others. As driving gives much independence, losing it can be a huge loss. Continuing though, can pose a serious threat to general safety. Doctors should cooperate with patients and their families to find best solution and balance together. They should also give useful advice to enable making reasonable decisions and adjusting new habits.


Dr Natalia Kaszuba, Dr Simon Manchip, Dr Sabarigirivasan Muthukrishnan 


References

  1. Alzheimer's Society. Facts for the media. https://www.alzheimers.org.uk/about-us/news-and-media/facts-media (accessed on 30.11.2019)
  2. Alzheimer's Society. Driving and dementia. https://www.alzheimers.org.uk/get-support/staying-independent/driving-and-dementia (accessed on 30.11.2019)
  3. UK. Dementia and driving. https://www.gov.uk/dementia-and-driving (accessed on 30.11.2019)
  4. UK. Assessing fitness to drive: a guide for medical professionals. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/670819/assessing-fitness-to-drive-a-guide-for-medical-professionals.pdf (access on 30.07.2018)
  5. Alzheimer's Society. Continuing to drive. https://www.alzheimers.org.uk/get-support/staying-independent/continue-driving (accessed on 30.11.2019)
  6. University College London. Impact case study. https://impact.ref.ac.uk/casestudies/CaseStudy.aspx?Id=36239 (accessed on 30.11.2019)
  7. Vella K, Lincoln NB. Comparison of assessments of fitness to drive for people with dementia. Neuropsychol Rehabil. 2014;24(5):770–783. doi:10.1080/09602011.2014.903197
  8. Alzheimer's Society. Driving and legal requirements. https://www.alzheimers.org.uk/get-support/staying-independent/driving-and-legal-requirements (accessed on 30.11.2019)
  9. General Medical Council. Confidentiality: patients' fitness to drive and reporting concerns to the DVLA or DVA. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality---patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-or-dva/patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-or-dva (accessed on 30.11.2019)
  10. Newcastle University. Driving with Dementia or Mild Cognitive Impairment Consensus Guidelines. https://research.ncl.ac.uk/driving-and-dementia/consensusguidelinesforclinicians/Final%20Guideline.pdf (accessed on 30.11.2019)
  11. UK. About us. https://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency/about (accessed on 30.11.2019)
  12. Alzheimer's Society. When DVLA/DVA decides that the person must stop driving. https://www.alzheimers.org.uk/get-support/staying-independent/when-dvla-decides-person-must-stop-driving#content-start (accessed on 30.11.2019)
  13. General Medical Council. Endnotes. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality---patients-fitness-to-drive-and-reporting-concerns-to-the-dvla-or-dva/endnotes (accessed on 30.11.2019)