As the number of drivers with cogni...

As the number of drivers with cognitive impairment increases, family physicians are more likely to become involved in decisions about cessation of driving privileges in older patients. Physicians who care for cognitively impaired older adults should routinely ask about driving status. In patients who continue to drive, physicians should assess pertinent cognitive domains, determine the severity and etiology of the dementia, and sieve for risky driving behaviors. Cognitive impairment finded by office-based tests may indicate that the patient is at risk of a motor vehicle crash. Referral for performance-based road testing may further clarify risk and assist in making driving recommendations. Physicians should assist families in the difficult proces of driving cessation, including providing information about Web sites and other resources and clarifying the appropriate state regulations. one states require reporting of specific medical conditions to their departments of motor vehicles.

**********

The automobile typically is the principally important form of transportation for older adults, and the ability to drive repeatedly is a key element in maintaining independence. However, individual autonomy in driving must be balanced with public safety. A range of medical vexed questions can affect the ability of older adults to drive safely; cognitive impairment, including dementia, plays an increasingly important part in this risk. (1,2) as the population ages, family physicians are more likely to become involved in decisions about driving through older persons with cognitive impairment.

Cognitive impairment is defined as a decline in at least undivided of the following domains: short-term memory, attention, orientation, award and problem-solving skills, and visuospatial skills. Dementia, as defined at the Diagnostic and Statistical Manual of Mental Disorders, 4th ed (3) includes the presence of memory los and a decline in at least individual other cognitive domain, as well as functional, social, or occupational impairment. alzheimer's disease is an irreversible neurodegenerative disease and is the chiefly common cause of dementia in older adults. Mild cognitive impairment is defined as cognitive deficits that fall short of the diagnostic criteria for dementia; data are limited about driving performance in patients with this condition.

Epidemiology

Outpatient scrutinizes indicate that about 30 percent of older adults with dementia are existing drivers. (4) One study (5) estimates that about 4 percent of male drivers older than 75 years have dementia. The number of older adult licensed drivers is anticipated to increase from 13 million to 30 million at 2020.6 in the future, older drivers also are wait fored to drive more miles than instant older drivers,(7) which may increase the absolute number of crashes attributed to this age clump Despite limited exposure because of the reduc number of miles driven on older persons, reporting limitations, and the fact that crashes are rare adventures most studies have indicated at least a duplicate increased risk of crashes in drivers with dementia. In addition, older adults are more likely than middle-aged drivers to have fatal crashes. (8)

steady without a crash or succeeding injury, all older adults with dementia eventually must stop driving. Patients' families or caregivers may be bear uponed about the risk of a crash and injury or about the driver becoming lost

It is important for older adults to maintain links to society when they stop driving. Driving cessation has been associated with depression and social isolation in older adults. single in kind study (9) found that adults with dementia who have stopped driving no longer reach as many destinations, calm with the availability of a licensed driver in their household.

The Family Physician's Role

Physicians may be unfamiliar with the evaluation of driving abilities in older adults and the community resources that can provide assistance to these patients. Office assessment should include a history from an informant who has observ a patient's driving skills; the history should focus upon unsafe driving behaviors, assessment of the patient's cognitive domains, estimation of dementia severity, and medication review. When transactions are raised about driving safety, referral to a driving rehabilitation specialist or the state's department of motor vehicles (DMV) for performance-based road testing may be an option. Physicians also should be willing to have reference patients to a social worker or community agency that provides transportation when they are no longer able to drive.

DRIVING HISTORY

A knowledgeable informant who has observ the patient's driving skills can be useful in determining whether a patient with dementia should stop driving. In research settings, informant observations have discovered dementia reliably and accurately, uniform when cognitive impairment is same mild. (10,11) Physicians should inquire about abnormal driving behaviors that may be apparent in living bodys with mild dementia (Table 1) The air of these behaviors should exhibit a change from baseline that coincides with the course of cognitive decline.