1. Brain tumor
3. Migraine and other recurrent headache syndromes
4. Movement disorders
5. Multiple sclerosis
7. Parkinson’s disease
8. Peripheral neuropathy
9. Seizure disorder
10. Sleep disorders
12. Tourette’s syndrome
13. Traumatic brain injury
Dementia deserves a special emphasis in this section because it presents a significant challenge to driving safety. With progressive dementia, patients ultimately lose the ability to drive safely and the ability to be aware of this. Therefore, dementia patients may be more likely than drivers with visual or motor deficits (who tend to self-restrict their driving to accommodate their declining abilities) to drive even when it is highly unsafe for them to be on the road. It becomes the responsibility of family members and other caregivers to protect the safety of these patients by enforcing driving cessation.
While it is optimal to initiate discussions of driving safety with the patient and family members before driving becomes unsafe, dementia is too often undetected and undiagnosed until late in the course of the disease. Initially, family members and physicians may assume that the patient’s decline in cognitive function is a part of the “normal” aging process. Physicians may also hesitate to screen for and diagnose dementia because they erroneously believe that it is futilein other words, that nothing can be done to improve the patient’s situation or slow the progression of the disease. In addition, physicians may be concerned about the amount of time required to effectively diagnose dementia and educate patients and their families.13
Despite these barriers, physicians are encouraged to be alert to the signs and symptoms of dementia and to pursue an early diagnosis. Early diagnosis is the first step to promoting the driving safety of dementia patients. The second step is intervention, which includes medications to slow the course of the disease, counseling to prepare the patient and family for eventual driving cessation, and serial assessment of the patient’s driving abilities. When assessment shows that driving may pose a significant safety risk to the patient, driving cessation is a necessary third step. With early planning, patients and their families can make a more seamless transition from ‘driving’ to ‘non-driving’ status.
|Brain tumor||Driving recommendations should be based on the type of tumor; location; rate of growth; type of treatment; presence of seizures; and presence of cognitive or perceptual impairments. Due to the progressive nature of some tumors, the physician may need to evaluate the patient’s fitness to drive serially.
See also the stroke recommendations in Section 3.
If the patient experiences seizure(s), see also the seizure recommendations in this section.
|Dementia||The following recommendations are adapted from the Alzheimer’s Association’s Position Statement on Driving14 and recommendations of the Canadian Consensus Conference on Dementia.15
|Migraine and other recurrent headache syndromes
||Patients with recurrent severe headaches should be cautioned against driving when experiencing neurologic manifestations (eg, visual disturbances or dizziness), when distracted by pain, and while on any barbiturate, narcotic, or narcotic-like analgesic. (See Section 5 for further recommendations regarding narcotic analgesics.)
|Movement disorders||If the physician elicits complaints of interference with driving tasks or is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for a driver evaluation (including on-road assessment) is recommended.
|Multiple sclerosis||Driving recommendations should be based on the types of symptoms and level of symptom involvement. Physicians should be alert to deficits that are subtle but have a strong potential to impair driving performance (eg, muscle weakness, sensory loss, fatigue, cognitive or perceptual deficits, symptoms of optic neuritis).
A driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist may be useful in determining the patient’s safety to drive. Serial evaluations may be required as the patient’s symptoms evolve or progress.
|Paraplegia/quadriplegia||Referral to a driver rehabilitation specialist is necessary if the patient wishes to resume driving or requires vehicle modifications to accommodate him/her as a passenger. The specialist can recommend an appropriate vehicle and prescribe adaptive devices (such as low-resistance power steering and hand controls) and train the patient in their use. In addition, the specialist can assist the patient with access to the vehicle, including opening and closing car doors, transfer to the car seat, and independent wheelchair stowage, through vehicle adaptations and training.
Driving should be restricted until the patient demonstrates safe driving ability in the adapted vehicle.
|Parkinson’s disease||Patients with advanced Parkinson’s disease may be at increased risk for motor vehicle crashes due to both motor and cognitive dysfunction.17 Physicians should base their driving recommendations on the level of motor and cognitive symptom involvement, patient’s response to treatment, and presence and extent of any medication side effects. (See Section 5 for specific recommendations on antiparkinsonian medications.) Serial physical and cognitive evaluations are recommended every six to twelve months due to the progressive nature of the disease.
If the physician is concerned that dementia and/or motor impairments may affect the patient’s driving skills, a driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist may be useful in determining the patient’s fitness to drive.
See also the dementia recommendations in this section.
|Peripheral neuropathy||Lower extremity deficits in sensation and proprioception may be exceedingly dangerous for driving, as the driver may be unable to control the foot pedals or may confuse the accelerator with the brake pedal.
If deficits in sensation and proprioception are identified, referral to a driver rehabilitation specialist is recommended. The specialist may prescribe vehicle adaptive devices (eg, hand controls in place of the foot pedals) and train the patient in their use.
|Seizure disorder||The seizure disorder recommendation below is adapted from the Consensus Statements on Driver Licensing in Epilepsy crafted and agreed on by the American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America in March 1992.18 Please note that these recommendations are subject to each particular state’s licensing requirements and reporting laws.
A patient with seizure disorder should not drive until he/she has been seizure-free for three months. This three-month interval may be lengthened or shortened based on the following favorable and unfavorable modifiers:
Single unprovoked seizure
|The patient should not drive until he/she has been seizure-free for three months.
This time period may be shortened with physician approval.
Predictors of recurrent seizures that may preclude shortening of this time period include:
Withdrawal or change of anticonvulsant therapy
|The patient should temporarily cease driving during the time of medication withdrawal or change due to the risk of recurrent seizure and potential medication side effects that may impair driving ability.
If there is significant risk of recurrent seizure during medication withdrawal or change, the patient should cease driving during this time and for at least three months thereafter.
If the patient experiences a seizure after medication withdrawal or change, he/she should not drive for one month after resuming a previously-effective medication regimen. Alternatively, the patient may resume driving after three months if he/she refuses to resume this medication regimen but is seizure-free during this time period.
|The patient should cease driving upon diagnosis. The patient may resume driving upon treatment when he/she no longer suffers excessive daytime drowsiness or cataplexy. Physicians may consider using scoring tools such as the Epworth Sleepiness Scale19 to assess the patient’s level of daytime drowsiness.
|See Section 11.
||See Section 3.
|Tourette’s syndrome||In evaluating the patient’s fitness to drive, the physician should consider any comorbid disorders (including attention deficit hyperactivity disorder, learning disabilities, and anxiety disorder) in addition to the patient’s motor tics. (For specific recommendations regarding these disorders, see Section 6).
If the physician is concerned that the patient’s symptoms compromise his/her driving safety, referral to a driver rehabilitation specialist for driver evaluation (including on-road assessment) is recommended.
Physicians should be aware that certain medications used in the treatment of Tourette’s syndrome have the potential to impair driving performance. (See Section 5 for more information on medication side effects.)
|Traumatic brain injury||
Patients should not drive until symptoms have stabilized or resolved. For patients whose symptoms resolve, driving may resume following medical assessment and, if deemed necessary by the physician, driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist.
Patients with residual neurological or cognitive deficits should be assessed and managed
If the patient experiences seizure(s), see the seizure recommendations in this section.
|Vertigo||Vertigo and the medications commonly used to treat vertigo have a significant potential to impair driving skills.
For acute vertigo, the patient should cease driving until symptoms have fully resolved. Under no circumstances should the patient drive to seek medical attention.
Patients with a chronic vertiginous disorder are strongly recommended to undergo driver evaluation (including on-road assessment) performed by a driver rehabilitation specialist prior to resuming driving.
13 Valcour VG, Masaki KH, Curb JD, Blanchette PL. The detection of dementia in the primary care setting. Archives of Internal Medicine. 2000;160:2964-2968.
14 Alzheimer’s Association. Position statement: Driving. Adopted by the Alzheimer’s Association Board of Directors, October 2001. Available at: http://www.alz.org/aboutus/ positionstatements/overview.htm. Accessed January 9, 2003.
15 Patterson CJS, Gauthier S, Bergman H, et al. The recognition, assessment and management of denenting disorders: conclusions from the Canadian Consensus Conference on Dementia. Canadian Medical Association Journal. 1999;160(12suppl):S1-S15.
16 Carr DB, Duchek J, Morris JC. Characteristics of motor vehicle crashes with dementia of the Alzheimer type. Journal of the American Geriatrics Society. 2000;48(1):18-22.
17 Zesiewicz TA, Cimino CR, Malek AR, et al. Driving safety in Parkinson’s disease. Neurology. 2002;59:1787-1788.
18 American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. Consensus statements, sample statutory provisions, and model regulations regarding driver licensing and epilepsy. Epilepsia. 1994;35(3):696-705.
19 Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540-545.