Why is driving and dementia a problem in Nova Scotia?

Answer: The issue of driving and dementia is complex. Several factors play a role in whether someone with dementia will stop driving:

Prevalence of dementia: Nova Scotia has one of the highest proportions of older adults in Canada. This leads to a higher per capita prevalence of dementia compared with other provinces. Currently, an estimated 15, 275 Nova Scotians have Alzheimer’s disease or another dementia.

Dementia-related factors: Although memory impairment is a widely recognized symptom of dementia, it is not the primary concern with regards to driving safety. Alzheimer’s disease and related dementias are associated with several cognitive changes beyond memory, which put the individual at increased risk of having a motor vehicle collision (MVC):

Insight(Ott et al., 1996). Loss of insight into cognitive deficits is often an early feature of dementia. Loss of insight may foster optimistic bias—the idea that “bad things happen to other people, but not to me”. (Adler et al., 2005) Optimistic bias impedes self-imposed driving cessation. (Anstey et al., 2006). Driving cessation in dementia often occurs only after the individual has sustained one or more MVC’s (Jett et al.,2005). Early loss of insight in dementia underscores the importance of not relying on self report of driving ability.

Reaction time: Reaction time slows with normal aging, however, people with AD show markedly slowed reaction time on driving related skills testing compared with age-matched controls. (Rebok et al., 1994)

Attention:> People with dementia may have a more difficult time shifting the focus of their visual attention to new stimuli, for example shifting attention away from the car in front of them to a child running into the street. This can impair ability to react quickly to hazardous situations. (Parasuraman & Nestor, 1993). Poor performance on tests of selective attention, divided attention, visual attention and range of attention are associated with increased MVC risk. (Anstey, et al., 2006)

Co-ordination: (Kray & Lindenberger, 2000). Executive function is important to integrating information from various stimuli and planning a response. Although executive dysfunction was traditionally thought to be more prominent in vascular dementia, it is now recognized to be an important feature of dementia of vascular or neurodegenerative cause such as AD (Moorhouse et al., 2008)

Visuospatial function and visual perception: Drivers with Alzheimer’s type dementia perform significantly worse on tasks of visual search and recognition of traffic signs compared with healthy age-matched controls (Uc et al., 2006)

Caregiver-related factors: Driving cessation is rarely carefully planned, and there is often a lag between the caregivers’ recognition of cognitive deficits and the initiation of the driving cessation process (Cotrell & Wild, 1999). This lag may be due to caregivers’ lack of knowledge about dementia and its impact on driving, and fear over increased burden of care if the affected individual can no longer drive (Perkinson et al., 2005).

Individuals who have access to a vehicle and a “willing copilot” (someone to sit in the passenger seat and provide instructions or supervision) are more likely to drive after driving cessation has been recommended (Jett et al., 2005). Women may be more likely to act as copilots, rather than assume the responsibility of driving (Jett et al., 2005).

Barriers to assessment: In Nova Scotia, there are no provincially administered agencies that assess driving safety in dementia. The assessment of fitness to drive (as it pertains to dementia) is most often performed by physicians. National and local survey data (Jang et al., 2007; Moorhouse et al., 2009) indicates that Canadian family physicians lack confidence in performing driving assessments. This is not surprising given that no single in office assessment tool has shown robust ability to predict which individuals are safe and which are not. (Molnar et al., 2006).

Barriers to reporting unsafe drivers: The provincial Motor Vehicle Act states that reporting of concerns with respect to driving safety is at the discretion of the physician (Motor Vehicle Act. R.S., c. 293, s. 1). Nova Scotia is one of three provinces with discretionary reporting (Quebec and Alberta). Discretionary reporting may compound physicians’ concerns about the negative effect of reporting an unsafe driver to the patient-doctor relationship (Marshall & Gilbert, 1999).

Some provinces require by law that physicians report unsafe drivers to provincial motor vehicle authority (mandatory reporting). Motor vehicle crash rates do not appear to differ between provinces with mandatory reporting and those with discretionary reporting (Jang et al., 2007). Some provinces permit physicians to release medical information to the motor vehicle authority that may be helpful in decision making. This is not the case in Nova Scotia where physicians cannot release any medical information to the Registry of Motor Vehicles (RMV) without a signed medical release of information. A template letter for notifying the RMV is available here.

Lack of alternative transportation choices: There are few accessible public transportation options for older adults in Nova Scotia. (Parker, McDonald, Rabbitt, & Sutcliffe, 2003). This is particularly true in rural Nova Scotia.

This is a link to a national paper on issues of transportation in rural areas:

Alternative Transportation links