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When to Turn in the Car Keys

DriveWise helps elders, children make tough decisions

BOSTON -- Sharon Miller considers herself a "poster child for the sandwich generation," taking care of two aging parents while holding down a busy job as an educational consultant and managing her own family. So when she wondered if it was safe for her now 77-year-old father to continue to drive, she was relieved to learn about Beth Israel Deaconess Medical Center's DriveWise program.

DriveWise was developed 15 years ago by clinicians in the Division of Behavioral Neurology and Occupational Therapy at Beth Israel Deaconess Center (BIDMC). These clinicians were often asked to make decisions about the driving abilities of medically ill patients. The DriveWise staff understood that decisions about driving competence should be made on the basis of each person's functional abilities rather than on the basis of age and/or a particular medical diagnosis. As a result, they developed a multidisciplinary, comprehensive driving fitness assessment for people of all ages who have medical illnesses or physical impairments.

For Sharon Miller and her family, turning to DriveWise meant that there was less need for an uncomfortable family confrontation, let alone hiding the car keys - or the car, as some families have been known to do. The BIDMC program provides an objective, outside-the-family resource to help decide one of life's toughest questions-when is it time for a loved one to stop driving?

Miller and her family had reason for concern. Her mother had had a stroke and her father, a retired executive, had been diagnosed with aphasia-difficulty speaking clearly and communicating. While her mother voluntarily gave up driving, her father, who otherwise seemed in good health, wanted to continue to drive to preserve the couple's independent lifestyle. But was it safe for him to drive? "At the very least, we feared if he was in an accident, he'd have difficulty clearly explaining what had happened," says Miller. Instead of taking away the car keys, Miller took her father to BIDMC in Boston to be evaluated by the DriveWise clinical team. "The family felt it was beneficial to have an impartial third party assess his driving skills and explain the results to him," says Miller.

"It was clear to me as I evaluated patients with Alzheimer's, Parkinson's, multiple sclerosis and other such conditions that the question of 'taking away the keys' often brings family members to their knees," says Lissa Kapust, a clinical social worker who directs the program through BIDMC's Behavioral Neurology Unit.

"Nobody wants to be the bad guy and tell the person they should hand over the car keys: not the patient's physician, who really can't tell in a brief office visit whether it's safe for the patient to drive and who wants to preserve a relationship with the patient, not the neighbor, the adult son, the spouse…" Kapust says. "When you make a person retire from driving, you jeopardize their independence and may reduce their quality of life."

The interdisciplinary DriveWise team, made up of staff from clinical social work, neuropsychology and occupational therapy, assesses driving ability not solely on the basis of a diagnosis but on the individual's functional abilities. "We don't want to prematurely end driving for the person, but we don't want to wait until they are in a crash, where injury occurs," says Kapust.

If it is determined that it is no longer safe for a person to drive, the DriveWise team provides emotional support and helps plan alternative transportation to keep the person as independent as possible. "It can have a domino effect on the individual. They may have to move from the suburbs to the city to be on a bus line, or to an assisted living facility," Kapust says.

To date, the DriveWise team has assessed about 500 patients of all ages. About 20 percent of the patients diagnosed with mild memory loss were found still able to drive. "Driving is a skill like bicycle riding. The brain is hard-wired and so, in early dementia, it may be safe for the patient to continue driving," Kapust says.

Sometimes the DriveWise team determines that simple precautions must be taken-like driving only familiar routes. If the person has a progressive neurological illness, eventually it will become unsafe for them to drive, so the team recommends re-evaluation every six months.

Those appropriate for screening by DriveWise include:

  • people with Alzheimer's or Parkinson's disease, head injury, multiple sclerosis, head trauma, Lou Gerhig's disease, bi-polar or other mental health conditions;
  • those who take medications that may interfere with driving, and
  • drivers whose reaction time, vision or hearing, strength, motor reflexes, or perception skills have decreased due to disease or aging.

"To be a safe driver people must have the ability to scan the environment quickly and effectively. The driver has to take in what they see as they drive, and be ready to respond to the many unforeseen things that can happen when they are driving-a child running into the street or a car stopping suddenly in front of them," says Dr. Margaret O'Connor, a neuropsychologist and a developer of the DriveWise program. "Some people have fluctuating levels of fatigue and alertness from medical conditions or medications that impact driving."

Questions to ask to decide if a loved one should be referred to the DriveWise program include:

  • Is the person easily distracted?
  • Do they become drowsy when they drive?
  • How is their judgment and insight about their abilities?
  • How are their upper and lower body motor skills? Can they safely operate the steering wheel and the brakes?
  • Can they stay on their route and not get lost?
  • Does the person drive through stop signs or lights?

The evaluation for Sharon Miller's father began with a thorough assessment by a social worker to understand the role of driving in his life and anticipate potential consequences of driving cessation. Then he was given a series of tests in the clinic; in one test, his reaction time was measured by how fast he pressed on the gas or brake when he saw simulated traffic lights turn colors. A vision screening was conducted and he was referred to his own eye doctor for more tests.

He then took the ultimate test-a 45 minute road test in a car adapted with a brake pedal on the passenger side. Instructions during this test were given by a driving instructor in the passenger seat. An occupational therapist with expertise in driving assessments rode in the back seat in order to make careful observations of his driving skills. On this particular day he had the added challenge of navigating through heavy Boston traffic in a rainstorm.

In the patient-family feedback meeting at the conclusion of the DriveWise screening, Sharon Miller and her parents were relieved to learn that her father was found to be safe to continue driving but he needed to be re-tested in six months. At that follow-up screening, it was discovered his multi-tasking skills had slightly declined. As long as he took certain precautions-like not playing the radio or having distracting conversations while driving-he could continue driving. But he must continue to come back for re-assessments every six months.

"While there's no guarantee-it's only a snapshot of his driving skills that day-it made the family feel that it's still okay for him to drive," says Miller.

What's more, the team helped Miller's father plan for the future. "The staff helped him anticipate that one day he will have to hand over the keys," Miller says. "When the time is right, he knows he will give the keys to me."

To contact the DriveWise program or to schedule an evaluation, contact Mickey Lentz at 617-667-4074.