How should we counsel adult daughters of a mother with dementia and impaired insight about safely restricting her driving and ensuring her overall safety?

Counseling Adult Daughters About Driving Safety in Dementia

The daughters should be advised that their mother must stop driving immediately if she has moderate-to-severe dementia or any recent crashes, near-misses, or episodes of getting lost while driving, and they should take control of the car keys as a necessary safety intervention. 1, 2

Immediate Assessment of Driving Risk

The first step is determining the severity of cognitive impairment and specific high-risk indicators:

• Patients with moderate-to-severe dementia should not drive and require immediate cessation, as severe dementia is generally considered a contraindication to driving 3
• Recent crashes, near-miss events, or getting lost while driving are strong warning signs that mandate immediate driving suspension 1
• Self-reported episodes of confusion, falling asleep at the wheel, or drowsiness-related incidents identify individuals at high risk for unsafe driving 1
• Approximately 70% of patients with even mild Parkinson's disease fail on-road driving tests, suggesting that neurodegenerative conditions significantly impair driving ability 4

Practical Interventions for the Daughters

Taking Control of Vehicle Access

The daughters should physically control access to the vehicle through multiple strategies:

• Take away the car keys as the most direct intervention—this is not cruel but necessary for safety 5
• Disable the vehicle by removing the battery or distributor cap if the mother finds spare keys 2
• Move the car to a location where the mother cannot access it 2
• Consider selling the vehicle to eliminate the temptation and make the transition permanent 2

Communication Strategies

Use a person-centered approach with sensitive communication when discussing driving cessation:

• Frame the conversation around safety concerns for both the mother and others on the road 2
• Involve the mother's physician to provide medical authority for the decision—physicians have a moral and, in some states, a legal obligation to report patients who are no longer fit to drive 3
• Consider having the physician write a formal "prescription" to stop driving, which can help deflect anger away from family members 2
• Acknowledge the loss of independence and validate the mother's feelings while remaining firm on safety 2

When Further Evaluation May Be Appropriate

If dementia is mild and there are no recent safety incidents, consider formal assessment before complete cessation:

• Patients with mild dementia are generally considered safe drivers, although specialized testing may be indicated 3
• An on-road evaluation conducted by the state driver's licensing authority is the gold standard for determining fitness to drive 1, 3
• Referral to a driving rehabilitation specialist can provide objective assessment when office-based screening suggests impairment but the situation is unclear 1
• Office-based cognitive testing focusing on speed of information processing, complex attention, visual attention, and executive function can help stratify risk 1, 4

Critical Pitfalls to Avoid

The daughters should understand these common mistakes:

• Chronological age alone is a poor predictor of driving safety—the focus must be on functional impairment 1
• Lack of insight in dementia means the mother cannot self-assess her driving ability—family members must take control 6, 2
• Waiting for a crash to occur before acting is unacceptable given the risk to the patient and public 1
• Relying on the mother's promises to "drive only short distances" or "only during the day" is ineffective when cognitive impairment and lack of insight are present 5

Addressing Transportation Needs

Proactively arrange alternative transportation to maintain the mother's independence:

• Identify family members who can provide regular transportation 2
• Research community transportation services, senior shuttles, or ride-sharing programs 2
• Consider hiring a driver or companion for regular outings 2
• Help the mother maintain social engagement through cognitively engaging activities, physical exercise, and socialization, which benefit dementia management overall 6

Legal and Reporting Considerations

The daughters should be aware of mandatory reporting requirements:

• Clinicians must be familiar with state-specific mandatory reporting laws for high-risk drivers 1
• In some jurisdictions, physicians are legally required to report unsafe drivers to licensing authorities 3
• The daughters can also directly report their concerns to the Department of Motor Vehicles in most states 2
• The ultimate responsibility for deciding fitness to drive rests with the state driver's licensing authority 3

Medication Review

Ensure the mother's medications are reviewed for sedating effects:

• Review current medications for sedating agents (anticholinergics, benzodiazepines, opioids) as these are associated with reduced driving performance 1
• Dopaminergic medications used in Parkinson's disease can cause sudden sleep onset during vehicle operation 4