Driving after a stroke: What helps Grandma drive safely?
Elizabeth Roaf, MD and
Janet Jankowiak, MD
Crashes involving elderly drivers hitting pedestrians are increasingat an alarming rate. With the graying of America, the impactof driving impairment is being reported more commonly. In theyear 2000 (according to US Census data), people over the ageof 65 equaled 13% of the United States population yet were involvedin 18% of all traffic fatalities. Many medical conditions maylead to problems with driving, including the process of normalaging. These may include conditions that affect the brain andits connections, the heart, eyes, ears, muscles, and even bones.But what can be done to ensure that people with these conditionscan drive safely?
New research reported in this issue of Neurology suggests thatpeople who have had a recent stroke may benefit from specialdriving training that takes place in a car modified with a drivingsimulator. In this study by Akinwuntan et al., the authors useda full-sized Ford Fiesta car which remains stationary. The carwas equipped with adaptive aids such as a left-sided acceleratorpedal, right-sided indicator stick, as well as a steering wheelcoupled to a simulator. The stimulator projected life-sizedimages generated by a computer that portrayed a driving scenariothat lasted about 25 minutes. Akinwuntan et al. divided 83 patientswho had had a stroke within the past 3 months into two groupsfor the study.1
In one group, there were 42 people who were chosen at randomto use the driving simulator. The other group of 41 people,called the control group, received standardized training byperforming driving-related thinking tasks such as finding aroute on a road map. The goal of the study was to see if thespecialized simulator-training program would improve drivingperformance and skills. Each potential driver spent 1 hour 3days per week for 5 weeks either in the stationary car withsteering wheel, signals, brakes, and a driving simulation program,or in the mental skills course. All the participants were youngerthan 75 years old, had a valid driver's license before theirstroke, and had no prior history of problems with speech, understanding,or a seizure disorder. The size and location of each strokewas noted; the subjects were checked for visual problems andthinking functions such as attention to visual and tactile inputafter the stroke. Information about driving experience, averagedistance driven annually before the stroke, and educationallevel was collected on each person.
Each participant was tested before and after the driving training.It was found that the individuals with higher levels of educationand smaller strokes tended to do better on overall driving performance.Those who received training in the car with driving simulationtended to do better on tasks practiced during the simulationthan those who just participated in the thinking skills program.More of the people who used the simulated training did wellon an actual on-road test taken about 3 months after the trainingthan the control group who did the thinking skills training.The authors concluded that motor learning skills are betterlearned when they are learned in a similar situation to wherethey will be performed.
This study suggests that driving simulation in a modified vehiclemay be helpful to certain individuals who have had a strokeand who want to resume driving. In this study, people with largestrokes and those over 75 years old were excluded. However,the results suggest that simulated driving training may be away to help improve driving performance. More research willbe needed to see if this could help other potential driverswith other neurologic disorders, such as early dementia.
What happens when you give up your driver's license?
In the United States, public transportation systems betweensmaller towns and cities are relatively limited and drivingis almost a necessity. The ability to drive has become a symbolof American independence. When there is a threat of losing theprivilege to drive, older people or those with medical problemsare faced with serious emotions. They may rightfully feel theyare losing their independence and mobility in our society. Ifthe retired driver does not have a strong social network offamily or friends he or she may feel socially isolated. Thismay lead to feelings of depression, anger, and loss of control.In addition, necessary trips such as shopping at a grocery storeor going to a doctor's office may become difficult.
Each state has different restrictions on an individual's abilityto drive given his or her medical condition. Many states requirethat drivers report certain medical conditions themselves. Afew states require that physicians must report specific conditions.These may include loss of visual sharpness or peripheral vision,seizure disorders, problems with heart rhythm, severe breathingdifficulties, and even severe arthritis. Medical problems thatmay interfere with an individual's ability to drive may be groupedinto the following categories.
These include any condition that affects an individual's abilityto think, remember, or pay attention. Examples are strokes,dementias, loss of sleep, alcohol use, and use of various recreationaldrugs or medications (both prescribed and over the counter,for example sleeping pills or certain painkillers).
These disorders include loss of feeling in the feet from diabetesor other nerve problems, loss of muscle power as a result ofa stroke, or weakness with sciatica. Poor range of motion mayalso limit safe driving, especially in turning the head or abilityto step on the brake quickly.
This includes conditions where an individual faints, passesout, or is otherwise not aware of his or her surroundings. Examplesinclude seizures, strokes, heart rhythm problems, low bloodsugar, and alcoholic intoxication.
This includes problems that affect the eye or eyes such as cataractsand macular degeneration, a common cause of partial blindness,as well as diabetic retinopathy, which affects the blood vesselsof the eye. In addition, brain lesions in areas that involvethe processing of visual information may affect vision. Theseinclude partial loss of the visual field from a stroke, tumor,or even a brain injury caused by trauma to the head.
What should you do if you wonder whether your loved one is able to drive safely?
Some people with medical problems such as visual impairment,hearing loss, or slowed reflexes frequently limit their drivingto local roads, shorter distances, daytime hours, and fair weatherduring non–rush hour traffic. Others with limited insightinto their abilities may not restrict themselves, which putsthemselves and others at risk.
Family members or caregivers may consider driving in a car behindan older driver or consider riding as a passenger with the driverfrom time to time. This will help the caregiver to watch thedriving habits and skills of the individual.
Particularly important areas of concern are the following:
Incorrectly making a left-hand turn
Driving too fast or tooslowly for the road conditions
Making sudden turns
Not usingthe turn indicator or forgetting to turn it off
Getting lostor seeming disoriented
Unexplained dents on a car or recent fender benders may be asign of frequent accidents or near misses. When there is anyquestion about an individual's ability to drive, the best placeto start is with the person's physician. The physician can makerecommendations about specialists to see and treatment thatmay help the driver resume or continue driving.
As discussed in the article by Akinwuntan et al., specializeddriving training using simulated driving scenarios in a stationary,specially equipped vehicle may be a way to improve driving performance.Although this study focused on individuals who had had strokes,similar training may be helpful to people with other neurologicimpairments such as brain injury, mild dementia, or Parkinsondisease, or perhaps even healthy elderly drivers.
Akinwuntan AE, De Weerdt W, Feys H, et al. Effect of simulator training on driving after stroke: A randomized controlled trial. Neurology 2005;65:843–850.[Abstract/Free Full Text]
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