Maturitas 78 (2014) 82–85

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Review

Mild cognitive impairment: Safe to drive? Kirsty Olsen ∗ , John-Paul Taylor, Alan Thomas Institute for Ageing & Health, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, England, United Kingdom

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Article history: Received 4 March 2014 Accepted 10 March 2014 Keywords: Ageing Mild cognitive impairment Driving

a b s t r a c t Driving is an important aspect of daily living and for many older people provides autonomy and psychosocial benefits. Cognitive impairment has been found to impact driving skills at the level of dementia, however, uncertainty remains around the impact of a diagnosis of the pre-dementia condition mild cognitive impairment. Current official guidelines are unclear, and assessment of fitness to drive can be problematical. This editorial examines current official guidance available to the clinician and problems with existing assessment as well as the current position of research specifically into MCI and driving, and considers future direction for research in this field. © 2014 Elsevier Ireland Ltd. All rights reserved.

Contents 1. 2. 3. 4. 5. 6. 7.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Driving and older people . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problems with assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current literature on MCI and driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction Cognitive impairment can have a significant impact upon driving safely, particularly when the level of dementia is reached (e.g. [1,2]). However, for those with a diagnosis of mild cognitive impairment (MCI) the impact is not so clear-cut, and this raises a number of issues for both clinicians and patients. MCI has several closely related definitions but perhaps is most commonly defined as the presence of clinically detectable memory decline with or without other cognitive deficits associated with only minimally impaired activities of daily living, that is not severe enough to be classified as dementia, but is worse than expected for age [3]. MCI is considered

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to be an early stage of the dementing process, with a high rate of conversion to dementia, particularly Alzheimer’s disease [4]. However, not all patients with a diagnosis of MCI will develop a dementia [5] and this makes it an uncertain construct and in the context of driving, makes it difficult to build legislation upon. The prevalence of MCI varies with definition but using the Peterson criteria, it has been estimated that 3% of an elderly population will meet the diagnostic criterion for a diagnosis of MCI [6] As with dementia it is strongly age associated. Currently, the National Office of Statistics, states that 17.6% of the population is over 65 years of age, with this set to rise to 20.3% by 2025 [7], showing that the numbers of those with mild cognitive impairment will increase substantially. 2. Driving and older people

∗ Corresponding author. Tel.: +44 0191 2481344; fax: +44 0191 2481301. E-mail addresses: [email protected] (K. Olsen), [email protected] (J.-P. Taylor), [email protected] (A. Thomas). http://dx.doi.org/10.1016/j.maturitas.2014.03.004 0378-5122/© 2014 Elsevier Ireland Ltd. All rights reserved.

Driving is an important aspect of daily living, for many people. For older people it can provide autonomy, continuing mobility, and

K. Olsen et al. / Maturitas 78 (2014) 82–85

other psychosocial benefits [8]. Those who need to cease driving report increased feelings of depression [9] and reduced access to social activities, household activities (e.g. shopping) and medical appointments [10]. Presently, 79% of people aged 60+, and 58% of people aged 70+ hold a current driving licence in the UK [11]. It has been suggested that driving is the ‘ultimate Instrumental Activity of Daily Living’ [12], as it requires co-ordination and the ability to mentally and physically multi-task. By definition, those with a diagnosis of MCI will experience some mild impairment of ADL’s. Early diagnosis can allow appropriate access to treatment and interventions [13] and permit clinicians and individuals to plan ahead for the future [14]. However, MCI is an ‘uncertain’ label [13] and can often be mis-understood [15] and this may create friction between the individual, clinician and family when key decisions need to be made. From a driving perspective, early diagnosis of cognitive difficulties can also lead to the question of someone’s suitability to hold a driver’s licence [16] and it can be difficult for clinicians and individuals to pin point when it becomes unsafe to drive. However, symptoms in MCI relevant to driving include decreased concentration, minor problems with geographical orientation and problems performing parallel actions [13]. 3. Current guidelines Official guidance available for individuals and clinicians currently appears to offer inconsistent classifications and no clear pathway for action. At present, guidance available to patients in the UK [17] requires the reporting of cognitive problems, memory problems (severe) and dementia. While the diagnosis of dementia may be more concrete, no definition of cognitive problems is given, and MCI is not defined as a separate entity, leaving the term of ‘cognitive problems’ open to broad interpretation. This may leave to individuals with MCI unsure whether there is a need to report their diagnosis, to the DVLA, or their insurance company. Additionally the guidance for clinicians in the UK [18] is not specific. MCI need not be reported if it is felt driving has not been affected. But if there are concerns, notification is required, so follow up can occur. Presently there is no mandatory testing. This leaves the clinician with the problem of assessing how severely, if at all, driving skills have been compromised. Throughout Europe the picture is mixed with some countries issuing unlimited lifetime licences (e.g. Belgium, Germany), some that do not require a medical exam but rely on an administrative or self report procedure of medical conditions (Sweden, UK), others that require a medical assessment for renewal when a specific age is reached (e.g. Italy, Denmark, Finland), and some countries requiring that licences must be renewed every 10 years and include a medical examination (e.g. Romania, Estonia, Spain) [19]. In the USA, the NHTSA recommends that drivers with cognitive problems should undergo assessment. However, this is given in terms of dementia diagnosis, with no specific mention of MCI [20]. Therefore overall, there exists a lack of consensus and thus highlights it is a key issue to be addressed. 4. Problems with assessment Assessing a person’s fitness to drive when they have cognitive impairment is problematical. It has been reported that a general cognitive test battery [21,22] selective attention tasks [23] maze test performance [24] and visuospatial tasks [25] may predict safe driving behaviour. However, many studies contest the usefulness of cognitive testing as a measure of driving ability [26,27]. Also, safe driving can depend on additional factors such as vision and hearing [28], which in conjunction with the cognitive impairment could affect driving ability. There currently is no definitive test or

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battery that can be used, and as these studies pertain to ‘mild’ or early stages of Alzheimer’s disease, rather than specifically MCI, the outcomes may well not be transferable to this population. 5. Current literature on MCI and driving In the literature, currently, there are a few empirical studies of driving performance and MCI, although the criterion used for defining MCI often differs between studies, and so it is difficult to say how generalisable and applicable the findings may be. Wadley et al. [29] used the Peterson criteria to identify individuals with MCI for their investigation, and found that on ratings of both global and discrete driving manoeuvres, those with MCI performed worse than healthy control subjects. However, these differences were not at a level of frank impairment in driving skills, but were simply of ‘not optimal’ performance. Findings by Devlin et al. [30] were also similar. In this instance the inclusion criteria was defined as symptomology of MCI/early cognitive decline identified by a geriatrician in a working memory clinic and those with this definition of MCI performed more poorly than controls across a number of domains (e.g. reaction time, hesitations), but trends did not reach statistical significance. Frittelli et al. [31], found that those with MCI performed worse than a control group in a driving simulator. This, in addition to Wadley et al. [29], suggests that at the stage of an MCI diagnosis, driving ability may be affected. A different approach, and one arguably more relevant, as it is based upon ‘real world’ situations rather than a simulated condition, was taken by Jeong et al. [32] who found there was no difference in the history of reported crashes and traffic citations between a population of elderly controls and an MCI group. This suggests that although subtle neurocognitive impairments may be present, driving may remain safe in people with MCI. Interestingly, this study also found that performance on a digit span, word list, recognition and recall was correlated with situational avoidance in driving (e.g. driving in bad weather or at night), suggesting that the better performance in a real world situation compared with cognitive tests may be due to self regulation. In addition to this O’Connor et al. [33] also found that those with MCI (defined using the Peterson criteria) and dementia were more likely to avoid complex driving situations (e.g. high traffic roads and unfamiliar areas) than controls. Regarding MCI subtypes, a study by O’Connor et al. [34] looked at differences between a normal, amnestic, non-amnestic and multidomain MCI group and found, using self-report measures, that at baseline there was little difference between the groups. But over time both the amnestic and non-amnestic group showed decline in driving frequency, with non-amnestic and multi-domain groups reporting increased difficulty in common driving situations. Further to this, Bangen et al. [35] concluded that those with non-amnestic MCI show greater impairment in abilities relating to health and safety. Currently therefore the picture with regards to MCI is unclear. The situation is further complicated by the movement towards the diagnosis of prodromal or preclinical Alzheimer’s disease rather than MCI which could potentially have negative consequences in relation to driving if people are given the diagnosis ‘Alzheimer’s disease’ when their cognition is only at MCI level. There is no evidence of how these pre-dementia disease states interact with driving skills, and whilst it seems a diagnosis of MCI can have an adverse effect on cognitive measures of driving ability, albeit a mild one, it is not clear this actually impairs driving performance. 6. Impact of diagnosis An important point for patients is they may be reluctant to receive a diagnosis of MCI if they fear that as a consequence

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they may lose their driving licence. Early diagnosis of cognitive impairment is important as it influences future care decisions and prognosis and it is widely encouraged and for example in the UK is in line with the national dementia strategy [36]. The process of screening for cognitive impairment, although for some an actively sought and positive experience may have negative effects on the individual, due to factors such as the fear of the consequences of receiving a diagnosis e.g. financial and social status, including loss of driving privileges [37]. People interpret an MCI diagnosis differently with some identifying it as part of a dementia process, whereas others see it as part of the normal ageing process [15]. Such differences may affect the limitations that are perceived as associated with it (e.g. whether or not their perceived right to hold a driving licence is affected). For those who receive a diagnosis of dementia, it is reported that one of the greatest difficulties faced, is the prospect of losses (e.g. role in the family, social standing), and particularly that of driving [38]. A commonly reported experience is that of the need to cope with the change of role within the family e.g. handing finances or no longer being the main driver [39], with this role being taken over by children or the spouse and some reporting that this has contributed to depression. There is no reason to think that this might not also be the case for those diagnosed with MCI, particularly for those who identify with the diagnosis as a dementia process [15]. 7. Conclusions As populations age the number of older drivers on the road will continue to increase and the incidence of MCI will also grow. At present there are few studies that have investigated the impact of MCI on driving ability, and those that have, have used differing criteria to define MCI. This presents a problem in generalising the findings, and due to the shortage of data available, the picture that has emerged is, so far, inconclusive, as to whether those with a diagnosis of MCI are safe to drive. There is little evidence that clinicians can use to guide their decisions, and presently, no universally agreed guidelines are available. There is currently very little consensus on what test batteries may be helpful in determining driving ability. While a practical driving assessment is the gold standard, it may be difficult to compel individuals to undertake this, particularly if no overt problems are evident. The differences in MCI sub-types (amnestic vs. non-amnestic) also warrant further investigation and at the time of writing, few studies could be found that specifically explored this area in respect to practical or real world driving skills. It could be that different subtypes of MCI have different effects on driving ability, and this could lead to the development of interventions that could delay driving cessation for a number of MCI patients. There is evidence to suggest that those with a diagnosis of MCI or mild dementia use self regulation to reduce their driving, e.g. not driving at night, sticking to well known routes and avoidance of driving at peak times [33] suggesting that many are aware when driving ability starts to decline. Evidence of this gathered from the individual or family could be a trigger point for the clinician suggesting driving ability may have been compromised, and that further investigation would be useful. Finally, since qualitative studies indicate that a particular worry for those diagnosed with a dementia is the loss of their driving licence, it is reasonable to suppose that this would also be the case for those diagnosed with MCI. It can be argued that the risk and fear of losing the driving licence may deter early assessment in that it may lead to reluctance to seek help or diagnosis for a mild memory problem, which in turn could have negative consequences for treatment, prognosis and quality of life. It is clear that this is an area that warrants further research, and that there exists a need for a defined clinical pathway and clearer legislation.

Contributors Kirsty Olsen – Lead author. Dr John-Paul Taylor – Author. Professor Alan Thomas – Author. Competing interests The authors declare no conflict of interest. Funding The authors have received no funding for this article. Provenance and peer review Commissioned and externally peer reviewed in appropriate place. References [1] Eby DW, Silverstein NM, Molnar LJ, LeBlanc D, Adler G. Driving behaviours in early stage dementia: a study using in-vehicle technology. Accident Anal Prev 2012;49:330–7. [2] Breen DA, Breen DP, Moore JW, Breen PA, O’Neill D. Driving and dementia. Br Med J 2007;334:1365–9. [3] Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183–94. [4] Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999;56:303. [5] Panza F, D’Introno A, Colacicco AM, et al. Current epidemiology of mild cognitive impairment and other predementia syndromes. Am J Geriatriat Psychiat 2005;13:633–44. [6] DeCarli C. Mild cognitive impairment: prevalence, prognosis, aetiology and treatment. Lancet Neurol 2003;2:15–21. [7] National Office of Statistics. Ageing in the UK datasets; 2012 http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition= tcm%3A77-285429 [accessed 16.12.13]. [8] Hiscock R, Macintyre S, Kearns A, Ellaway A. Means of transport and ontological security: do cars provide psycho-social benefits to their users? Transport Res D: Transport Environ 2002;7:119–35. [9] Marottoli RA, Mendes de Leon CF, Glass TA, Williams CS. Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. J Am Geriatr Soc 1997;45:202–6. [10] Taylor BD, Tripodes S. The effects of driving cessation on the elderly with dementia and their caregivers. Accident Anal Prev 2001;33:519–28. [11] National Office of Statistics. National traffic survey; 2012 https://www.gov.uk/ [accessed government/statistical-data-sets/nts02-driving-licence-holders 30.07.13]. [12] Sherman FT. Driving the ultimate IADL. Geriatrics 2006;61:9–10. [13] Joosten-Weyn Banningh L, Vernooij-Dassen M, Olde Rikkert M, Teunisse JP. Mild cognitive impairment: coping with an uncertain label. Int J Geriatr Psychiatry 2008;23:148–54. [14] Bamford C, Lamont S, Eccles M, Robinson L, May C, Bond J. Disclosing diagnosis of dementia: a systematic review. Int J Geriatr Psychiatry 2004;19:151–69. [15] Hagerty Lingler J, Nightingale MC, Erlen JA, et al. Making sense of mild cognitive impairment: a qualitative exploration of the patient’s experience. Gerontologist 2006;46:791–800. [16] Mattsson N, Brax D, Zetterberg H. To know or not to know: ethical issues related to early diagnosis of Alzheimer’s disease. Int J Alzheimers Dis 2010 [Article ID 841941]. [17] Gov.uk. Health conditions and driving; 2014 https://www.gov.uk/ health-conditions-and-driving [accessed 14.01.14]. [18] DVLA. At a glance guide to the current medical standards of fitness to drive; 2013 https://www.gov.uk/government/publications/at-a-glance [accessed 14.01.14]. [19] CONSOL. Driver licensing legislation; 2013 http://www.consolproject.eu/ [accessed attachments/article/16/CONSOL%20Report WP5.1 final.pdf 28.01.14]. [20] NHTSA. Driver fitness medical guidelines; 2009 http://www.nhtsa.gov/DOT/ NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/811093.pdf [accessed 28.01.14]. [21] Dawson JD, Anderson SW, Uc EY, Dastrup E, Rizzo M. Predictors of driving safety in early Alzheimer disease. Neurology 2009;72:521–7. [22] Lincoln NB, Taylor JL, Vella K, Bouman WP, Radford KA. A prospective study of cognitive tests to predict performance on a standardised road test in people with dementia. Int J Geriatr Psychiatry 2010;25:489–96.

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Mild cognitive impairment: safe to drive?

Driving is an important aspect of daily living and for many older people provides autonomy and psycho-social benefits. Cognitive impairment has been f...
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