Concerns about safe driving...
People who have been diagnosed with early stage Alzheimer's disease may wish to continue to drive and resist giving up their cars. Because few states currently require retesting of adults for driver's license renewal and many physicians do not want to be the bearers of this sometimes crushing blow to independence, family care givers are often placed in the difficult position of limiting or ending the vehicular mobility of a person who has Alzheimer's.

Vehicles and the option to drive symbolize many things: independence, convenience and competence among them. Even without a diagnosis of Alzheimer's, advancing age may bring a decrease in vision and hearing and a slowing of reflexes. Most people are able to judge for themselves how these or other developments affect their ability to drive. For example, an older person may decide to drive fewer miles, to avoid congested roads, more slowly and not at night. Even though it is never an easy choice, some people do determine for themselves when it is time to limit or stop driving.

Because particular memory loss and confusion are often early evidence of Alzheimer's disease, the impact on one's ability to drive—to recall routes and recognize roads and road signage may be substantial—compounding the risk. For a person with Alzheimer's disease, the decision to stop driving is often not voluntary. Just how long someone with Alzheimer's should be permitted to drive, if at all, is an issue that stirs the emotions of those with the disease, their caregivers and the public.

Factoring In Increased Risk
According to the National Highway Traffic Safety Administration, when driver fatality rates are calculated based on estimated annual travel, the highest rates are found among the youngest and oldest drivers. The fatality rate for drivers age 85 and older is 9 times higher than that of drivers in the age range of 25 to 69.

The onset of Alzheimer's may well increase this risk even further. Scientific studies covering this issue vary as to the relationship between Alzheimer's disease and a person's ability to drive. According to one study, per mile, people with Alzheimer's disease are 19 times more likely to have an accident than are older adults without the disease. However, another study found no significant difference in the traffic violation and crash rates between the two groups, although the researchers also concluded that the drivers with Alzheimer's drove fewer total miles.

Safety As An Issue
Knowledge of the rules of the road, good judgment and adequate eyesight, hearing and coordination are all needed for safe driving. Some experts say that over the years, the ability to drive is so ingrained that it becomes somewhat automatic or over-learned. In many people, driving skills seem to be well preserved into old age.

Yet most authorities agree that even if a person has good coordination and reasonably sharp senses, when judgment is compromised, driving becomes unsafe. Accidents—even minor ones—should not be considered a part of routine driving. A person with Alzheimer's has slower reaction time, less spatial judgment and diminished ability to think ahead and drive defensively.

Assessing Driving Abilities
Because the disease progresses differently in each person, it is nearly impossible to generalize about when people with Alzheimer's lose their capacity to safely handle a motor vehicle. What makes it even more imprecise is that some people in the early stages of the disease are still able to pass a driving test. Also, the disease can affect a person's ability to understand that he or she may be a danger to others on the road.

Sometimes psychological tests can help determine whether someone with Alzheimer's has the memory, perception and coordination needed to drive safely under normal conditions. However, no definitive, quantifiable, standardized tests exist that pinpoint when driving should be discouraged or stopped. As a result caregivers and family members remain responsible for continually reassessing the driving abilities of a person with Alzheimer's. As the person becomes more impaired, the caregiver must balance loss of independence and dignity against the risk to self and others.

Decision Making
If you are the caregiver or family member of someone with Alzheimer's, it is up to you to help assess that person's ability to drive. Many times it is the son or daughter who has just come to visit who notes that Dad's driving abilities have fallen off considerably from the last time home, and Mom hasn't been willing to say anything. When any of the following signs is apparent, it is time for the person to give up driving:

• Inability to locate familiar places, problems getting lost
• Failure to observe and obey traffic signs and speed limits
• Poor or slow decision making in traffic
• Increase in the number of fender benders
• A change in behavior not in keeping with a previous driving record
• Increased traffic citations
• Marked insurance premium increases or cancellations

Giving up the car keys
Whether or not a person with Alzheimer's continues to be licensed to drive as long as keys and car are available, there is a risk that driving might happen. Telling someone that it is time to give up the keys is likely to be difficult. The person may react with anger and sadness. Here are some things you can do to aid in the decision.

• Acknowledge the loss and offer reassurance. Talk about the issue of driving and the things it represents in the person's life. Reassure the person that alternative transportation will still be available and that this is a wise decision. [This underlines the importance of church vans, manageable public transportation and friends.]
• Consider having the person tested. If the person with Alzheimer's has lingering questions about his or her ability to drive, seek assistance in getting the message across. Psychologists and occupational therapists can help assess a person's driving aptitude by evaluating the thinking abilities and motor skills necessary to drive safely.
• Offer to be available for transportation. Driving reinforces independence, but it is a convenience as well. Often an major concern expressed by a person who is going stop driving centers on how he or she will get about to make purchases, attend events and gatherings (including church) or to visit others. If you can provide assurance that you or someone else will be available to drive, these concerns may be alleviated.
• Know your state's regulations. Some states require that people with Alzheimer's disease be reported by their doctors to state health and motor vehicle departments. Reporting the person's need for retesting can often be done anonymously. Some states automatically revoke the driver's license of people with Alzheimer's. Even after license revocation, the person may need to be reminded that he or she no longer has a license.
• Ask others for support. Ask a respected family member or friend, physician, attorney or insurance agent to reinforce messages about not driving. If your loved one insists on continuing to drive, ask his or her doctor to write a note explaining that the person must not drive. Remind him or her that insurance doesn't cover those driving against medical advice. Review this frequently with your loved one.
• Make the car and keys less accessible. If the person with Alzheimer's continues to insist on driving, keep the car and the keys out of sight. Cars can be disabled so that even if the person finds the keys, the vehicle cannot be started. Sometimes simply putting the car in the garage or in a neighbor's driveway will be enough to keep the person from driving. If worst comes to worst, it may be better to get rid of the car entirely rather than risk injury or the loss of a life.

What living arrangements are best?

Often family members are faced with making difficult recommendations or decisions about living arrangements for those in their care. Assisted-living arrangements are best for people who have moderate functional impairment but do not need full-time nursing care. They can still do such tasks as feed themselves and get in and out of chairs. Assisted-living facilities are typically complexes with apartments or townhouse-like units that feature communal dining, housekeeping services, social activities and help with personal care. Residents also may be encouraged to participate in meal preparation, laundry and other tasks.

Some questions to ask to help decide between assisted living or home care:

If your loved one lives alone:

• Does living alone make your loved one anxious? Does he or she call frequently needing reassurance or end up at the neighbor's needing help? If yes, an assisted-living facility may be the best option.
• Does your loved one need help on occasion with meals or medications? If your loved one is emotionally stable but needs periodic assistance, you may instead consider in-home care services such as Meals on Wheels or a home health service.

If your loved one lives with you:

• Is your loved one's nighttime wandering so disruptive that you cannot get adequate sleep? If yes, and medical remedies are not helpful, an assisted-living facility may be appropriate.
• Do you need assistance during the day because you have other obligations such as a job? If your loved one doesn't have significant behavioral problems and you need help during the day, consider elder-care programs before concluding that assisted living is your only option. You may also lighten your load by hiring a cleaning or meal service.

Other Factors To Consider
When making your decision about living arrangements, consider your loved one's wishes and needs, but also think about his or her personal safety. If independent living poses too many risks, it is best to restrict independence somewhat in favor of increased safety, which an assisted-living facility can better provide.

Also consider the ongoing costs of in-home care. Round-the-clock home care is expensive, and insurance usually does not cover it. However, some insurers pay for assisted-living care. Medicare restrictions vary from state to state.

Making The Decision
Deciding when a loved one with Alzheimer's disease needs a more structured care setting can be difficult. Feelings of love, loyalty and guilt can complicate your decision. But you can make the choice that is right for you and your loved one by considering all the relevant factors, asking questions and making careful observations. If you need help making the decision, consult your loved one's doctor or other health care professionals involved in his or her care, such as nurses or social workers. You may also want to consult other family members or an Alzheimer's disease caregivers' support group.