Practice dilemma - Driving with dementia

The Dilemma - You have been the GP to an elderly couple for over 20 years. The wife is disabled by arthritis and the husband has been slowly developing dementia. They never ask for a home visit as he always drives her to the surgery. While giving them the annual flu jab, you realise that his dementia has progressed and he no longer knows your name. As they go to leave the room you realise he is still driving. There is no record of anyone telling him to inform the DVLA. What will you do?

A patient with dementia drives his wife to the surgery
A patient with dementia drives his wife to the surgery
  • A GP's view - Dr Barney Tinsley is a GP partner in Yorkshire

Driving ability is very difficult to assess in patients with any degree of memory impairment or dementia. The guidance from the DVLA states that 'Those who have poor short-term memory, disorientation, lack of insight and judgment are almost certainly not fit to drive.'

Firstly, don't let them leave the consultation just yet. It would appear that the husband has not had a formal assessment of the severity of his dementia, although the snapshot of his condition during this consultation shows that his short-term memory might be significantly impaired. It is difficult to make a potentially life-changing judgment based on this alone.

The GP could perform a mini-mental state examination or abbreviated mental test score on the patient. Anecdotal information regarding his memory and day-to-day activity from his wife would also be of use.

It may be useful to take advice from the on-call elderly medicine registrar regarding the patient's driving, which the GP could relay to both the husband and wife during this consultation.

Common sense might dictate that we would strongly recommend he should not drive from then on, until further assessment is performed, and the husband should be given the chance to stop driving voluntarily from that point. This is unrealistic, especially as they need to get home from the surgery.

If the patient does lack insight and short-term memory, he is unlikely to usefully retain this information; a home visit or phone call later in the week to the patient's wife to ask whether he remembers the conversation, or to check whether he has continued to drive is in the best interests of the patient and other members of the community.

The DVLA has a team of experienced medical advisers who can be consulted via telephone to help with the advisory process; it may be that this patient needs its formal intervention with deciding whether he is fit to drive, which would most likely be after he is formally assessed via secondary care. If this patient does continue to drive, it is ultimately the GP's duty to inform the DVLA about this.

In addition to this driving dilemma, is the issue of this couple's continuing ability to cope in their own home, should they be unable to continue using a car. With the couple's agreement, referral to the community matron and/or social services might be useful to explore home care, meals on wheels, access buses, day centres and occupational therapy assessment for the home.

  • A medico-legal opinion - Dr Angelique Mastihi is a medico-legal adviser at the Medical Protection Society

The transport secretary acting through the medical advisers at the Drivers Medical Group, DVLA, has the responsibility to ensure that all licence holders are fit to drive.

The regulations apply to all drivers and they have a legal obligation to inform the DVLA if they suffer from one of a specified list of conditions, which may affect their ability to drive. If a doctor suspects that his patient has not informed the DVLA of a medical condition he must inform the patient of their legal duty to do so.

In this case there is no record of the doctor advising his patient to contact the DVLA at an earlier stage of his dementia. What is now paramount is that the doctor advises the patient that he should no longer drive. It appears possible that the gentleman is now no longer in a position to advise the DVLA himself.

Therefore the doctor should inform the patient that he will take steps to notify the DVLA. This conversation should be documented in the record and a letter sent to the patient confirming the action taken.

It may be that the patient is no longer in a position to consent to the disclosure of this information to the DVLA. However, in line with the recent GMC guidance 'Confidentiality', the information can be disclosed in the public interest in order to protect both the patient and public from serious harm. It would also be good practice to involve the patient's wife.

  • A patient's view - Elizabeth Brain is a member of the RCGP patient partnership group

Firstly, you must inform the husband of what he is legally obliged to do and secondly, for your own integrity, you should record that you have done so. Clearly, a probable cessation of driving will have a major impact on their family life, but the absence of surgery visits can be mitigated by home visits.

It is a legal requirement for a dementia sufferer to advise the DVLA as soon as dementia is diagnosed. In return, it will write to the person and seek their permission to contact their GP and discuss the extent of their condition.

Depending on the information received, the DVLA may allow him to continue to drive or may ask for a driving assessment. The patient, if able, should also advise his insurance company as his policy may become invalid.

The absence of any record of the above advice is unfortunate but does not preclude a record being entered once the advice has been given.

Resources

  • At a glance guide to the current medical standards of fitness to drive, September 2009

www.dft.gov.uk/dvla/medical/ataglance.aspx

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Before commenting please read our rules for commenting on articles.

If you see a comment you find offensive, you can flag it as inappropriate. In the top right-hand corner of an individual comment, you will see 'flag as inappropriate'. Clicking this prompts us to review the comment. For further information see our rules for commenting on articles.

comments powered by Disqus