Driving and Alzheimer’s Disease

The caregivers of my patients frequently ask me about the safety of their loved ones getting behind the wheel after receiving a diagnosis of Alzheimer’s Disease (AD). This is a sensitive topic for patients, but a very important one in terms of both safety and liability, as I will discuss here.

First, my own research has recently revealed that driving in moderate and late stage AD is a much larger problem than we first feared, and this is not attributable merely to aging. In fact, we have seen that 16 year old males have a higher incidence of accidents than healthy non-demented individuals over the age of 75. However, in mild cognitive impairment (MCI) and the early stages of AD, we do not see increased accident rates. But as early AD progresses into moderate AD accident rates rise sharply.

I’ve done some research correlating test scores to driving safety and will discuss that more in a later article. For now let me just say that by the time a patient’s MMSE (mini mental status exam) or ALZselftest score is as low as 20, they are at a increased risk of having an accident while driving. Put simply, these people should not be driving.

A complicating factor here is that a portion of AD patients who also have Anosognosia, may believe they are perfectly healthy and see no reason not to drive. I had a very distraught family come in one day and tell me that in spite of all their efforts, they could not get the patient to stop driving. He ended up getting into the back seat of the car, becoming very angry and accusing his family of stealing the steering wheel, yet he was certain he was okay to drive. These are the patients that refuse to give up the keys, exacerbating the problem.

Complicating things for the family is the fact that, according to the legal system, the family could possibly be held liable if their loved one takes the car and gets into an accident. The family could well be sued and held financially responsible.

As a physician, here are the things that I do with my patients, and suggest to others, to help support both the family and the patient, and especially to keep everyone involved safe and protected.

• The healthcare provider should assume responsibility – I always explain to my patients that I am a professional with a lot of experience in this area and, based on their test results I believe that they should not be driving. I attempt to be very fact-based in this delivery, explaining the results of their test scores (MMSE, ALZselftest, etc.) and indicate that they fall into a group with high accident rates.
• Next, I physically write a prescription and hand it to them, instructing them “no driving.” This prescription goes home with them and is placed on the refrigerator, or bathroom mirror, or somewhere they will see it regularly.
• Sometimes I offer my patients a follow up call. This is a buffer to allow them time to get used to the idea, and to give some space to the subject of driving as an option. In the office I tell them if they get home and still feel they need to discuss it, to give me a call back. I’ve made this offer over 500 times and no one has taken me up on it.
• I enable the family to agree with the patient, rather than argue. Family members can say “Hey, we agree with you about driving but, unfortunately the doctor said no, as you can see from this prescription. We cannot go against the doctor.”
• If necessary, I encourage the family to disable the car – often after a couple of weeks the patient will simply stop inquiring about driving.

The best way to both support the patient and ease the stress on the family is for the healthcare provider to assume full responsibility for the decision to take away driving. If you are a caregiver with these concerns, talk to your healthcare provider privately and ask for support in making this decision.

Whatever you do, do not ignore the problem. This is a problem than can and does cost lives. If you doubt your loved ones ability to drive, do not allow it until you can receive further assessment from your physician, and receive professional support for taking driving away. And above all, be sensitive in delivery of this news. Driving is a freedom that is very upsetting to part with and should not be taken lightly. But it should be taken when the patient becomes too impaired. Using these tips, the process should go much more smoothly for everyone involved.

I wish you good health.

Dr. John Dougherty
Director, Cole Neuroscience Center

“There’s Nothing Wrong With Me!” Caring For Loved Ones Unaware Of Their Problem

Anosognosia is a term used to describe a person who is unaware of or denies the existence of their condition or problem. Some researchers estimate 20% of Alzheimer’s Disease (AD) patients suffer from Anosognosia. My own research puts this estimate closer to 50%.

If you have a loved one suffering with Anosognosia you are probably very familiar with this concept, even if you didn’t know the medical term for it. AD patients with Anosognosia will argue with you if you point out deficits in memory or basic functioning. They tend to believe that they can function normally – still manage the finances, for example, when it is apparent to you that their cognitive deficits impair this ability.

AD patients with Anosognosia can be some of the toughest for caregivers to manage, and can create greater stress on loved ones than those without Anosognosia. It may help to remember that this is a medical condition and that special care is needed to manage these individuals. It is often important to ensure that some individuals with Anosoagnosia not drive vehicles, as this can present a dangerous situation.

Since the patient may not recognize the need for medication, creativity is helpful here. For example, I sometimes recommend that caregivers of patients using the anti-cholinesterase patch place the patch on the patient’s back (rather than chest), to keep them from seeing and removing it.

It is frequently best not to argue with patients with Anosognosia when the issues are often of little consequence. Important issues however, should be dealt with firmly and directly, especially when it’s time to explain to them that certain activities are dangerous for them, such as: driving is not safe!

As the caregiver, always remember that patients with Anosognosia have a distorted self-awareness and are not just trying to be difficult.

Mild Cognitive Impairment

Mild Cognitive Impairment, or MCI, has become better understood in recent years. It is broadly considered to be a transitional stage between normal, age-related cognitive changes and dementia. We have learned some key things about individuals with MCI that are very important to understand for long term quality of life. Believe it or not, if you have received a diagnosis of MCI, this is actually very good news. It means that you are one of the few people who have been brave enough to get yourself tested for memory concerns. And because of this, you have learned at the earliest possible stage of some potential future problems. It’s great news because at this stage we have a lot of options for treating you and others like you.

As a physician, I can tell you that almost 8% of people diagnosed with MCI convert to Alzheimer’s Disease (AD) within 1 year. However, 20% of people diagnosed with MCI revert to normal memory within 1 year. So a diagnosis of MCI is not a cause for panic so much as it is a call to action. MCI can be caused by a number of things and it’s very difficult to track down which one caused yours. However, studies of people with MCI who take Cholinesterase Inhibitors (CEIs), such as: Aricept and the Exelon Patch, have shown a slower 12 – 24 month rate of conversion to AD.

While there have been some mixed study results on the use of CEIs, the most recent study in the New England Journal of Medicine provides support for CEI effectiveness up to 24 months. I prescribe CEIs for my MCI patients and continue to see encouraging results.  I also suggest that my patients add vitamins, physical and mental exercises to their daily lives, all of which have been shown to slow the progress of AD.

If you have memory related concerns and haven’t been tested, know that *early detection is key*. If you have received a diagnosis of MCI, be aware of your options and continue to monitor your brain function. You can take our own clinical computerized screening test, or you can follow up with your physician for in-office testing. Which ever you choose, make sure you are being followed by a physician, testing yourself regularly to chart your progress and stay informed of all the latest research on how physical and mental exercise, diet and nutrition and other steps can keep your mind sharp and AD at bay. I wish you very good health.

Dr. John Dougherty

Is Forgetting The New Normal?

I ran across an article from Time Magazine from 2008, which is packed with great information.  It’s a wonderful overview on how memory is stored, why we forget and what we can do to help our brains function better.

The article cites several studies showing the positive impact of regular aerobic exercise on increasing cerebral blood volume (CBV), as well as some excellent nutrition sources for brain health like blueberries and walnuts.  The Time article cites studies on lab rats that have shown blueberries: “zap free radicals (highly reactive atoms that can damage tissue), reverse aging, enhance cognition and–and this is the kicker–cause new neurons to grow.”

It goes into detail about the benefits of maintaining a healthy weight, since studies have shown that obese individuals are at a substantially increased risk of developing Alzheimer’s.

I always promote diet, aerobic exercise and cognitive stimulation to my patients.  This article is a great summary on just how effective these small measures can be in sustaining our long term brain health.

Memory: Forgetting is the New Normal