Patients who have had a stroke should not drive for at least 1 month. During this time, assessment by their regular physician is required. Such patients may resume driving if the following conditions are met:
• The physician notes no clinically significant motor, sensory, coordination, cognitive, perceptual, visual, or neuropsychological deficits during the general and neurologic examinations.
• Any underlying cause has been addressed with appropriate treatment.
• A seizure has not occurred in the interim.
Any available information from the patient’s treating nurse, occupational therapist, psychologist, physiotherapist, speech pathologist, or social worker should be reviewed to assist with the determination of deficits that may not be visible or detected during an office visit.
The physician should take particular care to note any changes in personality, alertness, insight (executive functions), and decision-making ability, however subtle and inconsistent, in patients who have had a stroke; these types of changes could significantly affect driving ability. Reports from reliable family members may help the physician in discerning whether the patient’s judgment and awareness are altered in day-to-day activities.
Patients with a right-brain stroke are usually verbally intact but very much impaired with regard to their insight, judgment, and perceptual skills. Such patients may pass a standard on-road test, because such testing does not challenge their deficits. Patients with a left-brain stroke frequently present with some degree of aphasia. Although aphasia is not an absolute contraindication to safe driving, it requires the physician’s attention and further evaluation.
Where there is a residual loss of motor power, sensation, or other physical, perceptual, neuropsychological, or cognitive deficit, a driving evaluation at a designated driver assessment centre (Appendix B) may be required. The driver assessment centre can make recommendations for driving equipment or vehicle modification strategies, such as use of a steering wheel “spinner knob” or left-foot accelerator. Training in the safe use of the equipment should be provided.
Patients with a visual field deficit from a stroke must undergo a visual field study by an optometrist or ophthalmologist. Patients with major changes to their visual field should be counselled not to drive. The reporting requirements to the licensing agency vary according to the jurisdiction, although a patient’s refusal to follow advice not to drive should be reported in all Canadian jurisdictions.
Patients who have had a stroke and subsequently resume driving should remain under regular medical supervision, as the episode may be the forerunner of a gradual decline in their thinking processes (e.g., multi-infarct dementia or vascular cognitive impairment due to microvascular disease). In some provinces, licence restrictions, such as denial of expressway or high-speed driving privileges or limitation of driving to areas familiar to the driver, are available at the discretion of the licensing authorities. The aim of this restricted licensing is to bring the level of driving difficulty into alignment with driving ability; however, evidence to support this intervention remains limited.