Section 4

Driving cessation

Driving plays a central role in the daily lives of many people, not only as a means of meeting transportation needs, but also as a symbol of autonomy and competence. The prerogative to drive often is synonymous with self-respect, social membership, and independence.

Driving cessation can result from a gradual change in driving behaviour (i.e., voluntary restrictions that will eventually lead to driving cessation), a progressive illness (e.g., dementia), or a sudden disabling event (e.g., a stroke). Some drivers voluntarily stop driving; for others, driving cessation is involuntary. Gradual, voluntary driving cessation is more common than sudden driving cessation. However, the decision to stop driving is often complex and affected by a number of factors.

Voluntary driving cessation refers to self-induced changes in driving practices that are made for reasons other than the revocation of a licence or other strong influence from external sources. Several factors are associated with voluntary driving cessation.

• Age — older drivers are more likely to stop driving of their own accord than younger people (Edwards et al., 2010; Albert et al., 2018).
• Gender — women are more likely to give up driving voluntarily than men (Jette and Branch, 1992; Foley et al., 2002; Bauer et al., 2003; Choi et al., 2012).
• Marital status — drivers who are single, widowed, or divorced are more likely to stop driving than those who are married (Braitman and McCartt, 2008).
• Socio-economic status — drivers with lower income are more likely to stop driving than those with higher income (Andersen, 2016).
• Education — interventions that involve tailored training have been shown to improve knowledge of road safety, change self-perception of driving abilities, and improve behind-the-wheel performance of older drivers (Sangrar et al., 2019).
• Place of residence — drivers living in urban settings are more likely to stop driving than those living in rural areas (Strogatz et al., 2019).
• Functional impairment — drivers with impairments in sensory, motor, or functional abilities are more likely to stop driving than those without impairments (Uc and Rizzo, 2008).
• Transportation support — drivers who have transportation support (from family, friends, or organizations) are more likely to stop driving than those without such support (Choi et al., 2012).

These general factors can assist physicians in anticipating who may be more comfortable giving up driving privileges when it becomes medically advisable to stop driving.

Involuntary driving cessation occurs when a licence is revoked or outside sources (e.g., physician, family members) bring their influence to bear. Involuntary driving cessation often is due to the presence of one or more medical conditions or the medications used to treat those conditions.

The most difficult situation that physicians face is when a patient is functionally incapable of driving safely but has a self-perception of competence to drive. Physician involvement includes frank but sensitive discussions with the patient (with or without the patient’s family present), referral for a driving evaluation, and reporting to the licensing authority. Counselling on alternative means of mobility is needed. For those with cognitive impairment, “through- the-door” service, as opposed to regular “door-to-door” public transportation, will be needed. For those with progressive illnesses (e.g., dementia, macular degeneration, multiple sclerosis), early discussions can help the person and their family to plan for the inevitable need to stop driving.

Involuntary driving cessation is more likely to be required when insight declines and/or impairment in driving ability (e.g., with dementia) is present. To date, only a few factors are known to be associated with involuntary driving cessation:

• Gender — men are more likely to require outside intervention to cease driving (Schouten et al., 2022).
• Insight — those with impaired insight are more likely to continue driving and to need intervention (Carmody et al., 2012).

These factors can assist physicians in predicting who may be resistant to discussions about the need for driving cessation or resistant to and non-compliant with advice or a directive to stop driving. In addition to patients, families also may lack insight into the negative impact of an illness on driving ability. Family members may have their own reasons for wanting the person to continue driving (e.g., loss of mobility for the patient and often the spousal caregiver, time demands associated with a family member becoming the transportation provider, increased caregiver burden). Education and support for caregivers and other family members are frequently necessary.

Specialized driving cessation support groups have been shown to be effective in helping patients with dementia and their caregivers to cope with the loss of driving privileges (Dobbs et al., 2009). Such groups may be available to assist patients (and their caregivers) in the transition from being a driver to being a non-driver.

Few drivers plan for “retirement from driving” (Sommerfeld, 2016). However, data indicate that, on average, men outlive their driving careers by 6.2 years and women by 9.4 years (Foley et al., 2002). Incorporating “driving retirement plans” with financial planning for retirement may be an effective means of engaging both current and future cohorts of drivers in planning for the day when they will no longer drive. Research indicates that many older drivers are open to conversations about transitioning from the driver’s seat to the passenger seat, and older drivers believe that physicians and family members can assist with the decision-making process (Hartford Center for Mature Market Excellence, 2018). Advance driving directives, which may be included as part of advance directives for end-of-life care, may help to facilitate discussions about driving (Betz et al., 2013). Responsive forms of alternative transportation, as well as transportation assistance from family and friends, are needed to allow those who have retired from driving to remain engaged with their community (Curl et al., 2014). However, most forms of public transportation (e.g., light rail transit, public buses) are designed primarily for individuals who are healthy and mobile. Ensuring the availability of alternative transportation that is responsive and accommodating to patients who wish not to or can no longer drive (e.g., volunteer driver programs, for-profit transportation services) is critical to meeting the needs of this growing segment of the population. Physicians can and do play a significant role in helping patients and their families to become familiar with the transportation resources available in their communities.

It is important to recognize the consequences of driving cessation for both patients and families.

The following suggestions will help physicians to develop a strategy before meeting with the patient to discuss driving cessation.

• Before the appointment, consider the patient’s impairments. It may be important to ask if the spouse or another caregiver can be present. This person can provide emotional support to the patient during the appointment, and their presence can help to ensure that the family understands the need for the patient to stop driving. It also may be helpful to meet with the family (with the patient’s consent) before holding a meeting with both the patient and the family.
• Whenever possible, the appointment should be in a private setting, where everyone can be seated. Always address the patient preferentially, both in the initial greeting and during the discussion.
• For patients with progressive illnesses, such as dementia, discuss driving early in the course of the illness, before it becomes a problem (Perkinson et al., 2005). Early discussions also allow patients and family members to prepare for the day when driving is no longer an option.
• Be aware that patient and caregiver reports of driving competence often do not reflect actual competence. Evidence of impaired driving performance from an external source (e.g., driving assessment, record of motor vehicle crashes or near misses) can be helpful. Discuss with the patient and family members the risks of continuing to drive.
• Emphasize the need to stop driving, using the driving assessment if available, as the appropriate focus of discussion.
• Often the patient will talk about having a past clean driving record. Acknowledge that accomplishment in a genuine manner, but return to the need to stop driving. Sometimes the discussion can be refocused by saying “Medical conditions can make even the best drivers unsafe.”
• It is common for drivers, especially those who are older, to talk about a wide range of accomplishments that are intended, somehow, to show that there could not be a problem now. Again, acknowledge those accomplishments, but follow with “Things change. Let’s not talk about the past. We need to focus on the present” to end that line of conversation and refocus the discussion.
• Ask how the patient is feeling and acknowledge their emotions. Avoid lengthy attempts to convince the patient through rational explanations. Rational arguments are likely to evoke rebuttals.
• It is likely that emotions and feelings of diminished self-worth represent a real issue behind a patient’s resistance to accepting advice or direction to stop driving. Explore these feelings with empathy. A focus on the patient’s feelings can deflect arguments about the evaluation and the stop-driving directive.
• Ask the patient what they understand from the discussion. It may be important to schedule a second appointment to further discuss the patient’s response and explore next steps.
• Document all discussions about driving in the patient’s chart.
• To assist patients in staying mobile, have them create a “mobility account,” using the money that they would have used to own and operate their own vehicle. The Canadian Automobile Association has a Driving Costs Calculator that helps in identifying all of the ongoing costs of owning and operating a vehicle (see https://carcosts.caa.ca/). For example, on average, it costs $13,654 to own and operate a mid-sized car in 2022, based on 32,000 km driven per year. The purpose of the mobility account is to have funds set aside to cover the costs of alternative transportation.

An important consideration with involuntary driving cessation is compliance. Research indicates that as many as 28% of people with dementia continue to drive, despite failing an on-road assessment (Croston et al., 2009). Family members play a pivotal role in monitoring and managing compliance with a stop-driving directive and may try numerous methods to ensure that the patient stops driving, including hiding the keys, disabling the car, cancelling the vehicle insurance, or selling the car. However, evidence of the success of these interventions is largely anecdotal.