Expert: Mary Gordon - 6/19/2004

Question
My 84 year old mother in law lives next door to us, alone and at this point without a companion, yet needs one.  We are watching the early stages(?..or not so early) of alzheimer's. She has always been extremely independent and strong willed. Of course we love her dearly...she was diagnosed almost 2 years ago by a local highly respected geriatric psychiatrist.  She promptly said that she would never go back to him!...( Her husband had been a surgeon in our small community and was always "well taken care of" at a moments notice through her life....and of course, years have passed on and health care has changed.  )....You can imagine...the issue of driving is GIANT. We are about 150 miles from Seattle and she is still driving there and back! (once in awhile)....but mainly around town .  She is a great hiker still and physically is strong and agile for her age!  Friends are not wanting to drive with her..etc....we have talked til blue in the face, ...my husband is an Elder Law attorney and deals with older people all the time....but logic has certainly gone out the window for her.....HELP!....What does one do when the patient is still in many ways capable, BUT truly the best thing would be to STOP driving!...?  She has said "you willl have to fight me over the driving issue"....and we love her deeply and get along soo well most of the time...but is getting harder.  She will not listen to us...at this point if  the car were to just"disappear one day"...that would not slow her down in getting another one.  $$ is not an issue with her life style.  What do we do if she will not listen to her family or her doctor? My dear husband is too close, though dealing with other people all the time....this is tearing him apart.  Any thoughts?  Thank you

Answer
This is going to be long - I'll ramble on, and hopefully, you will take from what I say the useful bits you can apply to your own situation. I know that driving represents independence, competence and control, but Alzheimer's is not like other "changes" in later life that affect driving, such as eyesight problems and slow reaction times.

Many older adults who don't have dementia can assess their driving changes without family intervention and do make gradual changes to the way they drive (i.e. stopping driving at night or on the highway). Many are able to continue driving safely throughout their life.

With a dementia like Alzheimer's that causes brain damage, an individual's capacity to assess his or her driving ability diminishes. They really cannot see their own problems and deficits, so what may seem glaringly obvious to you, or to their friends, they will not recognize. They are especially likely to minimize the complexity of driving and overestimate their abilities. They may make excuses for their high-risk driving.

You should be aware that Alzheimer's doesn't just affect memory.  Cognitive functions critical to driving decline; such as judgment, emotional control, reaction time, multi-tasking and problem-solving abilities. Other areas of decline are physical and sensory (such as muscular coordination, depth perception etc.) and they also increase driving risks.

Although culturally we tend to view driving as an adult right - it really is a priviledge, predicated on being able to do so safely. In other words, being cognitively intact, and able to use reason and judgement. Never mind her own safety - think about others on the road or sidewalks. How would you feel if she were in an accident and injured someone else? While your desire to maintain a good relationship with her is understandable, I think you need to think about whether sparing her feelings to this extent would be worth having to face the family of someone she has injured - or worse.

As the adults with the intact brains in this situation, you have some responsibility to act. As you are learining for yourself, there is little point in trying to reason with someone whose “reasoner” is broken. All the logic on the planet won't get through to her - all you accomplish is to get her upset. Its kind of like arguing with a 2 year old about why they can't play in the knife drawer or with the power tools. You can't win with words since the fight isn't on a level playing field.

You have to cook up another way around the mountain - and since safety is the overriding factor, the fight doesn't have to be a clean one. You have to do what you have to do, and you will have to wade in with your sleeves rolled up.

You don't mention where you live. In many places, the doctor has a legal responsibility to report a person anyone who has been diagnosed with an illness that may impact their ability to drive.  Here in Ontario, the doctor reported my mother in law to the licensing authority, and she got a letter from the goverment telling her that in order to keep her license, she would have to do a drivers test (both written and road) by a certain date.  That was the end of that. My husband even had gotten the “rules of the road” handbook so she could study, but even though she felt she was fine to drive, I think even she realized she wasn't going to be able to pass (I think just the idea of having to remember all those signs and speed liimits was daunting). This was ideal because by making the doctor and the government the bad guys, we were spared a lot of angst and confrontation.  We sold her car, got her an account with a local cab company, and slept better at night.

Solicit the help of the doctor who diagnosed her and ask him for something in writing regarding the driving issue. Ask him for his  recommendations and suggestions. Ask him or her family doctor to report her to the licensing authorities. If they will not do it, contact them yourself, and inform them of your concerns in writing (i.e. XYZ is a hazard on the road and was diagnosed with Alzheimer's by Dr. G in 2002). You should also inform her insurance company about her diagnosis and issues. I'd be amazed if they knew about her condition and were still willing to insure her unless she had routine assessments of her ability to drive.  

I would also ask the family doctor to arrange for a full cognitive assessment for her - tell him what you are seeing and what friends are reporting. I think it would be extremely useful to everyone involved.  If she is reluctant to go, get the doctor in cahoots and say it's required for insurance purposes. My mother in law went for some comprehensive testing conducted by a psycometrist - my husband went with her.  He was completely and totally shocked at what he witnessed- it was a jolt of reality and moved us out of comfortable complacency. At the time, if you had met her, you would have thought she was peachy fine - maybe a little forgetful and vague, but that's about it. She could carry on a very good social conversation, she lived on her own, and her friends and most of the family thought there was nothing wrong with her. But the testing....oh boy. She was much, much more impaired, and on many more fronts than was obvious to those closest to her. If your mother in law was diagnosed two years ago, I suspect that you will be surprised if you have her tested - and it will give you ammunition to convince yourself and others it is past time to act.

Your husband is a lawyer, as well as a son. I expect he knows that if there has been a diagnosis of Alzheimer's,  a victim of an accident she causes will not stop their suit at the liability limit of the auto insurance. If negligence or a prior knowledge of incompetence can be found they can sue.  Auto insurance will indicate you knew but did not tell them of the medical diagnosis, and you could be in the liability soup.

There are many firms who will carry out drivers assessments on a fee for service basis as an alterntive to a government driving test.  The person goes out with a professional instructor who watches their driving and can say if the person appears to be safe to drive. If she goes for an assessment like this, as the person who administers the test to explain the results to you and your mother in law.

You could also disable the car - and do not HELP her get it fixed (in other words, don't lift a finger to enable the behaviour you are trying to stop - if she is so with it, let her figure it out).  Removing a battery wire will stop the car from starting - or a mechanic can install a "kill switch" that must be engaged before the car can start.  Replace her car keys with ones that don't work.  Come up with a plan to ease the transition.  Arrange for alternate transportation. You may be able to establish a payment account with a taxi service so that your loved one won't have to handle money (which is what we did - we just paid the tab monthly).

This system is going to cut off the end of my answer (it limits the length), so I'll send the rest in a separate answer after you see this part = send me a another question, a blank, and I'll send you the other half!

Mary G.

I think you both know that the scope of financial, legal and moral risk here is huge.  You and your husband have yet to make the big mental shift that all caregivers have to make - and believe me, I sympathise, because the day you make the shift and the full meaning of what is happening comes home to you is like getting kicked in the stomach. As hard as it is for you, it will be even harder for your husband - he will desperately want to believe that the mother