driving and neurological disorders

DRIVING IN NEUROLOGICLAL

DISORDERS

Prof. Ashraf AbdouNeuropsychiatry department

Alexandria university

OBJECTIVES

Mechanism of driving impairment

Driving in Epilepsy

Driving in Dementia

Driving in Parkinson’s D.

Driving after stroke

WHO 2012

WHO 2012

Driving

 Higher cognitive functions

Perception and attention to stimulus

Formulation of a plan based on memory experiences

Execution of an action such as applying a brake,

steering control, or accelerator

Vision

motor control and coordination.

Neurological impairment & Paroxysmal disorders

Neurological impairmentParoxysmal loss of awareness

Cognitive impairment - AD EPILEPSY

Motor control impairment

# Weakness

# Bradykinesia

# Incoordination

Excessive day –time sleepiness/sleep disorders

Acute hypoglycemia

Syncope# Arrythmia# Dysautonomia

Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49© 2013 American Academy of Neurology

USA current position for doctor responsibility

Pros & Cons on reporting

Patient’s safety

Community safety

Doctor-patient

confidentiality

Patient conceal

medical information

that help in treatment

Patient’s right

Epilepsy

Studies showedApproximately 700,000 of the 180 million1 Americans

licensed to drive have epilepsy Drivers with well-controlled seizures are not at a high or

unacceptable risk for crashesuncontrolled epilepsy poses a substantial risk for MVA50% patients who have seizures while driving have

motor vehicle crashesOne recent US study showed that patients with

intractable seizures often continue driving.  39% had a seizure at the wheel27% crashed because of a seizure

Evidence-based

Not predictive of motor vehicle crash (MVC).

protective against crashes

Short seizure-free intervals (≥ 3 months) (Level C)

Epilepsy surgery (Level B),

Seizure-free intervals (6–12 months) (Level B)

Few prior non-seizure-related crashes (Level B)

Regular antiepileptic drug adjustments (Level B)

Epilepsy Behav. 2012 Feb;23(2):103-12

Risk of driving in medical diseases

Seizure-free period & Driving

Most European countries; 1 yr seizure-free 

In USA: AAN – AES –EFA; 3 months

3 months (7 states), 6 months (14 states), and

1yr (7 states)

23 state no specific time [Neurologist – MAB]

7 states mandatory physician reporting

In Japan: 1 yr seizure-free

Figure. Seizure-free restrictions for noncommercial driving in the United States.

Krauss G et al. Neurology 2001;57:1780-1785

Copyright © 2012 British Epilepsy Association Terms and Conditions

Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49© 2013 American Academy of Neurology

USA current position for doctor responsibility

# The official position of the AMA. AES, AAN do not support mandatory

reporting of medical conditions to government

# Most European medical societies took a position against physician

reporting

F A V O U R A B L E

U N F A V O U R A B L E

Seizure-freeOff medication

USA: 10 yrs EU: 5 yrs

ONLY IN EGYPT

Dementia

Dementia and driving

Patients with mild AD showed double car

crash in age-matched controls.

The average number of crashes per year in

patients with AD increased dramatically after

the first 3 years from symptom onset.

75% can pass on-road driving

Evidence-Based : patients at increased risk for unsafe driving

FactorLevel of evidence

Clinical Dementia Rating Scale [CDR] AA caregiver's rating of a patient's driving ability as

marginal or unsafe 

C

A history of traffic citations  CA history of crashes CReduced driving mileage  CSelf-reported situational avoidance CMMSE scores of ≤24  CAggressive or impulsive personality characteristic C

AAN Practice Parameter update: Evaluation and management of driving risk in dementia 2010

Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49© 2013 American Academy of Neurology

Stroke

Driving after stroke

In developed countries, more than half of persons with stroke are fit to drive following a successful on-road examination

Most reliable test for recognition of resuming driving after stroke:

Road Sign Recognition test

Trail making test B

Compass task

Cube copy test

Stroke Drivers Screening Assessment

Parkinson’s Disease

Parkinson disease (PD):Typical motor symptoms Cognitive impairment/dementiaEmotional impairments (e.g., apathy and

disinhibition) Visual-perceptual deficitsPossible side effects (e.g., daytime

sleepiness) of PD medications

Parkinson’s D & driving

 A retrospective survey study: found that patients with Hoehn & Yahr (H&Y) stages 2 and 3 had a significantly higher crash risk compared to healthy controls. However, there was no evidence of increased crash risk among patients in H&Y stage 1

Another survey study: 82% of patients with PD held a driving license and 60% of them were still driving. Of the patients holding a driving license, 15% reported being involved in an accident.

Drivers with PD may not reveal medical information when renewing their license or adhere to physician's advice to quit driving.

Evidence-Based

Tying it all together! Neurological disorders

are most frequent cause for driving disability

Most studies focus on epilepsy and dementia followed by parkinson’s D

For epilepsy most studies and regulations focus on seizure-free period before allowing to drive again

For dementia ; evidence-based guidelines are available to help the physician to take his decision