Mr. Smith, a successful construction company owner, faced a life-altering challenge with his dementia diagnosis. Forced to retire from his role, he and his family were already grappling with the emotional impact when the local hospital memory clinic deemed him unfit to drive.
This decision sparked outrage and frustration, particularly given the family’s history of generous donations to the foundation of the hospital housing the clinic. Feeling betrayed, the Smiths halted their financial contributions to the foundation, highlighting the emotional and ethical complexities surrounding driving competency of individuals with dementia.
Assessing driving fitness in dementia patients is one of the most challenging aspects of care, requiring a delicate balance of medical, emotional, ethical and practical considerations. Dementia’s unpredictable progression and varied impact on cognitive abilities make it difficult to determine when driving becomes unsafe. Despite most people feeling very confident in their driving ability, baseline driving ability and skills, like many functional tasks, are quite varied; professional drivers such as police officers and transportation workers often have higher experience and skills compared to the average driving population. This variation, mixed in with fluctuations in cognitive function, further complicates determining fitness to drive.
Emotionally, driving is often deeply connected to independence and freedom. For patients like Smith, losing this ability can feel like a profound loss of autonomy. Many individuals with dementia may not fully recognize their cognitive decline, leading to resistance or denial when driving cessation is discussed. Families also experience significant emotional strain, torn between the practical need for their loved one to continue driving while ensuring the safety of the public and family and preserving relationships.
The ethical dimensions of this issue are deeply complex, requiring health-care providers to navigate a delicate balance between safeguarding public safety and respecting a patient’s autonomy. One of the most significant challenges lies in obtaining informed consent for assessing driving competence, as patients may struggle to fully comprehend how their medical condition could impair their ability. Legally, the matter is no less fraught. In certain Canadian jurisdictions, physicians are mandated by law to report patients deemed medically at risk – such as those diagnosed with dementia – to transportation authorities. This obligation, as outlined in provisions like Section 203 of Ontario’s Highway Traffic Act, often pits patient confidentiality against the broader imperative of public safety. Compounding these tensions are the concerns of families and health-care providers, who may fear potential liability should a patient subsequently be involved in an accident.
Practical challenges further complicate matters. While cognitive and driving assessments exist, none are foolproof. Cognitive tests may not fully reflect driving abilities which are dependent on health factors but also experience, and on-road tests can be stressful, often costly or difficult to arrange, especially in rural areas. Communication is another hurdle, as discussions about driving cessation are often emotionally charged and met with defensiveness or denial.
While cognitive and driving assessments exist, none are foolproof
In Ontario’s Niagara region , family physicians in a newly established community of practice identified this challenge as particularly pressing. The Niagara Family Physician Dementia Care Community of Practice (CoP) provides a collaborative platform for physicians to share strategies for managing complex dementia cases. Supported by a Niagara Community Foundation grant and led by Ehab Wassif, a family physician and memory clinic specialist, the CoP includes nine family physicians and one geriatrician. Full disclosure, the project receives advice from me. This groundbreaking initiative is the first of its kind in the region.
A key focus of the CoP has been addressing driving safety for patients with identified cognitive impairment through a partnership with Candrive, an international research program dedicated to assessing driving competence in older adults. The CoP is piloting Candrive’s Older Driver Risk Stratification Tool (RST) in memory clinics. The RST is a research-based screening tool that evaluates driving safety by analyzing key variables capturing the domains of physical functioning, memory and executive functioning. This tool will be integrated into data collection across Niagara’s six primary care memory clinics and the hospital geriatric assessment program, providing an evidence-based approach for screening driving risk for collision in older adults, including those with cognitive impairments.
The CoP is collaborating with Candrive to gather feedback on the RST’s feasibility and usefulness for health-care providers. CoP is also exploring partnering with the Centre for Research on Safe Driving at Lakehead University to incorporate driving simulator technology into evaluations of fitness-to-drive. Studies have shown strong alignment between simulator results and neuropsychological evaluations and on-road driving data, as well as strong inter-rater and intra-rater reliability. The simulator adds to the information gathered with in-office tests and may support the determination of fitness-to-drive without requiring an on-road test.
Preliminary discussions are underway to integrate the driving simulator into dementia care in Niagara. The proposed plan involves memory clinics referring patients in the “grey zone” of driving fitness to a single simulator site. Funding for the simulator’s hardware and software is expected from the Ontario Health support of the Niagara Ontario Health Team for Digital Innovation, and work is in progress to develop job descriptions for simulator operators.
While this initiative is focusing on dementia clinics, Candrive is also aiming to implement the Candrive RST in primary care clinics and is seeking health-care providers to participate in this research. If you are a primary health-care provider and are interested in contributing to this study, please contact Candrive (mgoubran@bruyere.org or smarshall@toh.ca.)
Mr. Smith’s case illustrates the nuanced and often difficult decisions health-care providers face when assessing medical fitness to drive. While the memory clinic’s determination was likely well-founded, the family’s emotional response highlights the critical need for clear, compassionate communication and sustained support. Rebuilding trust with the family and offering practical resources to help them adapt to these changes will be essential in navigating the emotional and practical complexities of the situation.
