For family physicians, few clinical decisions are as emotionally charged – or as uncertain – as deciding whether a patient living with dementia is still safe to drive.
These decisions carry serious consequences: reporting concerns to the Ministry of Transportation can mean the loss of independence for patients while failing to act can put drivers and the public at risk. Yet for years, physicians have been asked to navigate this terrain using tools that are often inconsistent, subjective or poorly suited to the realities of everyday practice.
In Ontario, physicians in the Niagara Family Physician Dementia Care Community of Practice (CoP) identified this challenge as particularly pressing; in 2025, the group piloted the CanDrive Risk Stratification Tool (RST), a research-based screening tool that evaluates driving safety by analyzing physical functioning, memory and executive functioning. Rather than presenting decisions as personal opinions, clinicians could refer to a structured process that supports more open and balanced discussions about safety and independence
But while the RST has improved structure in driving assessments, it has not fully addressed the issue that concerned physicians most: patients who fall into an intermediate, or “grey zone,” risk category. For these cases, clinicians questioned whether relying solely on cognitive testing was sufficient.
To address this issue, the CoP is working on a driving simulator to add to the RST. Niagara Ontario Health Team’s Dementia Care Working Group is being kept informed about the project’s progress.
Supported by a Niagara Community Foundation grant and led by Ehab Wassif, a family physician, memory clinic specialist and one of the authors of this article, the group’s CoP includes nine family physicians and one geriatrician. The CoP provides a collaborative platform for physicians to share strategies for managing complex dementia cases.
This exploration led to the introduction of a driving simulator housed at Niagara College that provides a controlled and standardized way to assess reaction time, decision-making and driving behaviour in scenarios designed to reflect real-world driving complexity.
Importantly, the simulator initiative did not originate as a research project. It emerged directly from clinical need, shaped by physicians’ experiences navigating difficult real-world decisions. Only later was it formalized as an evaluation, with research questions grounded in frontline practice. The work was further strengthened through a partnership with the Centre for Research on Safe Driving at Lakehead University, which supported the integration of driving simulator technology into assessments of fitness to drive.
Emerging evidence suggests alignment between simulator performance, neuropsychological assessments and on-road driving outcomes, along with high inter-rater and intra-rater reliability. When used alongside in-office assessments, the simulator may offer additional clinical insight and, in some cases, reduce the need for on-road testing when determining driving competence.
To ensure sustainability, six memory clinics and the Geriatrics Assessment Program have committed trained staff to conduct simulator assessments as part of routine practice. Niagara Ontario Health provided funding for the simulator software and hardware, and Niagara College allocated dedicated space to support the simulator’s long-term availability.
To understand whether the simulator truly improves decision-making, a phased research approach is underway. An initial feasibility and accessibility study is examining how the simulator fits into clinical workflows and whether it is accessible for people living with cognitive impairment.
A second phase of the study, now in development, will compare driving simulator results with on-road assessments in a cohort of 50 patients. These on-road evaluations are being provided in kind by the local AAPEX Driving Academy, strengthening the study while avoiding additional financial burden. Funding for Phase 1 was secured through support from Niagara College, and fundraising efforts for Phase 2 are progressing.
If a clear relationship is demonstrated between simulator performance and on-road driving outcomes, the findings could support future recognition of the simulator as a clinical assessment tool to complement existing in-clinic evaluations. While formal adoption would require policy and regulatory review, this work represents an important step toward more evidence-informed and equitable decision-making.
One of the defining features of the initiative is its focus on sustainability. Rather than relying on short-term pilots, the CoP has worked to embed its activities into existing organizations and workflows.
The Alzheimer Society of the Niagara Region provides administrative support and dementia care leadership, including hosting meetings and supporting the ongoing role of the Lead CoP Physician. Academic partners contribute research expertise while Niagara College’s Healthy Aging and Wellness Innovation Centre provides research management supported by national funding.
The CoP has helped shift how dementia care is understood and delivered in Niagara. Family physicians are now more closely connected with health planners, service organizations, and researchers, improving communication and reducing duplication across the system.
The success of the Niagara Family Physician Dementia Care Community of Practice lies not in a single innovation, but in how multiple elements – peer support, research, education and system planning – have been woven together. It demonstrates that physicians, when supported and connected, can drive meaningful system change from the ground up.
As dementia prevalence continues to rise across Ontario, the need for consistent, fair, and patient-centred approaches will only grow. The Niagara experience suggests that CoPs, grounded in real clinical challenges and supported by cross-sector collaboration, may offer a path forward.
While the work continues, the message is already clear: improving dementia care does not require choosing between safety and independence. With the right structures, tools and partnerships, it is possible – and sustainable – to pursue both.
