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Driving and Dementia Case Study
Review the following case study one section at a time, responding to the questions posed following the information provided. Expert opinion about how to respond to the case can be found at the end.
PART A: Case Information
Background
Mr. G. is an 85 year old man living with his wife Non-smoker, 2 – 3 beer per day Past Medical History: Osteoarthritis (neck, knees) Lumbar spinal stenosis with radicular pain and weakness in feet Mild Parkinson’s disease X 1 year Macular Degeneration & Glaucoma Diabetes with peripheral neuropathy and neuropathic pain poor diabetic control HTN
Medications:
Sinemet Oxybutinin (Ditropan) Nortryptilline and Gabapentin for neuropathic pain. Tylenol #3 PRN – takes 4 – 6 per day Glyburide and Insulin Oxazepam QHS PRN for sleep Adalat XL 120 mg OD
Physical Examination:
Pulse 60 and BP 110/70 supine Pulse 60 and BP 80/50 standing. Denies postural lightheadedness but slightly unsteady when first standing. Does admit that on occasion he does get more “dizzy” and has to sit down. Mild restriction in neck turning Possible left upper quadrant visual field loss (borderline finding) Pain in knees with movement Decreased light touch and proprioception in feet Mild ankle weakness Failed 2 of 3 Ruler Drop Reaction Time Tests (Failed = dropped ruler)
Cognitive Examination:
Somewhat slow in answering questions MMSE 25 / 30 (0/3 recall, problems with pentagon drawing) MOCA 19 / 30 (0/5 recall, problems with Trails, Cube drawing, Clock drawing) Trails A – 1 minute 10 seconds, 1 error Trails B – 5 minutes 20 seconds, 5 errors
Family Interview:
Progressive mild decline in memory X 2 years No major impact on Function. Still able to bank, cook, shop and use TV remote. Some mild problems remembering to take medications. Wife feels patient is “a great driver and has never had accidents”. Daughter cannot voice any specific concerns but seems worried.
PART A: Questions
- Using the 10-Minute Office-Based Dementia and Driving Checklist, is the patient safe to drive at this time? List any contraindications to driving.
- What is the cognitive diagnosis?
- What actions would you pursue with respect to driving? Are there any potentially reversible factors?
PART C: Case Information
1 year later… Memory problems worse Some impact on high level IADLs – medication use MMSE 24 / 30 (0/3 recall, more problems with pentagon drawing) MOCA 20 / 30 (0/5 recall, more problems with Clock and Cube drawing) Trails A – 55 seconds, 0 errors Trails B – 2 minutes 50 seconds, 2 errors Appears cognitively slow again Family history unchanged
PART C: Questions
- Using the 10-Minute Office-Based Dementia and Driving Checklist, is the patient safe to drive at this time? List any contraindications to driving.
- What is the cognitive diagnosis?
- What actions would you pursue with respect to driving?
PART C: Further Information
Passes – allowed to continue to drive. Initiate discussion regarding the inevitability of eventual driving cessation Arrange follow-up every 6 – 12 months regarding fitness-to-drive
PART D: Case Information
2 years later… Dementia has progressed despite aggressively addressing all reversible factors and attempting cholinesterase inhibitor therapy Having difficulty with several IADLs – medication use, banking, cooking and possibly TV remote use MMSE 19 / 30 MOCA 15 / 30 Trails A – 85 seconds, 1 error Trails B – 6 minutes 50 seconds, 6 errors Slow mentation is obvious Slow parkinsonian movements – can no longer catch ruler during Ruler Drop Reaction Time Test Wife is now expressing concerns regarding driving. She reports 2 near misses where patient almost struck a car and a pedestrian.
PART D: Questions
- Using the 10-Minute Office-Based Dementia and Driving Checklist, is the patient safe to drive at this time? List any contraindications to driving.
- What is the cognitive diagnosis?
- What actions would you pursue with respect to driving?
