Sadly, age and cognitive decline often go hand in hand. Approximately one in ten Americans over the age of 65 have dementia. As much as half of individuals with dementia still drive. The statistics on how many additional accidents occur as a result are somewhat murky. Some studies reveal twofold increases in risk of car crashes. But one study actually revealed lower risks among drivers with dementia possibly because that set of persons reduces their driving frequency so much relative to the non-dementia set that the occurrence of accidents drops despite the greater risks associated with cognitive impairments (and also because not everyone with dementia is incapable of driving safely). Still, no one doubts that the risks of driving with dementia are real, yet the law has had very little to say about the matter.
In Patient Autonomy, Public Safety, and Drivers with Cognitive Decline, Professors Hoffman and Robertson assess the predicament of drivers with cognitive impairments. Even individuals with only mild dementia are about ten times more likely to fail an on-the-road driving test than comparators without dementia. Currently, however, only one state requires road re-testing for all drivers above a certain age (75 and above, in Illinois). Simply renewing a driver’s license in-person is too anemic. Across-the-board mandatory road re-testing is too costly. A more thoughtful solution has thus far been elusory, but Hoffman and Robertson articulate and defend a multifaceted framework of enhanced protocols which is both compelling and thought-provoking.
The solution to roads filled with too many drivers with dementia, they explain, may lie in imposing responsibility among stakeholders and encouraging interventions by medical providers. Previous proposed solutions have relied too heavily on a single point of responsibility (whether it be the DMV, the primary treating physician, or family members). Interestingly, the tort system has already provided some degree of relief in the form of potential liability for family members and doctors who fail to intervene. While caretaker liability scares might move the needle a bit, a more comprehensive framework is more likely to significantly curtail crashes caused by cognitively compromised drivers.
Interestingly, the authors also explicate the precise nature of how cognitive impairments affect one’s driving abilities. “This is because driving requires a multitude of cognitive abilities” (P. 6.) First, there is working memory capacity, which involves the retention and manipulation of short-term events. Second, there is time-sharing ability which permits one to perform several tasks simultaneously, rapidly switching attention from one to another. Spatial skills allow a driver to monitor objects such as pedestrians and obstacles and locate them in relation to the driver by using forward vision, side vision, and – in the case of driving, in particular – those pesky rear-facing mirrors. Finally, a driver must blend all these cognitive operations together while abiding by a small constellation of rules of the road and adhering to the goal that will enable her to ultimately arrive at her destination. Toss in verbal commands from a smart phone and distracting conversations from a passenger and even experienced non-impaired drivers must fully engage different areas of their brains to avoid mishaps on the highway.
It shouldn’t be surprising, then, that a number of popular cognitive tests fail to evaluate the particular skills required for driving or their multifaceted combinations. One helpful cognitive test, for example, involves drawing the hands of a clock to reflect a particular time of the day. Others assess verbal cues and word recall. Just because a cognitive test proves to be a helpful diagnostic tool does not mean that it has anything to say about the individual’s ability to drive a car. The precise contours of any given individual’s cognitive decline must be assessed across multiple dimensions. Some of the more appropriate tests, the authors emphasize, are time-consuming and impractical. Still, primary care physicians are at the front-line of the problem and are better equipped to at least refer a patient for further driving assessments, if they could be properly incentivized to do so.
The problem of drivers with dementia is further exacerbated by the cultural/regulatory landscape of our extremely car-centric way of life, especially in low population density areas of the country with few options for mass transit. The authors convincingly demonstrate how the law not only fails to ameliorate the public safety hazard of drivers with cognitive impairments, but actually works to enhance Americans’ dependence on automobile transportation. Citing Gregory Shill and Jesse Singer, they explain how “the legal system isn’t merely responding to personal preference for automobile travel or allocating responsibility for traffic harms caused by individuals – instead, our law and policy create the very context in which those preferences and harms arise” (P. 20.)
Hoffman and Robertson’s full set of recommended protocols – which would involve doctors as well as law enforcement officers, insurance companies, families, and DMVs – cannot be fairly summarized in a jot. For that, a careful study of their readable, lively article is highly recommended.
