1. Prof. Ashraf Abdou
Neuropsychiatry department
Alexandria university

2. OBJECTIVES
 Mechanism of driving impairment
 Driving in Epilepsy
 Driving in Dementia
 Driving in Parkinson’s D.
 Driving after stroke

3. WHO 2012

4. WHO 2012

5. 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.

6. Neurological impairment & Paroxysmal
disorders
Neurological impairment
Paroxysmal loss of awareness
Cognitive impairment - AD EPILEPSY
Motor control impairment
# Weakness
Excessive day –time
sleepiness/sleep
disorders
# Bradykinesia
# Incoordination
Acute hypoglycemia
Syncope
# Arrythmia
# Dysautonomia

7. USA current position for doctor responsibility
© 2013 American Academy of Neurology
Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49

8. Pros & Cons on reporting
 Patient’s safety
 Community safety
 Doctor-patient
confidentiality
 Patient conceal
medical information
that help in treatment
 Patient’s right

9. Epilepsy

10. Studies showed
 Approximately 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 crashes
uncontrolled epilepsy poses a substantial risk for MVA
50% patients who have seizures while driving have motor
vehicle crashes
One recent US study showed that patients with
intractable seizures often continue driving.
 39% had a seizure at the wheel
 27% crashed because of a seizure

11. 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-seizurerelated crashes (Level B)
Regular antiepileptic
drug adjustments (Level B)
Epilepsy Behav. 2012 Feb;23(2):103-12

12. Risk of driving in medical diseases

13. 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

14. Figure. Seizure-free restrictions for noncommercial driving in the United States.
Krauss G et al. Neurology 2001;57:1780-1785

15. Copyright © 2012 British Epilepsy Association Terms and Conditions

16. 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
© 2013 American Academy of Neurology
reporting
Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49

17. FAVOURABLE
UNFAVOURABLE

18. USA: 10 yrs
EU: 5 yrs
Seizure-free
Off medication

19. ONLY IN EGYPT

20. Dementia

21. 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

22. Evidence-Based
: patients at increased risk for unsafe driving
Factor
Clinical Dementia Rating Scale [CDR]
A caregiver's rating of a patient's driving ability as
Level of evidence
A
C
marginal or unsafe
A history of traffic citations
A history of crashes
Reduced driving mileage
Self-reported situational avoidance
MMSE scores of ≤24
Aggressive or impulsive personality characteristic
C
C
C
C
C
C
AAN Practice Parameter update: Evaluation and management of driving risk in dementia 2010

23. © 2013 American Academy of Neurology
Drazkowski J F , and Sirven J I Neurology 2011;76:S44-S49

24. Stroke

25. Driving after stroke
 In developed countries, more than half of persons
with stroke are fit to drive following a successful onroad 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

26. Parkinson’s Disease

27. Parkinson disease (PD):
Typical motor symptoms
Cognitive impairment/dementia
Emotional impairments (e.g., apathy and
disinhibition)
 Visual-perceptual deficits
Possible side effects (e.g., daytime
sleepiness) of PD medications

28. 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.

29. Evidence-
Based

30. 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