Should Persons with Parkinson's Drive?
Who is Ergun Uc?
Ergun Uc is a movement disorders neurologist, professor, and clinical researcher at the University of Iowa Health Care and at the Iowa City VA Health Care System (https://medicine.uiowa.edu/neurology/profile/ergun-uc ). He is the director the Movement Disorders Division and the Parkinson’s Foundation Center of Excellence. His research has been funded by the NIH, VA, DoD, and major foundations, and focuses on cognition, vision, driving, and the role of exercise in PD.
Should Persons with Parkinson’s Drive?
It depends on the individual characteristics of the patient! A medical diagnosis by itself cannot determine fitness to drive. PD is a chronic condition that can affect movement, cognition, vision, mental health, sleep and alertness. It can start in midlife or older age. PD affects patients differently: Some have significant cognitive and vision problems early on, some continue cognitively intact for many years; some respond well to medication for a long time and have no major balance problems, others have a lukewarm response to medication and start falling early. Older age usually aggravates the disease manifestations.
Thus, patients who function well with their medications and do not have significant cognitive, visual, alertness, and balance problems can continue driving safely. However, patients who are rather slow and stiff, who have significant problems with memory, decision making, attention, multitasking, vision, or excessive daytime sleepiness are at a higher risk for crashes. These types of patients should be monitored closely and be offered alternative transport options as needed. The development of dementia usually leads to driving cessation.
What are the key highlights on recent driving research and PD?
· Cognitive and visual impairment are very important predictors of poor driving in PD. In particular, patients who have difficulties with attention, multitasking, decision making, memory of routes, differentiation of shades of grey (contrast sensitivity), correct recognition of positions and relationships of visual objects (spatial perception) are at high risk for driving errors, citations, and crashes.
· Movement related problems also increase driving risk. Usually, poor balance and postural instability, excessive slowness and stiffness are a better predictor of poor driving then tremors.
· Left turns at intersections, driving in reduced visibility, and multitasking during driving increase the risks of driving problems and crashes in PD.
· Driving impairment progresses faster in PD than in normal aging. For example, a patient who drives normally today might have significant driving problems in 1-2 years. Hence, it is important to monitor driving safety in PD.
· It is well established that drivers with PD stop driving earlier than their healthy age-matched peers. While experimental studies show increased crash rates in PD, real life follow up studies have not yetcfully confirmed this since thankfully many patients stop driving before a real-life crash happens.
· The role of driving rehabilitation is still being studied.
Should driving evaluations be mandatory in PD?
There is no federal policy on reporting and mandatory testing in PD in the USA. Hence, the rules are vary from state to state. Typically, it is between the patient, family, and his/her healthcare providers to decide on driving. As stated above, relatively young patients with early disease and good response to medications and no significant cognitive and visual and alertness problems, can continue driving safely for many years. Once it is determined that there are cognitive, visual, alertness, or movement issues that impair daily function, it is safest for the PWP to be referred to the appropriate specialists for testing in these areas to make a preliminary judgement on fitness to drive. If a patient fails on cognitive and visual testing, or they are really slow and unbalanced with poor response to medications, I recommend driving cessation. If the impairments are mild and a driving test is safe, I refer them for a road test by the state agency or a certified driving specialist. If the patient passes the road test, I recommend annual road testing or more frequent if needed.
What is the difference between a driving simulator and a road assessment?
The road test is performed under real life settings and reflects the driver performance— more realistically. In our experiments, we are using an instrumented road vehicle (https://www.nads-sc.uiowa.edu/sim_iv.php). Instrumented vehicles are equipped with special sensors and cameras that enable objective and detailed evaluation of driving performance.
However, road testing carries usual traffic risks and cannot include special high risk challenges. This is where driving simulation comes in. Driving simulation is done under complete experimental control in a computerized environment and there is no life or limb at stake. Therefore, a test subject can be exposed to extreme circumstances to measure their reactions. Of note, some people with migraines and motion sickness, may feel sick and dizzy in a driving simulator depending on the type of driving task.
Driving simulators have different levels of “fidelity” and can range from inexpensive desktop video game type settings to very expensive industrial set ups in a hangar like facility— where very realistic driving experiences can be administered in a full motion platform. Typical driving labs in hospitals or universities are in between this experience and usually are performed in fixed-base vehicle cab with a large screen placed in front of it. Here are examples of different driving simulators and instrumented vehicles used by our collaborator National Advanced Driving Simulator (NADS) at the University of Iowa.
Below is a recent interview by co-blog host Indu Subramanian on driving and PD.
Should I fear losing my license if tested?
There is a risk of losing your license if tested. However, the recommendation to cease driving can be made by the healthcare provider based on clinical features and non-driving tests as stated above. Ultimately it is about your safety and that of your family and loved ones.
Is it safe just to drive close to home? To the store and post-office?
Many patients restrict their driving to a couple of well-known places, during good weather and road conditions, and during the daytime with clear visibility conditions. While this reduces risk, it does not eliminate it completely since even in these setting unexpected hazards can emerge that require quick and accurate reactions.
What are the take home points about driving in
PD?
· The safety of a driver with PD is complex and depends on a range of characteristics and factors in the stage of their illness and types of symptoms.
· Early on, patients may continue driving as usual, but a time will come when testing and close monitoring with periodic road tests will be needed.
· Patients can improve safety to some extent by driving in familiar settings, avoiding congested traffic and complex intersections (especially left turns), avoiding inclement weather and poor visibility conditions. Staying fully focused and not engaging in distracting tasks while driving is absolutely critical.
· PD patients are at a higher risk of driving cessation and their crash risk is increased in driving research tests.
· Cognitive and visual impairments, excessive daytime sleepiness, and poor balance are the most important predictors of poor driving in PD.
· Assessment of driving fitness requires teamwork with the input from the patient, caregiver, primary care provider, neurologist, neuropsychologist, vision specialists, occupational therapy, other specialists as needed. State driving agencies are also important in the process. It is vital that everyone work together honestly and openly to help ensure the safety of our patients and their loved ones.
What resources would you suggest?
https://www.pmdalliance.org/portfolio/driving-and-road-safety-for-people-with-pd-with-ergun-uc-md/
https://www.parkinson.org/podcast/Episode-62-Driving-with-PD
Good luck on your journey and hope my metaphors help you on your journey.
To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside
He also serves as the Medical Advisor for the Parkinson’s Foundation.
To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.
This blog was provided by an interview with:
Ergun Y. Uc, MD
Professor of Neurology|Department of Neurology | University of Iowa
Director, Movement Disorders Division & Parkinson’s Foundation Center of Excellence
200 Hawkins Drive | Iowa City, IA 52242
Phone: 1.319.356.4757 | Fax: 1.319.384.7199
E-mail: ergun-uc@uiowa.edu | Website: Faculty Profile
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PI, Long Term Aerobic Exercise to Slow Progression in Parkinson's Disease (NIHRePORTER & ClinicalTrials.gov)
Partnering PI, Blood-Based Exosomal alpha-Synuclein Aggregates as a Quantifiable Biomarker of Parkinson's Disease (W81XWH-20-1-0811 on DoD CDMRP)
Associate Editor, Parkinsonism & Related Disorders