Driving After Stroke: What Are the Appropriate Criteria?

For most people, driving is a very important activity that enhances opportunities for social interactions. Stroke can result in impairments that potentially make driving unsafe, thus contributing to social isolation, reduced activities, and depression. At times, these impairments are obvious, but often the determination of driving competence is more difficult to ascertain. One solution is to obtain a formal driving evaluation. However, these can be costly and are often not covered by insurance. This case report and following debate highlights some of the challenges in the decision making process, and options to consider when facing a similar situation. A 67-year-old, right-handed man is seen by you for the first time. This is an initial outpatient clinic visit 6 weeks after discharge from acute inpatient rehabilitation. The patient sustained a left subcortical stroke 10 weeks earlier with involvement primarily of the posterior limb of the internal capsule. He did not have any seizures or loss of consciousness related to the stroke. Past medical history is notable for hypertension, which the patient reports to be well controlled. His recovery progressed well, and he was discharged independent in performing activities of daily living and ambulating with a straight cane. He was discharged back to his house, where he resides with his wife, who does not drive. A comparison of muscle strength findings at the time of rehabilitation admission and at the 10-week follow-up is shown in Table 1. No sensory or coordination deficits were identified in this patient. No visual deficits were noted both during acute rehabilitation and during the current examination. Cognitively, the patient did not have deficits noted during his rehabilitation stay (“MMSE 30/30” per chart), but his wife mentioned that for the past year or 2 he has seemed to be “more forgetful.” On current examination, he recalls 3 of 3 words at 5 minutes, is fully oriented, and describes accurately events related to the stroke and to subsequent care. Presently, he denies that memory has been a problem, and he is solely focused on receiving clearance to return to driving, emphasizing that he has driven for 50 years without any accidents. He also says that he has been driving in his neighborhood for the past week and has not noted any problems, even though he knew that the inpatient physician had told him that he should not drive until he received clearance by a physician. He originally learned to drive with the right foot on the gas and the left on the brake and resumed this without a problem. When the recommendation of a formal driving evaluation is brought up, he exclaims that it is too expensive and reiterates that he has never had, nor does he now have, a problem with driving. He points out that his wife does not drive, that there is no one else around to drive them anywhere, and that in their area there is no convenient public transportation. He states that, without being able to drive, he would be a “prisoner” in his house. What do you recommend? I can think of no other clinic- or inpatient-related discourse that engenders as much emotion, angst, and downright anger as the issue of driving after stroke. Telling patients that they should not drive and that they require a full driving evaluation often seems worse than informing them that they have an incurable disease. Patients sometimes seem to actually hate me for having the temerity to question their ability to drive. To them, driving is a right. I train residents and medical students to state to their patients that driving is a privilege [1]. It is certainly no privilege to have to talk about the issue with my patients. Physicians are the only health care professionals who are required to report patients to the Ontario Ministry of Transportation—none of our rehabilitation colleagues, including nurses, physiotherapists, occupational therapists, psychologists, recreation therapists, or speech and language pathologists are legally required to do so. I have been told by the College of Physicians and Surgeons of my province, Ontario, that patients frequently complain to the College when their physician informs the Ministry of Transportation that the patient may be unfit to drive, even though this is a legally sanctioned act. The responsibility of determining whether our patients can simply get back to driving after their stroke or, alternatively, be subjected to a specific driving test is certainly difficult from many perspectives. Of all the processes necessary for driving—including cognitive, perceptual, psychological, visual, and physical— the physical demands are probably the least important aspect entering into the quotient of being a safe driver [2]. Our patient has minimal hemiparesis. In addition, he is back at home, his most recent mental status examination result is 30/30, and he denies that memory has been a problem. He even says that he has been driving in his neighborhood for the past week. He may also say that he has a neighbor, friend, or work colleague who is far more affected than he is, “and he drives!” It is fair that the patient believes that he is a good driver and that he can get back to driving. I challenge the reader to find more than 2 patients currently driving on this planet who would admit that 1) they are bad drivers and 2) they should not be driving anymore. People's positive perception of their own driving skill is almost limitless [3]. In my driving-related research, I have rarely heard anyone describe him- or herself as a “bad driver.” However, it is my opinion that this patient needs a specific driving assessment. The key features of this case belong to the etiology of the stroke and to the patient's behavior before and after the stroke. He sustained a left subcortical stroke, also called a lacunar stroke. What is this? It is a “small” stroke, “lacunar” coming from the word “lac” (French for “lake”). With such strokes, the volume of brain that is actually damaged, which produces the hemiparetic deficits, is indeed quite small, often about the size of the end of a pencil. However, what is the etiology of our patient's stroke? The etiology is noted in the history to be hypertension. In general, we know that hypertension may lead to the presence of small-vessel disease, or microangiopathy, which is seen as multiple white matter lesions on brain imaging, better on magnetic resonance imaging (MRI) than on computed tomography (CT) [4]. The patient's stroke is a “sentinel event.” The definition of a sentinel event in medicine is 2-fold. In quality of care matters, it may refer to a type of clinical indicator that is used to monitor and appraise, including events that require immediate attention. It is also defined as an adverse event in health care delivery or other service that leads to, or has the potential to lead to, catastrophic outcomes, thereby often mandating initiation of emergency intervention or preventive measures [5]. In this case, it was the subcortical stroke that brought the patient through the doors of the emergency department and subsequently into acute care and then to the rehabilitation inpatient unit. As multiple scientific articles attest, however, this lacunar stroke is likely merely the tip of the cerebrovascular iceberg [6]. Small-vessel disease is probably prevalent throughout the patient's brain. Although a specific hemisensory or hemimotor loss may become dramatically evident, there is also much other brain activity, such as cognitive or perceptual function, that may be lost, but this is slower to come to the clinical surface—or to reveal more of the iceberg [6, 7]. Cognitive function is frequently lost with small-vessel disease, and our patient's history is indicative of cognitive decline. First, the wife indicates that for the past year or 2, her husband has seemed to be “more forgetful.” Although the patient may make light of this, I believe that the wife has identified a specific cognitive decline. Small-vessel disease can contribute to the predominant impairment of executive function and secondary impairments of associated cognitive functions such as memory and attention [8-10]. Our patient likely fits the bill. Second, what about the fact that the patient has been driving in his neighborhood when the inpatient physician has told him that he should not drive until he has been cleared by a physician? Perhaps this is simply the patient flouting this directive, or perhaps this is a reflection of cognitive decline resulting from the microangiopathy caused by hypertension. The patient heard that he should not drive but did not act on this very serious advice. Is his judgment impaired? He should know that a physician's recommendation not to drive would be documented in his chart, and that, if the car insurance company found out, there would be serious adverse consequences. Still, he went ahead and drove. This could indicate a lack of self-control, disinhibition, or myriad other neuropsychological sequelae, all of which are seen with the small-vessel disease that can be caused by hypertension [4]. The patient states that without being able to drive he would be a “prisoner” in his house. This is why there is so much emotion involved in the discussions that we physiatrists have with our stroke, brain injury, amputee, and other disabled populations. We feel badly for them. We know that our rural patients have even more difficulty getting about if they cannot drive. My own research demonstrated that people's integration back into their community after a stroke is impaired if they cannot resume driving [11]. However, these facts cannot realistically be considered when we have the patient in front of us and we are concerned that his/her cognitive or physical status, or both, could make it dangerous for the patient to drive. We, as physiatrists, have a specific responsibility to the patient; but as the law in many jurisdictions in Canada—and too few in the United States—indicates, we also have a responsibility to the public. In Belgium, patients diagnosed with stroke are not permitted to drive for 6 months. The Canadian Medical Association's driver's guide states that patients should not drive for 1 month after a stroke [12], but this is a guideline only. If our patient is a stockbroker, we are not legally obligated to report him to the New York Stock Exchange and tell them that he is cognitively impaired and can no longer trade stocks, even though we feel that we should. There is also no legal obligation for us to report to a contractor that his carpenter employee had a right brain stroke with subsequent left neglect, which could affect his safety on the job. However, we and other rehabilitation professionals certainly would want to tell the carpenter's family that the impairment of executive function that is frequently associated with stroke may present a danger for his work performance. We, as physiatrists, must take very seriously the legal obligation to report a person's inability to drive. Even if our jurisdiction does not require us to report patients who may be unsafe to drive, I believe that we must inform our patients and their families of any physical, cognitive, and/or perceptual deficits that may make it dangerous for these patients to drive, and must document these discussions in the chart. It makes medical sense that, in many cases, individuals who have sustained a brain injury such as a stroke will require a specific, formal driving evaluation to ascertain whether they are still safe drivers. Why are there not multiple, freely available facilities offering such a service? The problem is a financial one. To my knowledge, no state or provincial government funds formal driving evaluations, and, if there are any, they are few and far between. The patient must bear the cost. This creates hardship, wealthier individuals benefit, and return to driving may be inhibited. Here is a “made in Canada” analogy. If I want to know whether my patient can adequately paddle a canoe, I can test her triceps, biceps, wrist extensors, wrist flexors, and balance in the gym. I can throw objects in front of her and see if she avoids them. I can order neuropsychological tests that may correlate with unsafe canoeing practices. However, if I really want to know whether she can paddle that canoe, the best place to do so would be on a lake, river, or ocean where she typically paddles, and have an expert assess her stroke, her balance, whether she falls out of the canoe, and whether she slams into an oncoming canoeist, shore, or rock face. In keeping with this analogy, I believe that a specific driving evaluation facility with expert evaluators should be available to our disabled patients, at a cost that they can easily afford. Alas, this is not the case in the majority, if not all, of the locations in which physiatrists practice. Driving is too dangerous an activity, and one that can affect too many persons' lives, to be taken lightly. Although they are mild, the patient described above does have some physical deficits. Cognitive deficits are also present. His stroke etiology almost certainly indicates that there are microvascular lesions of the brain in numerous other locations that are just waiting to break through the surface and constitute an even bigger “tip of the cerebrovascular iceberg [6].” In conclusion, I sympathize with this patient. I understand his frustration and desire to drive as soon as possible after his stroke. I cannot, in good conscience, however, recommend driving without a full, formal driving evaluation, and I believe that my decision is based on sound clinical and scientific reasoning. It is time that jurisdictions across Canada, the United States, and elsewhere in the world the of having formal facilities available for stroke then will both the public and the patient be in a fair and the of activity and after One activity that can have a on community and quality of is driving. a patients may no longer be safe to drive. Physicians to in making this However, it is often not whether is safe to drive. of the potential of loss of driving the decision to should not be A formal driving evaluation is one that may be used to make this any other clinical we must consider whether it is and The most important to a person's ability is the physical examination. Although he has not fully our patient has function and good coordination in all muscle of the right and He has no deficits in of There is no by history or physical examination of or mental status, mental or If there were such then there would be a to competence before to driving, and a test would to be of that In the of such deficits, a test not be an to driving can also be as may the determination of the of of driving. The physician can recommend of of transportation. 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It would be to her whether he has had or from if she has noted other drivers when he is or if other and/or are with his driving. in the that require and may to be of that The fact that he has driven physician to the is also of but is not [4]. and evaluation in the or outpatient have been for stroke a of and found that the and are tests that can stroke at for [5]. a of of driving ability after stroke and found that the A and and the were the most and tests [6]. I a of tests from the to and which visual and visual in to of and strength With such the physician will have about cognitive processes that affect executive function, and the ability to attention. The and tests all have one test does not out a patient being a safe it should the physician to evaluation, most an assessment. If this patient all tests it is likely that he will be a safe possible evaluation driver and other for and time. are available through some occupational and may be covered by insurance. have been in populations. In a of cognitive tests drivers who who an driving and of [3]. The test also has been shown to be of driving ability after stroke [6]. such as the the and the may who will well on driving tests who do not [3]. If these would to the of this patient being a safe a of and evaluation are available to the physician make the decision as to whether to recommend return to driving. If this with very good all such tests without it is that there will be a problem, and the patient should be the and of an evaluation. 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A to in driving-related his disabled patients. the of cerebrovascular disease and the of in patients who present with initial acute However, the physician is obligated to the patient's on current examination findings and behavior and not on of Small-vessel disease is not with and cognitive If the patient all the tests that I or my and has of and cognitive and by my examination, then he is likely to be a safe driver and an driving Of it would be to require that the patient make a to and The patient and family should be about the of he should be not to drive if he does not feel well or It is not right to require the driving test based on my for the or the of of cerebrovascular disease. The issue of responsibility is If a patient to take for or in a that is it may lack of of the stroke deficits and In that case, an may be As patients they often their Driving in this patient's neighborhood may have been well his and was the recommendation by the inpatient physician not to If the recommendation had been then the patient may not have from driving. In any case, the physician should him why he went the inpatient recommendation that he not drive. It must be that and I both that the physician who this patient needs to be about his ability to drive. the injury to brain there is a that the patient does have impairments that will with driving and make driving I that the physician should the patient to that visual, and cognitive and are and then the physical examination with or if the patient all of this should he be able to return to driving without an assessment. The formal driving evaluation should not the physician's evaluation and, other medical should be when more is to make a

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