Medical Driving Evaluations

Driving After a Stroke

Posted by Joan Cramer on Mar 29, 2019 1:49:03 PM
Joan Cramer
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Life after a stroke isn't easy, and may never be the same. There is no easy answer to the question about when a person can drive after having a stroke.   Every person is different, every stroke is different and this leads to very different aftercare.  Past medical history, age, other medical complexities and the severity of the stroke all play a role in the potential for a person to recover and demonstrate the ability to consider driving. In this article, I'll talk about my experience as a Certified Driving Rehab Specialist working with stroke patients and help you understand the possibilities of driving (or retiring from driving) after a stroke.

Baseline functional skills for some stroke patients return quickly (often related to the type of stroke and timeliness of intervention) but these individuals may have subtle issues that were not identified in their brief rehabilitation admission.  Other stroke patients have obvious and complex limitations that make it evident they are not safe to resume driving.  For either group there will be a timeframe during which they will need to adapt and accept help with transportation.   

 

Types of strokes

Ischemic strokes

  • associated with plaque build up in arteries
  • block or restriction of blood flow to brain
  • atherosclerosis or cardiovascular disease

 

Hemorrhagic

  • damage to arteries in the brain
  • bleed into the brain or between the brain and skull
  • changes in artery health from aging or illness (ie: high blood pressure, smoking)

 

Basic questions need to be considered when working with a stroke client:

Did anyone even ask the stroke victim if they planned to drive?

  • Learn about existing support systems to lessen the worry about getting to appointments
  • Ask if there is a desire to return to driving.
  • Understand why driving is a goal of the individual
  • For many, driving after a stroke is anxiety inducing, scary and not something they look forward to. Forcing someone to leave their comfort zone will not help in their recovery. It is important to understand their real goals before you proceed with care.

 

Who is responsible for assessing driving skills and risk factors associated with this task? 

The State of Connecticut Department of Motor Vehicles does not have a mandatory reporting requirement for medical professionals to comply with when an individual experiences a medical condition that may have a temporary or permanent influence on the ability to drive.  There are a number of documents which a physician can refer to for reporting concerns (https://www.ct.gov/dmv/cwp/view.asp?a=818&q=245036).  In a study completed in 2012 regarding elder driving risk factors the DMV indicated that they encourage doctors to submit documents that would trigger the DMV to suspend a licensees right to drive until the are tested and found to be safe behind the wheel.  This study documented that the reporting can be anonymous or if the doctor is identified: “No civil action may be brought against someone who provides such a report in good faith”. 


 

Before discharge from a hospital or rehab program was there an assessment regarding options for transportation until seen by their neurologist for a follow-up assessment?

  • When there is a medical issue many caregivers are focused on saving lives. It is important to assure that there is a transportation plan in between the severest parts of the stroke and a return to transportation.
  • Different levels of care will be concerned about different discharge needs.
  • If a person lives alone there needs to be a defined point person to address transportation. A stroke victim that hasn’t received instructions or limitations their driving can put themselves and others they share the roads with at risk. I have heard and seen horror stories of a recent stroke victim driving themselves to their first follow up appointments at the doctor, simply because no one told them no to. Be sure to clearly communicate the limitations and restrictions to a stroke patient. If you are the family of a stroke patient, do what you can as a family unit to provide support and transportation resources for your family member.

 

Common physical challenges that may affect driving safety


Common visual challenges that can affect driving safety

Impaired peripheral Vision

Neglect of either visual field

Poor depth perception

Delayed visual processing speed

Limited ocular motion

Change in acuity

Scanning

Divided Attention

 When did they last see the eye doctor, especially if there is a possibility of a change in visual abilities?

 

Driving requires visual awareness in multiple directions and vision is the sense used the most to accomplish driving.

 

“Spatial relation” needs to be assessed to ensure safety in moving, busy environments with unexpected events occurring

 

 

Common cognitive and/or verbal challenges

Impaired judgement

Expressive Aphasia

Receptive Aphasia

Impaired communication

Right/Left discrimination

Learning new things

Memory

Problem solving

Those who suffer a stroke may have varied language issues associated to the area of the brain affected.

 

Cognitive impairment is unique to each person depending on severity of the stroke, timeliness of treatment, premorbid medical issues

 

Difficulty with roadway communication, judgement with reactions to other drivers’ behaviors, limited reaction times

 

Recall of travel route, location of common locations and recall of people may result in the need for supervision

 

Driving after a STROKE

At some point following a stroke, the patient may return to the physician/APRN/PA expressing that he/she wants to resume driving. Some drive themselves to the appointment before getting permission to drive since they may perceive that they are ready to engage in this complex task.  Others are less adventurous with concerns about liability and follow the advice of the healthcare professionals working with them and avoid driving until officially cleared by the doctor.

There are many aspects of driving after a stroke that need to be considered:

  • Reaction times to unexpected situations caused by other drivers
  • Control of the wheel with sensory loss or weakness in one hand
  • Trunk control and sitting posture to allow for good head placement
  • Visual processing to attend to multiple mirrors for critical lane changing information
  • Appropriate vision to allow for proper placement of vehicle near other cars
  • Timely attention to all signs and visual instructions presented while the car is moving

 

Young or old, a person who experiences a stroke, or trauma to the brain, is quickly forced to apply the brakes for driving.  The many learned and automatic behaviors they have mastered when driving a vehicle may need adjustment and for some, have been forgotten completely.  Each stroke patient will have a unique cadre of challenges to manage.  Each person will find that their known sense of freedom is going to be influenced by their limited ability to drive, temporarily or permanently.

Making a decision based on facts

It would be best to recommend a stroke patient for a specialized driving assessment nearing the point of their plateau in progress with traditional rehab services or before they hurt someone or themselves.  The rehabilitation team places their efforts on building the foundation skills needed to participate in a driving assessment.  Stroke patients with limited extremity functions may need to be taught how to operate a car using adaptive devices; each person will need to be fitted for the devices that work best for them.

Don’t get your family together and say “mom seems good, let’s give her the keys back.” Even if you come from a family of medical professionals, the skills required for driving are a very specific skillset and require a professional’s eye. You can ask your doctor(s) for their recommendations, and you can ask your doctor for a referral to a Certified Driving Rehab Specialist for a thorough and specific driving assessment.

WHO IS RESPONSIBLE TO ASSESS ACTUAL SKILLS

Healthcare providers need to be encouraged not to pass the buck regarding the difficult question of continued driving.  This includes care givers in all venues – hospital, acute and sub-acute rehab settings, homecare, and out-patient services.  A common response I hear from Physicians is that they “do not feel qualified since they are not driving with them”.   In my years of providing rehab services, every stroke patient I have treated has been unique and presents with varied deficits. An individualized approach is critical to respect the person being treated, especially when dealing with the sensitive subject of independence.

If a healthcare provider is unable to carve out extra time to assess all aspects of performance needed for driving safely, it is best they refer the person to a Certified Driver Rehabilitation Specialist (CDRS) for a Comprehensive Clinical Assessment and if possible, an actual Driving Assessment.  You can find your local CDRS by going to the ADED web page.

It is important to keep in mind that the complex task of operating a motor vehicle involves many skills performed simultaneously.  A comprehensive assessment by a CDRS will look at each task in isolation and collaboratively.  The CDRS will compare testing results to evidence-based data when determining if there are risks involved with driving.  

Possible outcomes

Specialized training is available for CDRS professionals to ensure best practice in the assessment procedures used to meet the needs of every individual.   Knowing what options are available to assist a right hemiplegic person as compared to a left takes specialized training.  In addition, each situation has its own list of precautions to consider when training an individual in the use adaptive driving equipment.

Drive On

It is completely possible that a stroke patient that has had low or limited impact on their wellbeing will be able to continue driving as they did before.

RESTRICTED DRIVING PRIVILEGE

For others there may be some training required to relearn some skills in order to get back behind the wheel. It may be determined that night driving is not safe or that the intensity of a highway is too much to process given their current condition.  There may need to be some formal training to break certain habits and/or to learn some compensatory techniques to ensure safety.

ADAPTIVE DRIVING DEVICES

 Still others may find that driving is possible only if using adaptive devices specifically designed to match their abilities.   This option needs to be thought out since there may be DMV criteria to comply with as well as licensure testing to complete before being allowed access to a modified vehicle.  Individuals in need of adaptive equipment to drive are also faced with an expense that for some is beyond their financial limits.  Reimbursement for the equipment may be available through grants, civic group/church donations, or accident/work injury related insurances. 

RETIREMENT FROM DRIVING

For some the impairments from a stroke may mean the end of driving but they are very capable of being driven around by others.  It is critical to educate the individual on options in their home town that would promote independence (Uber, Lyft, Metro Taxi, hired assistance, time with friends/family, public transportation options)

Each scenario results in a new normal that each person will have to decide to accept. 

While driving is an important piece of independence, not driving does not mean you have to completely hibernate.  Find a way to be active. Engage with others making positive memories.  We work with our clients to achieve their future goals, but also will never sacrifice their safety nor that of those they will share the roads with. And in the event retirement is a necessity, we can work with clients to help them understand how they can maintain independence without a driver's license. If you have specific questions or concerns for yourself, a family member, or a patient regarding their driving following a stroke, please don't hesitate to contact me. 

Driving is Important

We Are Here to Keep You Safe Behind the Wheel

Our Driver Rehabilitation program works with patients whose change in health may affect their ability to safely drive. We have a team of Certified Driving Rehab Specialists that will work with patients on evaluating your driving abilities. We also have a team of professional instructors to help you gain or regain the skills you need to drive. We created this blog to talk about the various diagnoses we experience and how they may affect your experience behind the wheel. 

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