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The challenge for doctors and the licensing agency is to balance mobility and safety in a growing population of older drivers Dementia is important in relation to driving. As the disease progresses the ability to drive safely is eventually lost and at that point current regulations demand that driving stops. Many patients continue to drive after dementia has been diagnosed, w10 however, and withdrawal of their licence should not be undertaken lightly. A study highlighted the negative consequences of stopping people with dementia from driving.

W11 Stopping driving can limit access to family, friends, and services and is an independent risk factor for entry to a nursing home. W12 Traffic medicine has evolved significantly since the 1990s, with more emphasis on preserving mobility. As populations age and increasing numbers of older people drive w1 general practitioners are key players in ensuring that older people are not constrained by an unfair attribution of risk. Health professionals, however, practise in a society where the perception of older drivers is negative. W2 This may stem from misconceptions about the impact of age related disease on driving: these misunderstandings also apply to medical journals, which commonly reproduce statements on the apparent increase in crashes per mile driven for older people, w3 despite several studies having established that this is related to low mileage rather than to age. W4 w5 Indeed major problems arising out of increasing numbers of older drivers w6 have been shown to be unlikely, with improvements in driving occurring with successive cohorts of older drivers. W7 Surveys of drivers aged more than 80 consistently show prudent driving behaviours.

W8 Even the presence of medical conditions is associated with a relatively modest increase in adverse driving events. Sources and selection criteria We carried out a literature search from 1966 to April 2007 of several electronic databases (Medline, PubMed, CINAHL, Embase, and the Cochrane Library) using the search strategy: [dement$.ti.

OR alzheim$.ti.] AND [driv$.ti. OR mobil$.ti. OR crash$.ti.] LIMIT to human AND English. The references generated were checked for relevance on the basis of their title and abstract, and we followed up other references from the papers identified. We used the Google search engine to explore the internet. We also contacted the major stakeholder agencies for relevant information. Who decides on medical fitness to drive?

Although the Driver and Vehicle Licensing Agency in the United Kingdom has the legal responsibility of deciding on medical fitness to drive, general practitioners and specialists have important parts to play (figure). The Royal College of Psychiatrists and the General Medical Council have gone to considerable efforts to clarify their expectations of reasonable practice. The council is clear that for several conditions (including dementia), doctors should not only advise patients of the possibility of stopping driving but also take steps to ensure that the relevant statutory authorities are informed of breaches of regulation if there is reasonable concern about public safety. Studies have found that psychiatrists have a poor knowledge of the guidelines issued by the Driver and Vehicle Licensing Agency and that relatively few patients are advised that they should not drive, although the reasons for this pattern of advice may be complex. What should I do in the clinic? Whenever dementia is diagnosed it is vital to inquire about the driving status of the patient and to maximise traffic related health (for example, checking visual acuity, ensuring arthritis does not affect ability, and reviewing medications). The Driver and Vehicle Licensing Agency states that anyone holding a driving licence must, by law, inform the agency when given a diagnosis of any medical condition that might affect safe driving (box 1).