Case Study: Dementia and Stopping Driving
You are a nurse practitioner in a busy primary care office. Janet, an 81-year-old widow with a past medical history significant for hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus type 2 (DM2), obstructive sleep apnea (OSA), bilateral cataract surgery approximately six years ago, anxiety, and mild cognitive impairment (MCI), is seen for follow-up with her son as she has just returned to her home after being admitted to the hospital and then a skilled nursing facility (SNF). Nearly two months ago, she tripped while golfing and fractured her right hip, which required surgery. Her hospital course was complicated by post-surgical delirium. Delirium initially improved with a reduction in opioids; however, she then developed a urinary tract infection (UTI), causing a reemergence of delirium. After treatment with antibiotics and the discontinuation of opioids, her mental status improved. She participated in physical therapy and was discharged to the SNF for ongoing rehab. Her son is concerned because he recalls a doctor in the hospital telling him that "it probably isn't safe for Janet to drive anymore" and referenced some cognitive testing that she scored poorly on. He didn't recall her score or which cognitive test it was. He did recall that they scanned her head because her behavior was so "wild," but everything was "fine." As he is telling you all this, Janet is becoming visibly frustrated. She interrupts and says, "My behavior wasn't that bad! I was confused because of all those pain meds and that darn infection!" She then insists, "I think I can drive just fine. I'm getting along all right now on my own. I'm just a little slower on my feet, that's all!" She then turns to her son and says, "What, are you going to drive me around everywhere I need to go? You're busy working all the time. I've been stuck at home all alone since you wouldn't let me drive until we came and talked about this here." It becomes clear to you that Janet is concerned Page 2 of 4 about the isolation and loss of independence she is experiencing and that her son is concerned about her safety.
In reviewing Janet's records, you see that she completed a Montreal Cognitive Assessment (MoCA) three months prior to breaking her hip and scored a 24, indicating MCI (Nasreddine, 2022). This represents a one-point reduction from her previous score two years prior. Her HTN, HLD, DM2, and anxiety have been well controlled for years with chlorthalidone, amlodipine, atorvastatin, metformin, and citalopram. She uses a CPAP machine for her OSA and has good adherence, as demonstrated by data uploaded from the machine to her electronic medical record (EMR). When last seen, she declined starting a cholinesterase inhibitor for MCI because she did not find her cognitive issues troubling enough to add additional medications. She has been noted to have issues whenever given narcotic pain medications in the past, including confusion and hallucinations. Janet has not missed any routine appointments with you for the last few years. She uses the messaging function in the EMR appropriately and has gone to specialists when referred. She was approximately 15 minutes late for an appointment nine months ago because she got lost on the way to the clinic. The clinic had moved to a new building about three miles from where it had been previously, and Janet had only been to the new building one time. Since cataract surgery, she has only needed readers. No recent vision or hearing testing is available. Janet can hear you when you speak in a slightly louder than conversational tone. You did overhear her son complaining about how loud she turned the radio up in the car while he was driving her to the appointment. From her hospital admission records, you can see that a MoCA was completed during her admission; she scored 15, indicating moderate cognitive impairment. Additionally, her head computed tomography (CT) scan that her son referenced showed no acute intracranial findings, along with mild generalized atrophy consistent with her age. The MoCA was completed on the day she started antibiotics for her UTI, and no repeat cognitive testing was done in the hospital or SNF. Some medication changes were made during her hospitalization due to her acute condition, but by the time of discharge from the SNF, she had returned to her previous dosages of the medications she was maintained on previously to manage her chronic conditions.
Janet values her independence, her friendships with the women from church, her volunteer groups, and her golf, garden, and bridge clubs. Since the death of her husband eight years ago, she has maintained an active lifestyle with no plans on slowing down. Janet has made some modifications with the help of her children over the last eight years. Her children are designated medical and financial powers of attorney in the event she becomes incapacitated. Her daughter helped her set up online bill pay so her bills are paid automatically. She orders her groceries online and has them delivered to her home or her car in the store parking lot to avoid navigating the store with her cart and having to carry the bags. This habit proved quite helpful during the COVID-19 pandemic. When golfing, she uses a driving cart rather than a walking cart for her clubs and has someone at the course get her clubs out of her trunk for her. She stores her clubs in the trunk of her car to avoid having to lift them at home. Finally, her medications are delivered from the pharmacy in bubble packs, so she doesn't have to pack a weekly pill box. Despite this, she is still able to list the names, dosages, and purposes of her medications.
Since discharge from the SNF a week ago, Janet's son has been keeping her car keys to prevent her from driving based upon the recommendation of the hospital. This has been a significant source of conflict and frustration between them. Janet is hoping to sort it out with you today and resume driving. She insists that she hasn't had a ticket since she was a teenager and has not been in any crashes, so she must be safe to drive. You know that there are many benefits to extending Page 3 of 4 a senior's ability to drive such as improved social connectedness, independence, prevention of isolation, and facilitation of access to nutrition, healthcare, and other services (American Geriatrics Society [AGS], 2020).
To assess safety in an older driver, you know you need to consider a patient's vision, cognitive, and functional status at a minimum (AGS, 2020). Risk factors for unsafe driving in older adults include polypharmacy (> 5 drugs), driving < 60 miles per week, deficits in cognitive functioning or attention, presence of a sleep disorder, hearing impairment or vision disturbance, alcohol abuse, caregiver concern about driving, lacking function in two or more activities of daily living, and a history of two or more traffic citations in the past three years (Pozzi et al., 2017). You don't think it is possible to complete a thorough assessment to evaluate Janet for risk factors for unsafe driving as well as complete the other necessary tasks of your follow-up visit with Janet. Based upon her ability to engage in the visit and describe her recent medical and life events, it appears that Janet's cognition has improved from what you would expect based on the MoCA testing completed in the hospital-though you have no evidence to support that and may be wrong. She is ambulating independently with a cane; she appears weak and readily acknowledges that she is slower than typical. You haven't assessed her strength and flexibility in her right leg as she is post-fracture, surgery, and rehab. It is clear you do not have enough information to make a definitive decision regarding her driver safety. Furthermore, you practice in a state with mandated reporting of unsafe drivers to the department of motor vehicles (DMV; Aronson, 2019). Janet's son does not know if a report was made to the DMV.
Respond to the below questions to discuss how you will manage this case. Keep the ethical principles in mind, as well as the nine provisions of the Code of Ethics for Nurses (posted for you on Canvas under this tab assignment).
1. Identify the ethical concerns with this situation and relate them to one or more ethical principles (there is no right or wrong for this, each person will have their own or different perspective).
2. What information will you need before a responsible decision can be made? (Consider what the information is and where it will come from.) Want Professional Help?
3. Who are the stakeholders involved in the decision (for example, will the person be harmed, and is there a greater benefit to others that justifies the harm?) and what is the process in which those involved could come to a decision (e.g., what tools are/could be used to create an informed decision)?
4. What are the values relevant to this problem? [Values are the things that you believe are important in making the decision; Values are things that have significance or worth relative to some state of affairs, such as human well-being, respect, and fairness. They may determine priorities. Values relevant to this problem may not be representative of your own personal values or moral framework].
5. What are the options for the decision? Think in terms of values and feasibility (e.g., legal, financial, political, organizational, and religious constraints).