Dementia from organic brain disease, and its influence on driving

Dementia is a clinical syndrome characterized by the acquired loss of cognitive capacities, that is serious enough to interfere with the quality of life of the patient and preventing driving.

It occurs mainly in the old age, and affects 1% of the people 60 years old, and doubles every 5 years until reaching approximately 30%, at the age of 85-90 years.

In Spain there are more than 600,000 people who suffer dementia, and only 30-40% are adequately diagnosed and treated.

Multiple factors promote the development of dementia, including the elderly age, low educational or socioeconomic status, hypertension, diabetes, smoking, hypercholesterolemia and ischemic heart disease.

Also hypotension and hypoperfusion states or hypoxia, occurring in bradyarrhythmia, syncope, generalized epilepsy and pneumonia.

Static dementia is established after a significant single injury, or after the last of several injuries due to head injury, brain bleeding or cardiac arrest.

Progressive dementia can be associated with brain disorders such as Huntington’s chorea, chronic alcohol or drug abuse, degenerative diseases, Parkinson’s, multiple sclerosis, lateral amyotrophic sclerosis, brain tumors, etc.

Etiology

Starting presenile and senile Alzheimer dementia have similar clinical characteristics, with the former appearing between the 5th and 6th decades of life and the senile between the 7th and 8th decades.

Dementia due to multiinfarction is most frequent in hypertensive men in the 7th decade of life. It is called vascular dementia, that causes loss of the intellectual capacity, autonomy, and independence.

One out of four people suffering a stroke, after the first months, have persistent loss of intellectual function that on many occasions prevents him from returning to their previous lifestyle.

It progression is usually step-wise related to the appearance of infarctions, with intellectual impairment and the possible appearance or worsening of symptoms or neurological signs.

Depressive symptoms are frequent and suicide is possible.

With the progression of the disease, neurological signs can appear, including hemiplegia, pseudobulbar paralysis, with pathological laughter or crying, and other signs of extrapyramidal dysfunction.

Dementia of AIDS is frequent in the last stages of the disease.

The first manifestations are slow thinking and expression, difficulty to concentrate, and apathy, with preserved understanding and low expression of depression.

The movements are slow and the patient sometimes shows ataxia and weakness.

Chronic communicating hydrocephalus with “normal” pressure can have a history of an episode of meningitis, encephalitis, cranial injury, or tumor.

It can cause dementia of insidious onset, and these patients have a careless appearance and slow activity, unlike the characteristic sharper behavior characteristic of Alzheimer’s disease.

Gait is unstable, slow, dragging the feet, with frequent episodes of urinary incontinence.

Serious cranial injury can cause significant cerebral injury resulting in non-progressive dementia.

Signs, symptoms, and outcome

The most frequent clinical condition is a slow disintegration of personality and of intelligence due to an impaired ability of judgment and a loss of affection.

The interests are reduced, with rigid prospects, difficulty in conceptual thinking, certain poverty of thinking, diminished initiative, and easy distraction.

As dementia advances, a defect occurs in the entire upper cortical function, with variable degrees of aphasia, apraxia, and agnosia. Spatial disorientation is striking and the memory impairment is progressive.

In some patients, the cognitive dysfunction is preceded by changes in their normal behavior and their emotional responses, with dulling of affection.

Irritability and periods of anger or violence are frequent. Depression, paranoia and anxiety are frequent, and the affection becomes increasingly superficial, as dementia progresses.

The associated neurological signs depend on the distribution and nature of the brain injuries, which in turn depend on the etiology.

Although the course of dementia is usually progressive and slow, some patients with mild signs show an acute serious confusion usually due to a situation of stress, for infection, new treatment, personal loss, surgery, hospital admission, home move, etc.

Treatment

The chronic nature, old are and mental disorder all together make treatment more difficult.

The prevention of dementia is based essentially on maintaining the control of all risk factors since the mild-adult life.

The physicians should train the patients to control their blood pressure, cholesterol, blood glucose levels, and bodyweight.

It is beneficial to carry out physical exercise, restrict alcohol intake and include in the diet high quantities of monounsaturated fatty acids, plenty of vegetables and to fulfill stimulating activities of cognitive brain functions.

Advice on dementia for brain organic disease

• Dementia is an irreversible, progressive loss of the intellectual capacity that, once diagnosed, does not permit driving.
• Making the decision of advising against driving to an individual where the symptoms are not highly advance is difficult, and should be done with care.
• The patient can refuse to stop driving and lose his independence, but his safety and that of others is the most important.
• The physician should suspect possible driving disorders if, when questioned, the patient describes that he is disoriented in familiar places, he drives too fast or too slow, or he does not pay attention to traffic signals.
• Although the patient appears to improve, he cannot be permitted to drive.
• If necessary, his family will be recommended to hide the keys of the car. If having keys is important for the person, the keys can be changed.
• As a last resource, the car can be made inoperative. If necessary, the location of the car can be changed so that the patient cannot find it.
• The pedestrian with cognitive impairment, usually elderly, is clumsy in his movements and decisions, with dangerous actions when moving in the streets and changing direction or ways when walking.
• He usually crosses through non-recommended sites, without looking, with a high risk that a car knocks him down.
• Drivers usually overwhelm and frighten blowing the horn to these pedestrians with global impaired memory, thinking, and the capacity for judgment, increasing the risk of knocking down.
• These pedestrians should go to the street accompanied by their caregiver, in order to avoid being run over.
• It would be advisable to perform an autopsy in all persons dying from traffic accident. We would thus be sure if the organic injuries are cause or the result of the traffic accident, and collecting these data would enable to know better the group of drivers at risk from the disease.