Growing up in Michigan, the home state of the automobile industry, Jack George, 68, loved driving. Whether in a car or truck or on a motorcycle, he relished getting in the driver's seat and going wherever the road took him. His wife, Susan, 62, says Jack never liked taking the same route twice and enjoyed the thrill of finding new byways.

In 2004, Jack had to start creating elaborate spreadsheets and placing Post-it notes around his office in order to keep doing his job at a quality-systems supplier to the automobile industry. He also began having visuospatial problems and kept overreaching for things. It took several years and misdiagnoses before Jack and Susan learned what he had: behavioral variant frontotemporal dementia, a rare form of dementia characterized by changes in behavior, personality, and cognition.

During this time, Susan became increasingly worried about her husband's driving and asked Jack to call her if he couldn't get home from work safely. She brought up the topic several more times, but her husband routinely dismissed her fears. “I decided to involve our doctor, who strongly encouraged Jack to stop driving,” says Susan, who lives with Jack in Lima, OH. “Jack hated the thought of stopping, but after hearing it from the doctor, he realized it was time. He reluctantly handed over the keys but complained about my driving for a while.”

Before then, Jack had stopped driving at night and avoided unfamiliar parts of town or busy highways—all safe strategies but not a foolproof way to prevent tragic accidents. Since 2014, motor vehicle fatalities involving drivers 65 and older have increased by 34 percent, according to the Centers for Disease Control and Prevention. That includes a more than 15 percent rise, from 7,902 to 9,120 fatalities, from 2020 to 2021 (the most recent year for which numbers are available).

Driving requires a sophisticated blend of operational, cognitive, and higher executive functions as well as good reflexes, concentration, and spatial perception—skills that may decline as people age. Yet many older drivers are keeping their licenses longer.

Neurologic disorders such as dementia, stroke, traumatic brain injury, peripheral neuropathy, Parkinson's disease, and epilepsy can impair these skills to varying degrees, potentially compromising the ability to drive at any age. The Journal of the American Geriatrics Society reported last year on a study involving 635 older adults experiencing cognitive problems: More than half of them (360) were still driving, while over a third of the subjects' caregivers (36 percent) expressed concerns about the older people's driving abilities.

“The study findings were not particularly surprising because we suspected that people who shouldn't be on the road continue to drive,” says study co-author Lewis Morgenstern, MD, FAAN, professor of neurology, neurosurgery, and emergency medicine at the University of Michigan School of Public Health in Ann Arbor. “We hope the study raises awareness about this issue and encourages families with concerns to have their loved ones undergo assessments to determine whether it is still safe for them to drive.”

Signs of Impairment

Some people who are in the early stages of Parkinson's or Alzheimer's disease or have well-controlled epilepsy might be fine to drive for a while. “Because symptoms emerge at varying rates, every person needs to be assessed individually,” says Ergun Uc, MD, FAAN, director of the movement disorders division at University of Iowa Health Care in Iowa City. “Some people may retain the basic ability to operate a car but may become lost when driving or feel unsure when they have to make a decision quickly.”

Other problems that could develop include going too fast or too slow, getting confused by stop signs and traffic signals, and having difficulty changing lanes or making turns. If a driver starts getting into fender benders or receiving more traffic tickets than usual, that also could be a red flag. Family members can share their observations with the person's doctors, who might refer the patient to an occupational therapist, the department of motor vehicles, or a driving-test center that can assess driving skills, says Dr. Morgenstern.

Preston Lewis was diagnosed with Parkinson's disease when he was 59 and continued to drive until he was 72, when his daughter, Kelsey, saw him cross the center line in the road and almost hit an oncoming car near their home in Frankfort, KY. She was following him in her own car. “That was a wake-up call for our family, and it finally convinced my dad that it was time to stop driving altogether,” says Kelsey, associate director of advancement at the Michael J. Fox Foundation for Parkinson's Research. “Because I witnessed the incident first-hand, it helped our family have that much-needed conversation about my dad's driving.” Prior to that incident, Lewis had been limiting his driving to daytime and only to local spots.

Any conversations about restricting someone's driving must be approached compassionately and collaboratively, says Gary J. Kennedy, MD, director of geriatric psychiatry at Montefiore Medical Center in the Bronx, NY. “Driving is a form of independence for many, and taking it away marks a lack of control, so it has to be approached without using inflammatory or threatening language,” he says. Instead, families should focus on the risks to the driver and others on the road. The conversation should also mention alternative ways to get around, says Dr. Kennedy. “Families should be prepared to offer transportation to shopping, appointments, and worship services to help preserve a sense of control.”

“It's not about taking keys out of someone's hands, it's about helping him or her understand the why behind the decision,” says Susan George, who used an empathetic tone with her husband, Jack. “We had lots of emotional conversations about driving, and it took Jack several months to get used to being driven around,” she says. “But now he takes a senior bus to doctors' appointments when I'm not available.”

Ride Alternatives

Mark Timmons lived on 21 acres in rural Maine when he gave up driving. For a while, his daughter and her boyfriend drove him around, but Timmons, a former tax accountant who was diagnosed with epilepsy as a child and dementia at age 48, eventually decided to move to Rockland, MA, a suburb of Boston. With help from family and friends, he chose an apartment within walking distance of stores. “I order groceries online and get them delivered, which is definitely not something I could do in Maine,” says Timmons, now 55.

Alison Kukla, who'd been diagnosed with epilepsy during college, stopped driving in her mid-twenties after she had a serious car accident in 2010. While exiting a highway, she had a focal seizure, lost control, and hit a car in the intersection. Fortunately, no one was injured, but Kukla realized it was time to relinquish her driver's license.

As an indirect result of the accident, Kukla later moved from Boardman, OH, to Chicago with her husband, Preston Reilly. “After we got married, we both knew that we needed to move to an urban area so Alison could get to work more easily and have a greater sense of freedom,” says Reilly.

In most states, people with epilepsy can drive if they are seizure-free for a specific period of time and submit a physician's affirmation. In New York and a few other states, a physician decides whether someone with epilepsy should drive, says Jacqueline French, MD, FAAN, an epilepsy specialist and professor of neurology at NYU Langone. “In those cases, we usually determine the likelihood of a seizure as well as whether the person's awareness is altered during the seizure. If either is true, we would advise the patient not to drive. If we are changing or discontinuing antiseizure medication, we also would usually suggest a driving moratorium.”

“A major topic in epilepsy support groups is having to tell your doctor you've just had a seizure and may have to give up your license,” says the 37-year-old Kukla, who is senior manager of programs and partnerships at the Epilepsy Foundation. “It's upsetting and stressful because it affects your ability to work, raise a family, and be independent.”

People who are no longer allowed to drive have alternatives beyond depending on family and friends. “Some ride-share services offer discounts for seniors, and some drivers will help passengers enter and exit the car,” says occupational therapist Elin Schold Davis, a coordinator of the older driver initiative at the American Occupational Therapy Association. SilverRide provides door-to-door service for seniors with serious health conditions in big cities such as Atlanta, Chicago, Los Angeles, San Francisco, and Seattle.

Many faith-based organizations, senior centers, and other service groups have volunteers who provide free transportation. Some communities offer carpooling or minibus or van transport for free or at reduced fares. These services often require advance reservations but provide a lot of flexibility, especially for those requiring door-to-door help.

Dr. Kennedy recently saw a patient diagnosed with dementia who had been ticketed for running stop signs and red lights. He didn't want to give up his car because it was on a lease. “I pointed out all the expenses, like insurance, parking fees, and traffic tickets, related to keeping the car, and that finally sank in. He ended the lease and now uses Uber and taxis to get around.”

Driver Safety Resources

• AAA Foundation for Traffic Safety; 202-638-5944
• AARP; 888-687-2277
• American Occupational Therapy Association; 800-729-2682 (members), 301-652-6611 (nonmembers)
• Association for Driver Rehabilitation Specialists; 866-672-9466
• Department of Motor Vehicles