Practice Parameter update: Evaluation and management of driving risk in dementia: Report of the Quality Standards Subcommittee of the American Academy of Neurology

PRACTICE PARAMETER UPDATE: EVALUATION AND MANAGEMENT OF DRIVING RISK IN DEMENTIA: REPORT OF THE QUALITY STANDARDS SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY To the Editor: In their analysis of driving and dementia, Iverson et al.1 included research on older drivers, tapping into broader literature that has evolved considerably in the last decade.2 While risk to other road users is a concern, maximizing mobility is also a priority for patients and clinicians, given the negative impact of dementia on transportation and social inclusion of those affected.3 However, a concern about the Quality Standards Subcommittee report is the reliance on traditional cognitive measures, focusing on specific cognitive domains. This approach is increasingly recognized as being not aligned with the modern concepts of driving behavior and risk4 and Iverson et al. have failed to establish clinical utility in this context. Driving calls on procedural memory and hierarchical decision-making and motivation, among other factors. It would be helpful if studies on driving and dementia included these. The operationalization of hierarchical decision-making (strategic, tactical, and operational) has shown initial promise in the assessment of older drivers.5 Clinical neuropsychology, in its broadest definition, is the understanding of brain–behavior relations and the clinical use of this information. Clinicians and neuropsychologists need to be mindful of this broader vision, and untether themselves from a narrow interpretation of a range of legacy tests. In turn, we need to develop approaches which draw on the wider breadth of knowledge of driver behavior, allied with a low threshold for on-road driver testing for drivers with dementia.