Dear Dr. Cynthia:

The incident in California recently in which an elderly man drove through a street market and killed 10 people has dramatically increased my concern about a situation with my father.

	Dr. Cynthia Napier Rosenberg

A few years ago, my father began to have mild memory problems -- not very severe, but enough that my sisters, mother and I all started to notice. About three months ago, my mother became very worried one afternoon when my father failed to return on time from his church choir practice. He arrived two hours late, saying that he had made a wrong turn on the way home and had gotten lost. He eventually stopped at a gas station and was successfully redirected. But the church is only 15 minutes away from their house and he and my mother have been attending that same church for more than 20 years.

A few months before that he became woozy while driving one evening and had to pull over. He is a diabetic and thought that his blood sugar possibly had dropped too low. Since then he has not driven by himself at night. In fact, my sisters and I have asked him not to drive by himself at all. We felt that if my mother was in the car she could help to keep him from getting lost.

The California incident sent a shiver through our entire family. My sisters and I are now even more concerned that he might hurt himself or someone else. We have tried to discuss this with my mother, but she is afraid to bring it up with him -- she doesn't want to hurt his feelings. He has never had an accident and does not drive on high-speed roads. Also, he is the only driver in the house and she needs him to drive her to the grocery store and other errands.

Any advice?

A Worried Daughter

Dear Worried Daughter:.

The issue of driving and the elderly is a very, very complicated one. Unfortunately, there are no easy answers. And after a tragedy, such as the recent one in California, everyone is likely to become more reactive and emotional -- no matter which side of the fence they're on.

Let's review a few general facts about the older driver. Motor vehicle accidents are the leading cause of death from traumatic injury in older adults. Also, if involved in a crash, older drivers are more likely to sustain injury or to die than younger drivers. Older drivers actually have fewer collisions than younger drivers, partly because they drive less. They also drive more slowly and take fewer risks. But once they reach the age of about 80, older drivers have the highest crash rate per miles of travel of any age group over 25.

As we age, our peripheral vision, which warns us of things coming at us from the sides, becomes less reliable. Ditto on our twilight and nighttime vision. Reaction time also can increase. The faster a person drives, the more important it is to react quickly. Many older drivers monitor themselves by limiting driving on high-speed roads or avoiding them all together. From a public safety point of view, the question of which, if any, restrictions should be placed on older drivers involves balancing individual confidentiality and rights with obligations to the community and public health.

But apart from all of this, I am quite concerned about the two incidents you describe in your letter. Both the diabetes and the confusion are greater risks to your father's ability to drive safely than is his age alone. When we drive, we make decisions on a minute-by-minute basis. If nothing out of the ordinary happens, people with memory problems can often continue to drive well-established routes without difficulty. But even mild memory problems, especially if they are the beginning of an early dementia, can impair a person's judgment and problem-solving skills. If something out of the ordinary does happen, such a person might be less able to process the information quickly, react appropriately and make a good decision.

Let's take the example of getting lost on the way home. I would imagine that you and your sisters have had the experience of driving a well-known route and turning the wrong way because your mind was on something else. But once you made the wrong turn, you probably said to yourself, "What am I doing?" and turned around and got back on track pretty quickly.

Not so for a person who is experiencing generalized mild confusion or memory impairment. Once that person makes a wrong turn, he or she is likely to panic and become totally confused and disoriented. Remember "Driving Miss Daisy?" Once she started backward with her foot on the gas pedal rather than the brake, she was unable to readjust.

Fluctuating blood sugars exacerbate this problem. Mental confusion is one of the primary symptoms of low blood sugar, and older people are particularly vulnerable to the effects of dipping blood sugar levels if they take oral diabetic medications.

The first thing that you need to do is sit down and talk with your father about all of this. I doubt that he would voluntarily want to place himself, your mother or anyone else in a potentially dangerous situation. Although he may be defensive, he should ultimately be able to discuss this matter with you in a reasonable way and to take the steps needed to evaluate and treat correctable problems. If he denies there is any problem at all, you have additional information that he is not using good judgment in this matter.

In summary, I most definitely do not think that you should ignore this issue. Your father needs to see his primary care physician as soon as possible to make sure that his blood sugars are under good control. Because he is experiencing memory problems, it would be a good idea for another family member to accompany him. His doctor will want to evaluate his mental status and check to see that he is not developing other medical problems. He may refer him to a specialist for further evaluation or recommend that he be specifically evaluated for his driving skills by a certified occupational therapist (although driver evaluation programs typically are not covered by insurance).

In the meantime, he should not drive alone, at night, to unfamiliar places or on high-speed roads.