Parkinson’s and Driving When Safety and Independence Collide

[00:00:00] This episode is brought to you by Crexont. That's Crexont, Carbidopa and Levodopa, extended release capsules. To learn more, visit Crexont.com. That's C-R-E-X-O-N-T dot com. They may be slower, stiffer, and they themselves don't get those cues that they're not moving as well. And Parkinson's is never a linear. It's not really always predictable. When we think about driving, a lot of people rely on their natural skill set of driving. I mean, things became an automatic response.

[00:00:29] But there's certain situations when we think about cognitive challenges with Parkinson's, it's harder to multitask.

[00:00:54] Welcome back to The Caring Neurologist. Today's episode is one that tackles a very emotional and difficult topic when dealing with Parkinson's disease. And it actually affects any neurological disease. But the topic of driving comes up and it's a sensitive topic. Driving isn't just about transportation. It represents independence. It represents identity and also dignity.

[00:01:19] I'm Dr. Sandeep Sikhar, and I'm here to navigate the conversation about clarity, compassion and safety without the fear or shame. So let's dive in. Hi, Dr. Takara. It's good to be diving into such an important topic today. And why is driving such a sensitive topic for people with Parkinson's and their families? Well, when I was thinking about this situation, you know, driving again is not only just in the United States, but everywhere and culturally.

[00:01:48] It's not just a plastic car, right? It's the ultimate symbol of self-reliance. It's when someone has the ability to be independent. You know, we associate getting to a certain age and then you're independent and you can drive. And that's kind of what takes you away from being like a kid to a young adult. So there's a lot of status that comes with that. And so I think one of the first reasons is it feels like you're losing independence.

[00:02:16] And that's a big deal for a lot of people. And I think about the context of when you're diagnosed with Parkinson's in your 60s or 70s, you know, this is also a time period that's when people are retiring. And so they've already lost a lot of their identity about what made them a breadwinner. So it comes with that threat of now I can't do things alone is that there's a threat of that isolation. You're giving up the keys and it kind of feels like you're losing your role of who you used to be.

[00:02:46] So I understand that it becomes a very sensitive topic. It's also sensitive because of the fluctuating nature of Parkinson's. Patients take their medicines. They feel good. Then there's other times it's not necessarily knowing that they're getting into an off state. They may be slower, stiffer, and they themselves don't get those cues that they're not moving as well. And family members see that. So that also makes it this kind of hindrance of being aware that you're not doing well. And Parkinson's is never a linear.

[00:03:15] It's not really always predictable. And again, each patient's so different. So when we think about driving, you know, a lot of people rely on their natural skill set of driving. I mean, things became an automatic response. But there's certain situations that when we think about cognitive challenges with Parkinson's, it's harder to multitask.

[00:03:38] And the visual spatial processing in Parkinson's is also very much affected where people aren't aware of how their multitasking is slow, delayed, how they handle situations when the light is turning red. And then they're processing that visual cue to then their physical cue. And that's one of the situations that make it sensitive. The last part I think that makes it sensitive is a phenomenon called the bad guy family dynamic.

[00:04:06] And it's sensitive because either the family members or the caregivers, it strains the relationship when they're first noticing that the patient's dealing with driving issues and safety. And they don't want to see anyone get hurt. And at the same time, there's that fear of confrontation about saying, hey, you know what? I think we need to, you know, talk about driving and make adjustments. And sometimes we never know that there's a problem until we get in the car with that person.

[00:04:35] And it's all like it's quite significant. It's a shock to the family, like that the driving has been so compromised. And so it becomes one of those heated conversations overall. Yeah, I can see how it's difficult to transition to that stage of life where you need to depend more on others. That's kind of what it is as well, right? You have to ask to get to one place or the other. But at the same time, it's a safety matter.

[00:05:02] So it's kind of hard to juggle both situations of respecting somebody's independence, but at the same time, taking care of safety. And what aspects of Parkinson's can impact someone's ability to drive safely? Well, as we think about the aspects of Parkinson's, you know, I commented already that there's slowed reaction time. There's this slowness coordination of the hands or legs.

[00:05:26] And, you know, we depend on the right foot, you know, for the pedal of the accelerator. And that's what we were taught. So if the right side has been more affected in Parkinson's or the foot's been affected, why there were tremors, then maybe patients don't feel as comfortable when they're at a stoplight or when they're trying to push down to accelerate. Maybe they're slower to react or not feeling the depth of the pedal. There's sometimes stiffness of the muscles where it involves the neck.

[00:05:55] Again, we're talking about turning, looking over the shoulder on either side. These are things that become a problem. The tremor itself can be a distraction. So for instance, when someone's driving, you know, you have a passenger in the car, you're talking with them, maybe the tremor comes out, maybe you're trying to hide the tremor. Tremor comes out under like cognitive processing, thinking, or even stress. So when someone's thinking about ongoing traffic and judging distance, you know, the tremor may come out.

[00:06:24] And so patients also are distracted by that tremor, trying to focus on that, whereas maybe they're giving up their actual cognitive processing and executive thinking that they need to on the road. So there's so many different factors there. What's really important as a disease progresses is the visual spatial problems. And what we end up seeing again is that judgment of distance between the cars, the executive decision of split second traffic situations of like, do I go? Do I not go on this yellow light?

[00:06:53] But, you know, judging how fast the car is coming is also perceived very differently in Parkinson's. And we do see that patients have a tougher time with that. And that's where that cognitive load becomes an issue where we, again, feel slower to react in our thought processing. What I end up telling patients is, you know, if you're having a tough time with like using a remote or learning new technology, that could also be a sign that you're having a tough time multitasking, which could also associate with driving.

[00:07:23] Now, I'm talking about the pure Parkinson's features, but what happens when you're in your, you know, 50s and 60s and 70s and even 80s and 90s, right? Your vision already is changing. Parkinson's doesn't directly affect pure vision, but it can make the focus feel off. Maybe you get a little bit more double vision if the eyes feel like tired, but the actual vision could be affected by the cataracts, could be affected by other macular degeneration.

[00:07:48] And so highly recommend that at the time of, you know, driving being compromised, make sure that you get your vision checks. And I think that's also a very important aspect when we think about our senses. So what else is really important, Ibrae, is our hearing. And so you also get a lot of cues driving when you're listening around.

[00:08:10] And so even for myself, just, you know, I'm getting older in my days and when I'm in a parking lot that's busy and hectic, I actually roll down the window so I could hear if a car is going to come out or where cars are coming from. So it's really important to have all our senses intact. Yeah, I guess we forget because driving becomes such a second nature activity when you do it so much throughout your life that we forget how much it involves, how much attention it demands.

[00:08:38] And when we're perhaps challenged by all these different aspects that you mentioned, that's when you realize how much you needed to listen and look around. Yeah, there's a lot of cues. I mean, and again, we'll talk more about it again, adaptive therapies and adaptive tools. But still, like you said, it's second nature. And when things are second nature, you kind of forget about your automatic response. And then cars are getting so much better that, you know, you have this backup camera.

[00:09:07] And then as you get dependent on these tools, you forget about how important it is to, like, you know, put your shoulder over the car seat, look back. And I mean, these are still inherent things that we learned that were safety. And then we've given up a lot of our safety, you know, skills because now we have other technologies. But at the same time, technology can help us drive, too. Absolutely. And how do cognitive changes in Parkinson's affect driving, even before dementia is diagnosed?

[00:09:37] And we have many episodes prior that we've talked about cognition and processing and visual hallucinations. And so I would definitely recommend if you haven't seen those episodes to reach back because it can help you understand more about the cognition and attention that's required for even driving.

[00:09:55] But what happens is with dopamine being the key chemical messenger in regulating movement, it's also very important in the cognitive circuits of the brain, especially in the frontal lobes. And when we are seeing that there's a lot of tasks taken on with driving and that executive dysfunction is the loss of multitasking. We use dopamine for that. The medications are taken. It really helps help those pathways signal better.

[00:10:22] You know, when someone gets levodopa in the beginning, they feel like they're alive. I mean, family members even say like, wow, there's that spontaneity. But in the part of the brain, in the frontal part of the brain, dopamine is very useful for executive function. And so is acetylcholine and other neurotransmitters. But that part of the brain is the air traffic controller or the air traffic control center. And it manages that planning, the decision making, that rapid adaptability, even early in the disease state.

[00:10:52] And it's there. It's functioning fine early on. But then we start getting divided attention. We start feeling that, you know, it's harder to gain that quickness to make the decision or maybe when our attention is a little bit distracted. We don't realize that.

[00:11:08] And then there's also how do we handle those hesitancies at intersections, the left hand turns of ongoing traffic when we actually have to use our cognitive processing centers, our frontal lobe, like to calculate the speed of is a car coming that I need to go now or do I wait? And so that timing gets really affected. And some people even feel that there's this sense of analysis paralysis.

[00:11:34] And that's, again, very dangerous behind the wheel and causes a lot of misjudgment. So that's one of the executive component. When we think about the other aspects of the brain, more of the occipital lobe, which is the visual center, there's a connection between visual spatial processing. And again, dopamine is very important with that. With Parkinson's dementia, it's different from Alzheimer's.

[00:12:02] And so Alzheimer's dementia is a lot more of that recall memory, short-term recall. With Parkinson's, it's visual spatial deficits in cognition. So patients may have like lane drifting, especially early on. They may have a struggle of staying within the lane itself.

[00:12:22] And also that, again, going back to the depth and distance of accurately judging where the car is in front of you, seeing that red light of the brakes, and then judging like, you know, when to kind of slow down. Sometimes there's a late braking that happens. And that late braking can be a combination of the foot on the pedal in the reaction time or the slowness of the foot itself to make that decision. And the last thing about the cognitive flexibility is we lose that set shifting.

[00:12:52] So set shifting is the ability to quickly switch your mental focus from one context to another. And if a driver's cruising down a familiar road, suddenly they encounter a detour, what you end up seeing is that cognitive flexibility about like, how do I react? Where do I go now? You can sometimes feel overwhelmed or stuck or even anxious in those unpredictable situations. So, you know, the cognitive processing and thinking is there's a lot of demand with driving.

[00:13:21] And as we said, things become second nature, but we forget of all the tools we use to drive. By that time, you've probably driven for so long, you're not a new learner. So everything that you learned when you started driving, like you said, it's a second nature. But we forget how much timing is important in driving. Like that's one of the most important things, just timing and knowing when to go. And it's like a sense that you developed over years.

[00:13:50] And if this becomes impaired later on, then I think that kind of just shifts the whole way you approach driving. It's like forgetting the basics, right? Totally. And in a way, I mean, I'm not a golfer, but a lot of patients tell me, you know, when they golf, they have to make sure they get a good instructor and they learn those basics. And they learn, again, how they put the weight on their foot versus their shift and turn and how they're holding, you know, their club.

[00:14:18] Well, you know, if you learn something the right way, you're going to be better and you keep practicing it. If you learn something slightly off, then you are always going to have problems in situations of golfing. Well, same thing goes with driving. You know, there's different situations. You're in a rough patch, you're on the green. You know, it just depends if you're on the highway or if you're on the streets or if it gets busy at a rush hour.

[00:14:40] So if you think you know how to drive, but you have some created some bad habits because of maybe inattentiveness, you know, like that puts you in a compromised situation. It goes back to not just Parkinson's disease, but you have to have attention all the time. I mean, young adults themselves, they're starting to drive. You know, they got their friends in the car. They got the music playing. You know, think about like in the world we live in, we like these audio books.

[00:15:08] We got these different podcasts that are very educational, like the caring neurologist and people listening when they're driving. So, you know, there's a lot of distraction that goes on when you're driving and having kind of the temperature of the room or in the car set in a more calm, focused pattern is always key. Absolutely. And what are red flags that suggest driving may no longer be safe? Yeah.

[00:15:34] So when we think about red flags, you know, we want to identify when driving is no longer safe, but sometimes those red flags don't come about until you're actually in the car with the person dealing with Parkinson's. So the physical aspects of it is the car itself can tell the story before the driver does. And you may see physical signs on the car itself.

[00:15:57] There's these mysterious dings, new unexplained scratches, dents, paint transfers on the bumper, the side view mirror being scraped or even broken, depending on like, you know, the garage door being affected or a mailbox. So those are situations that are physical, the pedal misapplication or stumbling.

[00:16:20] So when, you know, I've seen scenarios or heards of scenarios where, you know, patients are accidentally pressing on the wrong pedal and maybe even pressing on both pedals with one foot struggling to swiftly, you know, move the foot from the accelerator to the brake. And then there's these sudden stops that are occurring, the stiffness that's impaired in scanning so that the neck itself is also something that makes it so difficult to turn to check for blind spots.

[00:16:50] And again, it goes back to safe driving. A lot of the cars now have a lot of amazing technology and have the blind spot monitors. Sometimes those things need to be added on. Or if you are buying a new car, maybe that's something you want to look for to avoid such red flags. The other red flag, I think, is misjudging the left hand turns, the ongoing traffic, as we've talked about, the slower reaction times.

[00:17:15] If someone has word finding difficulty, that doesn't guarantee they're not going to be a good driver. But what I'm seeing is word finding difficulty is part of a cognitive processing about how to think about something and then get the word out. It's the same thing with processing in the car. There's a delay that's associated with that. So slower reaction times with speech could also be a red flag with how someone's reacting to a red light.

[00:17:41] For instance, Ibre, we've seen people, you know, they're stuck at a red light and they're not ready to put the foot on the accelerator because, you know, maybe they're on a phone call, right? But that's the same type of delayed reaction you may see with Parkinson's, that they haven't processed the red light that is ready to go. And they're worried or they're anxious about other traffic. So when there's also anxiety, that's a red flag. That social anxiety or avoidance is also seen as a red flag, in my opinion, because maybe the driver refuses to drive in new places.

[00:18:11] Maybe they don't want to drive on the highway. There's this co-pilot reliance where the driver's really depending on the passenger, telling them where to go, where to turn. And that's also not a great situation because then they're so distracted about getting the direction about then they're missing the cues on the road.

[00:18:29] And so if there's also a sense of more honking, more people flashing their lights, passing aggressively, you know, those are cues that others are around them are saying, hey, something's going on. There's maybe not safe driving going on related to the cues from other drivers. And then the passenger fear. There's no one better to say that you're a safe driver than the family members.

[00:18:55] If a daughter or a son were to make a comment about safe driving or a spouse were to make a comment about safe driving, then I know in the clinic that this person needs to have an evaluation and that something needs to be some intervention needs to be done. So I usually have to make some strategies. And that's when the conversation changes to such a serious tone.

[00:19:21] Support for this podcast comes from Crexont Carbidopa and Levodopa Extended Release Capsules. If you'd like to learn more about Crexont, ask your health care provider or visit Crexont.com where you'll find full product information, including the prescribing information. To learn more, visit Crexont.com. That's C-R-E-X-O-N-T dot com.

[00:19:47] To be clear, not because you get a Parkinson's diagnosis, you're being revoked from driving. You can have Parkinson's disease diagnosis and still drive for a while. Well, yeah, definitely. Okay. Parkinson's without Parkinson's as a disease state does not have to be a disability. It does not have to be. I mean, symptoms are very mild. I mean, if someone has, again, I always bring up these type of scenarios, but just because someone has diabetes doesn't mean their foot's amputated, right?

[00:20:16] Like that was an old mindset. That's something with it's the longstanding situation of diabetes uncontrolled. Well, same thing goes with Parkinson's. Early in the stages, you can manage things very well, but you just got to be aware of how those symptoms affect safety with walking and thinking and processing and safety with swallowing. So same thing goes with driving, you know, early on is probably not as big a deal, but we need to monitor how those symptoms progress where it could maybe compromise coordination. And we do need to assess thinking as well.

[00:20:44] But no, when someone gets diagnosed with Parkinson's, you know, it is definitely an important thing that we see in California, at least, is that you definitely, when you're getting your license renewed, never say that you don't have that as a problem. In fact, they will have a questionnaire that will tell you about any health issues that are going on. And so one of the most important health issues are going to be about your vision, about cognition.

[00:21:13] And then again, I would always say that, you know, if you have Parkinson's, you want to say yes, that you have Parkinson's. And then it does not guarantee that, you know, your license is revoked. In fact, there's much more like awareness about disease state that, you know, they'll do certain quick assessments or they may get a note from the neurologist to say, hey, is everything okay? And then, you know, that's when it's applicable for us as neurologists to report accordingly.

[00:21:39] And so what role does the neurologist play in assessing driving safety? Yeah. So I always tell people when they come into the clinic, I don't know how you drive. I mean, I can't assess how you drive, can't assess how their spouse drives as well when they're sitting in the clinic. You know, it may be one of those situations that the clinical judgment is limited. And so because, you know, there's that cognitive component to it, right? And then there's also the physical component.

[00:22:04] Now, physically, if someone's coming into my clinic and I'm doing the unified Parkinson's rating skill and I'm checking their hand control, I'm checking for finger taps, fist opening, pronation movements, and then I look at their legs and I'm looking for foot stomps and toe taps. If I'm seeing some struggling on the right foot or the tremor is predominantly in the right foot or there's a lot of rigidity in the right leg, then I'm going to talk about how are you with driving? You know, has it been any accidents? Have you been pulled over? Has there been any suspensions?

[00:22:34] And then, you know, then I need to kind of figure out, do I need to make medicine changes accordingly to make that control of their foot or their arm better? Now, what's very unique is with Parkinson's and the tremor in the foot, I mean, I know the muscles well enough that I actually, again, Botox some of the foot muscles so that the tremor is reduced.

[00:22:54] Or if someone's very rigid in their foot, I know the muscles where to relax them by giving a little bit of medications or Botox or other injections to help control that foot so they're not as rigid. Now, I also do the same thing with the neck because patients with Parkinson's get their neck kind of pull forward and then it's harder to turn. So there are certain muscles in the back of the neck, the posterior neck muscles that we inject with treatment and other therapies of medications to reduce that stiffness so they can turn a lot easier.

[00:23:22] And that's also with another condition called cervical dystonia. So we see that our role as a neurologist to do the physical aspect of it, then we can do cognitive screening. But that's where I really rely on my neuropsychologist to do a neuropsychiatric assessment and then look for, like, again, the visual spatial issues, the processing. Those are very important.

[00:23:46] The other thing that's essential, and again, we do this in every visit as a neurologist and also as a primary care doctor would be medication review. Make sure that the medicines they're taking aren't causing any problems of sleepiness, drowsiness, and potentially there may be drug interactions. And then as a neurologist, we would refer to driving evaluation.

[00:24:08] I tell people go to the DMV to get a behind-the-wheel assessment or go to AAA or even call in for driving instructor or driving schools like you would when you're first learning and get some tidbits about how to improve your driving, where the problems are. Because we don't go back and get instruction after we've had our license for, you know, 20, 30, 40, 50 years. And sometimes it's good to get that reassessment in a safe spot, you know, in that situation.

[00:24:35] Now, as a neurologist, we also send patients to occupational therapy, and there are occupational therapists that do assessments. They do special assessments with driving simulators and many centers, like I work with St. Jude and Fullerton as well, and they have a very amazing setup there where they have a driving simulator and occupational therapist to assess safety there.

[00:25:01] And then as a neurologist, one of the last things that we have to do is state reporting. That's a requirement. If we feel that it's a safety issue for the patient or others on the road, then we are having by law, again, reporting. But that's, again, does not guarantee that someone's not driving. There is this DMV involvement where they'll do assessments, they'll check for vision, and they'll assess for cognitive, like remembering if the patients are aware of the traffic lights and symbols.

[00:25:31] And how that may affect. But there is a lot that goes into it, and it's not that someone's license is totally revoked, unless it's like lapse of consciousness, like seizures, right? And that's not typically associated with Parkinson's. But, again, seizures could occur for other factors, and that's the only time that there's a true kind of where we need to avoid those lapse of consciousness, because that can really, truly affect safe driving. So it's not associated with Parkinson's, but it can overlap.

[00:25:59] It just can happen to be that a person with Parkinson's also has seizures for some reason. Well, it doesn't, yeah. I mean, like you can have Parkinson's, so get migraines. You know, it's a separate entity, not directly related. But as we get older, well, let's say if we've had strokes, or maybe we're on different medicines that put us at risk for a seizure.

[00:26:19] The other key thing is that if there is actually frank dementia, like we are having true memory problems, that itself is a reporting mandate thing that we need to send in to DMV. But, yeah, you know, lapse of consciousness, seizures, people who are diabetic, they can have loss of consciousness because they become hypoglycemic, their sugar levels go low.

[00:26:40] And then, again, if there's frank dementia and getting lost, like where you're going, where you're, like what are you going to get at the grocery store or the whole like directionally challenged situation with severe dementia, like that brings up the discretion of us to report. And what is a formal driving evaluation? And when should someone consider one? That's a great question.

[00:27:04] So, in the clinic, our standard quick cognitive tests, memorizing words, drawing a clock, they're very simple. They don't capture the deficits of someone. You know, a person can score perfectly fine on the standard memory test, but they still experience a lot of visual spatial deficits. And, you know, when you're driving, you're not doing memory tests, you're doing multitasking. And so the formal testing could be in that simulator-based driving assessments with the occupational therapist. It could be actually on-road evaluations.

[00:27:34] Like I've said, you can go to a school instructor for driving. You could go to AAA and get the assessment. AAA and other such entities have also tools to help you, like with, again, larger mirrors. There could be other devices that can be utilized. And, again, those are situations that can be offered.

[00:27:56] And when we think about the formal driving, the neuropsych testing is very important because those testing evaluations also tell us a lot about processing. And so that's when we think about formal driving, eval, that would be one of the aspects of it. And now in terms of the conversation, how should families approach conversations about driving without damaging trust?

[00:28:21] Yeah, that's a key circumstance here. So, and I want to definitely, after we finish this, I definitely want to talk about the different aids to help people like different strategies to continue driving. So we'll talk about that as well. So this is definitely a hard question, though, because, you know, family members, they don't necessarily confront the patient that there's a problem. They usually come to our clinic.

[00:28:51] This is when I get notes on the side or before the visit, and they give it to them, you know, the medical assistant, or they give it to my front staff saying, can you pass this on to the doctor? And this is when it comes up to usually actually the doctor has to end up being the one to start this conversation. And so I'm okay with that. That's totally fine. Like, it's really about that the family members have trust in us. And I know it can be concerning that if they bring it up directly, but there are times that probably they have brought it up.

[00:29:20] And so most of the situation is, you know, you bring up this conversation because there's a concern. It's a caring phenomenon. It's not about control. But what I would always say is lead with the concern. Avoid the ultimatums. You know, involve the neurologist. You want to frame everything about safety and not about ability. You know, you want to validate someone's emotions that we're saying that we need to cut back on the driving.

[00:29:48] That things that I have seen where, and the stories I've heard about the incidence of an accident. I mean, it's deadly. I mean, it can be very detrimental. It could be worse than just dealing with a neurological disease. I mean, you could lose, you know, lose your ability to totally function. Again, there's complications of an accident that involve maybe requiring surgeries.

[00:30:14] And again, when it's an accident and, you know, it may involve your own family, that's also a serious thing. So, you know, that conversation needs to be had very early on when there's compromise in our coordination physically and also cognitively. And when we are having these conversations, I think it needs to be done in an environment that the patient's been multiple times had this conversation with the family member.

[00:30:43] And then if they're not adjusting to that, then maybe bring in other family members to safely discuss this. But it should be also done in the neurology clinic so that we can point out what we need to adjust. I mean, just because there is some compromise driving, it does not mean that someone has to completely stop driving.

[00:31:06] And that's why I want to bring up that later on about the modifying tools that are there and other strategies that are there. And so can you share with us what strategies those are? Yeah. So, you know, sometimes the circumstance of driving is that if you're driving too long, that's when someone may get tired, right? You're taking medicines, medications you take, maybe they start wearing off.

[00:31:32] Or when you start driving, you're doing fine, but the medicine now starts to wear off and you get into that on-off fluctuation within, you know, five minutes, 10 minutes or 30 minutes. So you may want to limit the driving distance. You may not want to do like a huge expedition or you take turns driving. Like I have family members of patients that they rotate when they're driving from one state to another. If they're doing a family vacation, maybe every hour or two hours they switch driving.

[00:32:00] Maybe it's better to drive during the daytime only. I know nighttime is when our coordination is a lot slower. Our reaction time is a lot slower cognitively. Sticking to familiar routes, maybe even avoiding freeways or highways could be a strategy because, you know, how do we take the time to turn left or right off, you know, the freeway entrance can also, you know, like create a lot of anxiety.

[00:32:27] And then potentially even avoiding rush hour, like those times can be where it's again, just too much traffic. People are in their road rage mentality, you know, and they've had a tough day. So then they're erratic drivers. So, you know, patients who have Parkinson's aren't, you know, the dangerous drivers. It's the road rage issues are much worse, but there are adaptive tools that are out there.

[00:32:53] And there are these steering and upper body supports that exist. Like there's these spinner knobs that could be on the steering wheel. There's palm grips or tri-pins that are available for drivers who have a weak grip. Or if their tremors are interfering with the squeeze, then they have these standard spinner knobs that help with driving and turning in the steering wheel. You don't have to use so much effort in steering. So that way, maybe the power steering can be adjusted.

[00:33:20] The pedal footwork alternatives exist too. So what happens is, you know, there's hand controls, these mechanical push-pull systems that exist and levers that can be mounted below the steering wheel and it connects directly to the pedals. So, you know, pushing the lever forward applies to the brakes while pulling it backward or rocking it like it helps with acceleration. So you don't have to really depend on the foot.

[00:33:45] But there's also modifications that can happen where now you have a left foot accelerator. And then in Parkinson's, if it's affecting the right foot or right side, then the second pedal is installed on the left to help with the braking or on the left side of the braking. And then there's a protective pedal guard that blocks the original right pedal to avoid accidents. So there's pedal extenders that exist.

[00:34:13] There's visual aids that may be there. And those panoramic or blind spot mirrors can be there. There's also problems with reaching for like the seatbelt. Like there's seatbelt grabbers that exist. And one of the best things that for like a lot of my patients with mobility, they have these swivel chair cushions. So it's like a low friction rotating cushion that's placed on the driver's seat. And so allows the driver to kind of sit down backwards first and then smoothly rotate their entire body.

[00:34:43] And when they're sitting down, that the legs can then turn and twist over. So that makes it easier for them. And that's been very helpful for a lot of my patients who get stuck or frozen in those tight spaces of getting into the car. Dr. Thien, you mentioned about having the conversations with your patients sometimes. What emotional reactions do you see when driving has to be limited or stopped?

[00:35:09] Dr. Thien, you mentioned about having the same emotional responses we see with anything that's stressful. When there's emotional response with losing a loved one, infidelity, you name it. Like these are the same very similar ones. So there's grief. There's also a feeling of shame, sentiment of anger potentially and resentment that comes with being told that you cannot drive. There's also the opposite where it's relief. It's like, hey, someone's understanding what I'm going through. It's that anxiety that's there with driving.

[00:35:39] And I really think that it's a really important discussion to have where patients have come to me like they do say that they do feel a little bit anxious. Sometimes I have to bring it up because I'm like, hey, how are you driving? Because when I see the foot dystonia, like the foot turning down or foot turning in, you know, I've seen it with my stroke patients as well in the past. And those are the patients that they actually have an ankle foot orthotic, but then they don't have the flexibility on their ankle.

[00:36:06] So now they're using their knee and a lot more of the hip flexion to to actually press on the pedal. So like people make modifications, but they sometimes say, you know, I'm not as good at when I'm at a stop sign or stop light and my foot's on the pedal of the brake that, you know, I don't feel as steady. And they may not be even saying that they feel steady. They just say they feel anxious. So when we have this discussion, sometimes it's a relief that we understand what they're going through.

[00:36:33] And so those are those identity shifts at that time of their life as well. Again, so many things have gone on where they just retired. So, you know, there's a lot of back and forth that we do need to make sure we address emotionally. And so why is it important to discuss driving early in Parkinson's? Yeah, and it's the obvious that we want to prevent a crisis. We want to prevent a situation where we want to preserve dignity for a patient.

[00:37:01] They can still keep active, meet friends. We want them to participate also in in in the decision of of when to reduce driving or when it's appropriate to drive or when it's appropriate to stop driving. And so that also, I think, reduces that family conflict that, hey, you know, it was my husband who told me to stop driving or my wife that told me to stop driving or this resentment against the kids. I think this early discussion is like, hey, you know what?

[00:37:30] Like, I knew there was a problem with driving. I'm going to keep my independence in a certain way. We're going to maybe, you know, our car is getting older. Let's get a newer car that has these safety features. You know, maybe maybe some people still drive a manual, you know, version of a car and they can go to an automatic car. They may need to downsize from a big, huge SUV that's hard to get into to maybe a smaller car that's more appropriate for them.

[00:37:58] There's there's so many different avenues and things that we can discuss. So you can also save money. It's also very important to understand how it affects insurance. And, you know, driving is very expensive, let alone just the obvious gas prices that we see. It's that insurance can go up significantly. So, you know, I think that when people give up driving, they may think that they're going to save money on driving. But that's not always the case. Sometimes the driving rates don't go down just because one family member is not driving.

[00:38:28] So I think it's important to understand those ramifications. And Dr. Takar, we've reached the end of our episode. Is there anything else you would like to leave the audience with today? Well, this is this is an important topic. And I think driving comes up this episode. Yes, we talk about for Parkinson's and related to Parkinson's. But it may affect someone who has other health issues, other neurological conditions as well, maybe even dementia. So this episode hopefully provides a little bit of wisdom related to that.

[00:38:57] You know, I think on the closing remark is we as physicians prescribe medications and medications can be very beneficial for patients. It can help them get into an on state, have symptom relief when it comes to their tremor stiffness and slowness. But at the same time, some of our medicines we give can make people very sleepy and tired. I know a lot of our older medicines that we use for tremor. They they have a lot of side effects of sleepiness and there's things like sleep attacks that can occur.

[00:39:24] So if there's side effects from medications, please let doctors know right away that a medicine was started and it created some issues, whether it's dizziness that can also lead to unsafe driving. And then at the same time, when you are getting a new medication, you never really want to start a medication on a on the beginning of a long drive or road trip or or such situation. So maybe, again, there's times for a discussion about when it's appropriate to start or change medications.

[00:39:53] But always bring your list of medications to the doctor's office. And then I think that hopefully we're promoting safety here. Thank you for this valuable information, Dr. Takar. Driving and Parkinson's is not a conversation about taking something away. It's a conversation about protecting what matters most safety, dignity and quality of life. If this episode helped you feel more prepared or less alone, please share it with someone navigating this decision.

[00:40:22] This is the care neurologist where difficult conversations are met with compassion and clarity.