Dr. Eleanor McConnell is an associate professor in the School of Nursing at Duke University. Dr. McConnell is interested in social factors that influence cognitive decline in older adults. She has presented on the transition from driving that many people with disabilities or people who are aging undertake.
AWD asked Dr. McConnell, or “Ellie” as she is known, to share with us some tips about talking with a family member, friend, etc. about transitioning from driving. Her expertise led to a rich and interesting discussion about cognitive impairment generally, too. The 2025-2030 Durham Comprehensive Aging Plan’s transportation domain includes several goals, including one similar to this topic – how to support a loved one who needs to transition away from driving.
How did you get interested in cognitive impairment and older people?
I guess it was a really long time ago. I was a staff nurse in a nursing home. I remember going there thinking I was going to go there to hone my skills, my bedside nursing skills, to be a better ICU nurse. And what I discovered was two things. One is that the clientele there were really diverse and really interesting, you know, everybody’s lived a long and usually interesting life.
And there were just a lot of different faces of cognitive impairment. from people who may have been quite impaired, but lived well with it, and then those who did not, who were either angry or frustrated or whatever.
Through the last decade or so, I really got in touch with the idea that there’s potential to make a real impact if you really focus less on what’s wrong with someone and more on what’s left. You know, what people still do or enjoy, and that’s where I’ve been focusing my energy.
When Shelisa connected the two of us, she was saying you were particularly interested in the driving and dementia part of things?
Yes, yes I am! Yesterday was his birthday. He’s 91. My 91 year old father, who’s still driving. And is very able, very active, he’s on the ball. And he does drive, and sometimes it scares me.
So does he have cognitive impairment, or is he just 90 something, and has, maybe, a memory that isn’t quite as sharp as it used to be, but fundamentally, he’s…
It’s just simple aging. His reflexes aren’t as quick as they were, and I don’t know if he may have some cognitive impairment, but he’s so smart that it doesn’t manifest. Which I discovered with my mother who had Alzheimer’s, we didn’t recognize the symptoms because she was such a smart woman. She could compensate.
I think you’re not alone in that by a long shot. This is part of what interests me.is the ability of one part of the brain doesn’t work right, quite right. There’s another part that kind of takes over, or may help compensate, and sometimes that can become a little problematic if it’s masking symptoms that you could do something about, right?
Sometimes people think that someone with dementia is being willfully difficult or stubborn. In fact, they’re doing the best that they can. But the neurologic resources that they’ve got at their disposal can be a source of, I think, both frustration, sometimes regret. “Oh, if only I’d known, I would have been a little bit more tolerant.”
So I’m curious about your Dad then. Driving, as you I’m sure know, is a huge issue for folks. It’s a huge issue, both because we live in a pretty car-centric society, and it’s tough to get stuff done if you don’t have your own wheels.
Let’s start with:
Then there’s also a lot of symbolism with driving. (Independence, for instance.) Figuring out both how the driving figures into someone’s life, and what’s important about it, and how do you get those goals accomplished, is a little bit different than just the mere objective -is this person fit to drive, or under what circumstances.
I was talking with a geriatrician recently about driving, and there’s a lot of euphemisms people use. People talk about retiring from driving, or giving up the keys, almost a developmental event, as opposed to, oh, there’s something wrong with you.
And she was saying to me,”You know, most people don’t love to drive,” As in, “Oh, I can hardly wait to get behind the wheel and have a Sunday drive or whatever” – that’s not what they’re about. They want to keep driving because either there’s something they want to do that they can’t do if they don’t drive there. Or they don’t want to give up the feeling of control that being able to hop in the car whenever you feel like it gives you.
Is there any planet on which you can imagine having this conversation with Dad? “Gee, Dad, what would you think about, for nighttime events, tapping into Uber instead of driving the car yourself?” A lot of people don’t know what Uber even is. And I am always stunned at the ease of Uber as opposed to taxis. You just put something in your phone and they appear. And I don’t have to count change or worry at the moment about how much to tip.
Uber’s a fantastic stand-in. I think the problem with Uber for some older people would be the interface with the phone. A lot of older people I know just really can’t use the phone well. Is Uber online? (It is!)
I don’t consider myself an expert in driving and dementia, but I guess I have talked about it, and I have forgotten that for a number of years, we did something called dementia round table. Our purpose in that was to try and get information that anyone can use in the hands of people who need it.
This was an idea that had popped up a lot of years ago, from a grant funded initiative that we had. For any given challenge in cognitive impairment, usually lots of people are affected. And it’s probably important to get all those people around the table to think together about what are the challenges, what are the resources, and what might some potential solutions be?
I’m wondering how, because you are an expert in this, how do you initiate these conversations?
I don’t have great tip of the tongue answers. But if you’ll bear with me, I think there are a handful of ways to approach it. I feel like what unites those handful of ways is the idea that you want to begin and end with the person’s best interest. Even that can have different facets of a diamond, right? This geriatrician that I was mentioning earlier has been a big fan of this thing called Patient Priorities Care. I’m gonna take a little detour here for a moment.
The idea behind Patient Priorities Care is that a lot of medical care is focused on the clinicians’ priority. On the face of it, there’s nothing wrong with that. You know, you go to medical school, or you go to nursing school. You learn how to treat hypertension. And it’s important to treat high blood pressure, because bad things happen if you don’t. There’s a lot of clinician behavior that’s around being evidence-based in our approach and following guidelines.
- What are patients’ values?
- What’s important to them?
- What kind of goals do they have that this care is getting in the way of, right?
If your goal is to go out with your girlfriend every evening, what types of medical care treatment might get in the way of that? The idea is once you really understand what some of the patients’ priorities are, their goals, then you can align medical care to that.
If someone, for example, is taking a fluid pill to manage their blood pressure and that makes them have to go to the bathroom too often – that’s going to interfere with going out with their girlfriend. Maybe there’s a different way to manage the blood pressure. That’s the general idea.
If you take that and map it on to the driving conversation, it is about what’s important to this person? How do we make that happen? And if we can anticipate what someone’s going to give up by giving up driving, and find another way, maybe it’s easier to have that conversation than by focusing on, essentially, deficits. “Oh, Dad’s scaring me.” Nothing’s wrong with saying Dad’s scaring me, right? You don’t want to overlook something really bad that could happen..
I think just being aware that those conversations about driving always have an emotional overlay. Often the focus is on – what am I giving up or what’s the loss instead of -how do I maintain but just in a different way? I think that’s the secret to having the outcome you want. Which is a conversation that doesn’t devolve into, ,”You’re a terrible driver.”.
Do you come to the table with solutions?
I think you can talk to 100 people and probably get 100 different responses to that. But I guess mine would be, I don’t know if you’ve ever heard of a book called Crucial Conversations. It’s essentially about conflict management. Basically, their idea is that sometimes you’d have to have a really hard conversation with someone to resolve an important issue.
They talk about starting with the heart. You really want to reflect on why this is important to me and be compassionate about it. They also talk about the idea that we need to really check the story that we’ve invented about why someone might be behaving in a certain way, and really seek to understand the other person’s perspective. Then from that, you try and build together a solution.
If you could start with the heart, and say, “Gee, Dad, you know, when we drove together the last time, you missed the turn and ended up in the median, and I’m really worried about that. What’s your take on that?” Or some way open up the conversation to hear his take on things as opposed to deciding for yourself what’s going on, that might be helpful.
Now, it could be, he lacks safety awareness, right? And that conversation can still go poorly. But I feel like the crucial conversations approach allows you to at least hear how the person who’s directly affected by all this might be seeing it. Sometimes we’re surprised by either the insight people have, or the insight they don’t have.
I work with a woman by the name of Melanie Bunn, who works in the dementia care space all the time. She points out that people like to solve their own problems. So I could come up with a solution for you, but it would probably be the wrong solution. Because, you’re going to want to solve this in a way that makes sense to you or that fits with how you live your life or your family. I feel like you never go wrong trying to invite the person who’s struggling into the conversation. It may go well. It may go poorly. But at least you can tell yourself, you…
Checked that box.
Yes, that’s right.
I think in my particular case, I’m very fortunate that my father is a very logical science driven person. And so he has in his mind that there will come a time that this will happen, or will possibly happen. What about people who really, you touched on this earlier, have people that push back?
Again, there are a couple of different pathways. Something I heard senior leaders say once is, “no doesn’t mean no forever.”Sometimes people can tolerate the idea of something for a short period of time, as long as it’s not forever, they can tolerate it. An example would be someone who has cognitive impairment of, say, Alzheimer’s. This person has very little awareness of the risk that they’re posing to themselves or other people, and they’re still driving.
And it’s clearly unsafe. You might take that person to a medical provider, and ask that medical provider how this person, medically, is unsafe to drive. There are other examples besides dementia of that. A good example would be epilepsy. I’ve seen clinicians do this pretty artfully where it’s like, “We’re really concerned about you neurologically right now. And right now, it’s not safe for you to drive.Between now and the next time I see you, you need to stop driving, right”
There’s an end date. I was pretty impressed, because, again, it’s not, “You’re an old person who’s losing your faculties.”, It’s just, there’s a simple fact here. Which is right now, it is not safe. And I need you to make other arrangements.
I think the other thing that’s important is, it’s not the son saying this. Family relationships are fraught? The caregiver is there to be the second pair of ears and support the patient. I feel like it’s a very different dynamic if it’s somebody outside the family saying, “This isn’t safe.”
It’s this woman who, I believe, lived in St. Louis, Washington University in St. Louis, which has a big Alzheimer’s DC Center. They also have strong occupational therapy, and oftentimes a driving evaluation is done by an occupational therapist. You know, literal driving tests, like when we were in driver’s ed.
There’s this woman who has probably moderately severe dementia, but socially, is very intact. She comes in with her family to have this driving evaluation. How the camera’s framed, you’re like in the back seat as you’re watching her and this occupational therapist do the evaluation. And it’s stunning in the sense that she does get goofed up on the road, right?
She kind of gets turned around, lost, and, again,there are controls on the evaluator’s side, so it’s not totally unsafe, but I remember him asking her, at one point, there’s a “no left turn” sign. So what would you do? Oh, I turn left. And it’s like, wow. Clearly not safe, right?
We go back into the office and the driving evaluator and the woman with dementia and her family are all in the same room, and they’re going over the results of the test. They show her the objective information about, here’s where a challenge is. And they say, Mom, we’re gonna have to make other arrangements for your driving. You can’t drive anymore.
The woman looks like she’s dressed to go to church. She is just indignant. You are taking away my independence. We have so much faith in objective data, and if we just get the right test done and show the results, oh, they’ll get with the program. And the truth is, maybe, maybe not, but probably not. Because the facts don’t matter, right? The woman can’t really process the facts. All she knows is she’s losing something.
And the idea of taking away, that’s really powerful.
One thing I haven’t said that probably is worth saying is that when people have cognitive impairment, it is this trial and error to figure out what’s going on, because the person’s ability to think rationally may have eroded. I guess the other thing is, I don’t know if you’re familiar with the field of behavioral economics, but it’s this idea that we like to think that we make decisions based on rational thinking, but in fact, a lot of times it’s on emotion. That’s super true for people who get cognitive impairment, because you’ve lost reasoning and still have got emotion there. So being willing to cycle through a couple of times, when you don’t get it right, with the idea that you’re just gonna keep at it till you do, get to the bottom of it, I think is a helpful awareness to have. I’m sorry, you’re not gonna get it right the first time. Don’t give up.
The last thing I’ll say is, as I was speaking at a roundtable,.there was a pharmacy student. He spoke up and said, “I work in this clinic where we just treat cognition as another layer of the person.” And I thought, “Wow. I want to go to that clinic.” I want to understand what the thought leadership there looks like, because I think that’s actually the right approach. That we all have our type of strengths and weaknesses. If we could just understand that most people don’t reason like Ellie McConnell does. Most people reason differently than Sam Peterson. If we just try to understand and align our explanations, or our attempts to persuade along the lines of how they think. I feel like we’d just do better.
