Publication
Article
Psychiatric Times
Driving and Epilepsy: Issues to Discuss With Your Patients
Author(s):
Because automobiles are such an important aspect of our culture, driving restriction is an enormous problem for many of the 65 million individuals with epilepsy worldwide and their families.
TABLE 1. States that require mandatory physician reporting of seizure[5,11]
TABLE 2. Favorable modifying factors that might lead to a shorter seizure-free requirement and unfavorable modifiers that might lead to a relatively longer seizure-free requirement for driving[4]
Dr Sanchez is Assistant Professor and Dr Krumholz is Professor Emeritus, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD.
Worldwide there are more than 65 million individuals with epilepsy.1 In the US because driving an automobile is such an important aspect of our culture, driving restriction is an enormous problem for many of these individuals and their families. Indeed, surveys find individuals with epilepsy report driving as a major concern.2 Physicians and other medical providers play an important role educating and counseling people with seizures and their families regarding driving. Here, we provide some background and guidance regarding this issue.
Individuals with seizures are restricted from driving because of concerns that a seizure while driving might result in loss of control of the vehicle and a crash, potentially injuring the driver or others, and damaging property. Tragically, such crashes cause fatalities.3 Therefore every state in the US restricts some individuals with epilepsy from driving. Driving restrictions vary by state and are ultimately determined by the Department of Motor Vehicles (DMV).4 Physicians and other medical providers are involved to varying degrees throughout this process of driving regulation and restriction. They serve as advisers to patients, with a duty to inform patients regarding rules and regulations as well as consultants to state regulatory authorities.
To properly counsel patents, it is important that physicians and other medical providers are familiar with the rules governing driving for patients with seizure disorders. Our recommended approach to counseling patients with seizures and epilepsy regarding driving is illustrated in some of the following examples and discussion.
Case example
A 23-year-old woman presents to your office with new-onset seizures. She generally feels well, has no other relevant history, and her examination is normal. Brain MRI with and without contrast and EEG are performed and are normal.
Q: As the medical provider, how would you counsel this patient regarding driving after her first unprovoked seizure (a seizure not related to an acute precipitating cause)?
A: She should be informed that a seizure while driving could be dangerous and result in a motor vehicle crash. Since she has had a seizure, she is at risk for further seizures. Regulations exist in an effort to prevent injury, death, or property damage that might result if a seizure were to occur while driving. She should be informed to stop driving and that patients are required by law to report their seizures to the DMV in their state. In some states, physicians and other medical providers are also required to report (Table 1) that a patient has had a seizure.4 The DMV will determine when she may resume driving.
A seizure-free interval is typically necessary for the DMV to approve a person to drive after a first seizure, this too varies by state. The typically required seizure-free interval may be as short as three months to as long as one year.4 There may be positive or negative modifiers that shorten or lengthen the seizure-free interval (Table 2).5 Antiseizure medication (ASM) is not always prescribed after a first seizure; this is a variable that may be considered on a case by case basis.6
After reporting her seizures to the DMV, the patient and the medical provider are required to complete paperwork regarding the condition. A medical advisory board or similar type of state review will consider the case and make recommendations. Then a final decision regarding any driving restrictions will be made by the DMV. Decisions may be appealed by the patient.
Q: What if the seizure was provoked by some specific factor, such as triggered by a medication the patient was prescribed?
A: The driving restriction may be shorter if it is determined that a seizure was provoked and the provoking factor has been eliminated and is unlikely to recur.5
The patient remains seizure free for several months, and the DMV determines that she is able to drive. Several months later, the patient has a second seizure and is prescribed levetiracetam, an ASM.
Q: Now how do you counsel the patient?
A: She is instructed that she should immediately stop driving and report the recent seizure to the DMV. Driving restrictions then resume while further medication adjustments are considered. She should be encouraged to try to utilize public transportation or be referred to the Epilepsy Foundation and other resources for transportation for patients with disabilities.
The patient has several more seizures and her dosage of antiseizure medication is increased. After the most recent dosage increase, she has had no further seizures. Her last seizure was 6 months ago. Paperwork is resubmitted to the DMV and the patient is told by the DMV that she can drive with close follow up in several months. She remains seizure free for five years, then she asks a question.
Q: The patient wonders now that she has been seizure free on medication for five years, might she come off antiseizure medication.
A: It is not unreasonable to consider taking her off ASM. There are no specific accepted state standards for restricting drivers with epilepsy when antiseizure medications are reduced or stopped. However, we would advise counseling patients that this is a period of somewhat greater risk for seizure recurrence, which may be about 30% in the first year after ASM is discontinued, and advising them to carefully consider that whether to discontinue ASM and their driving plans.7
Q: What are some other legal issues for physicians or medical providers for drivers with epilepsy to consider.
A: In some cases, a physician should consider reporting a patient to the DMV even in a state without mandatory reporting. This would be the case if the patient was judged to be of considerable risk, for example, a patient who is having frequent uncontrolled seizures, did not self-report, and has been involved in crashes because of the seizures.5
Physicians and other medical providers should familiarize themselves with their states’ legal standards.5 The Epilepsy Foundation has a State Driving Laws Database (https://www.epilepsy.com/driving-laws). They should also document all discussions about driving and state laws in the patient’s medical record.
Discussion
Individuals with epilepsy are permitted to drive in every state in the US when their seizures are controlled. However, individuals with uncontrolled seizures are restricted from getting a license.5 In general, the main standard for determining adequate seizure control for licensure to drive is the duration of time that an individual has been seizure free. In the US this varies from three months to about one year. Details regarding the standards for licensure throughout the US are available on the Epilepsy Foundation website.4 The main reason that the seizure-free interval is used is because it is a reasonably reliable predictor of the risk of subsequent seizures.
There is evidence that the longer an individual remains seizure free the less likelihood there is for a seizure recurrence.8 A 3-month seizure-free interval has been proposed by a US Consensus Statement, and recent evidence supports that it is a reasonable standard.9 Both favorable and unfavorable factors are also proposed to influence the decision as to when someone with epilepsy may be licensed to drive (Table 2). These are based mainly on expert opinion, and one of the proposed favorable factors, reliable auras, has recently been questioned.10
Noncompliance with legal standards is a major factor limiting the effectiveness of state regulations for drivers with epilepsy. Approximately half of all drivers with epilepsy or seizures who drive do not report their condition to state authorities. Such noncompliance limits the value of excessively long seizure-free intervals as they may promote greater noncompliance.
A major change is on the horizon for individuals in our society with epilepsy and other transportation disabilities. Pending their successful development, cost, and implementation, so called “smart” or autonomous driving cars are likely to be in our futures and will revolutionize and benefit transportation and opportunities for people with epilepsy. Until that future when autonomous driving vehicles are widely available, reliable public transportation remains an important practical alternative that should be promoted for people with uncontrolled seizures and transportation disabilities.
This article was originally posted on 9/5/18 and has since been updated.
References:
1. England MJ, Liverman CT, Schultz AM, et al. Institute of Medicine (US) Committee on the Public Health Dimensions of the Epilepsies. Washington, DC: National Academies Press; 2012.
2. Gilliam F, Kuzniecky R, Faught E, ET AL. Patient-validated content of epilepsy-specific quality-of-life measurement. Epilepsia. 1997;38:233-236.
3. Sheth SG, Krauss G, Krumholz A, Li G. Mortality in epilepsy: Driving fatalities vs other causes of death in patients with epilepsy. Neurology. 2004;63:1002-1007.
4. Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology. 2001;57:1780-1785.
5. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. Consensus statements: Sample statutory provisions, and model regulations regarding driver licensing and epilepsy. Epilepsia. 1994;35:696-705.
6. Krumholz A, Wiebe S, Gronseth GS, et al. Evidenced-based guideline: management of an unprovoked seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015:84:1705-1713.
7. Bonnett LJ, Shukralla A, Tudur-Smith C, et al. Seizure recurrence after antiepileptic drug withdrawal and the implications for driving: further results from the MRC antiepileptic drug withdrawal study and a systematic review. J Neurol Neurosurg Psychiatry. 2011;82:1328-1333.
8. Krauss GL, Krumholz A, Carter RC, et al. Risk factors for seizure-related motor vehicle crashes in patients with epilepsy. Neurology. 1999;52:1324-1329.
9. Ma BB, Bloch J, Krumholz A, et al. Regulating drivers with epilepsy in Maryland: results of the application of a United States consensus guideline. Epilepsia. 2017;58:1389-1397.
10. Punia V, Farooque P, Chen W, et al. Epileptic auras and their role in driving safety in people with epilepsy. Epilepsia. 2015;56:e182-185
11. Epilepsy Foundation. State Driving Laws Database. https://www.epilepsy.com/driving-laws. Accessed August, 29, 2018.
