In 1994, a coalition of experts in brain health and epilepsy published a consensus statement on the appropriate criteria for driver licensing for people with epilepsy. Issued by the American Academy of Neurology (AAN), the American Epilepsy Society (AES), and the Epilepsy Foundation of America (EFA), the statement recommended guidelines to help protect public safety while also preserving the rights of those with seizures and epilepsy. (The AAN also issued a position statement on the topic in 2007.)
In the three decades since the original consensus statement, new research has offered deeper insights into the risks of motor vehicle accidents among those with epilepsy and the kinds of oversight and guidelines that can help minimize those risks. Yet in the United States, regulations still vary from state to state, sowing uncertainty and confusion for patients and clinicians alike.
This week, the same organizations issued an updated version of the 1994 consensus statement that reflects the latest research and addresses gaps in the original document. The paper, published in the journal Neurology, was led by Yale neurologist Benjamin Tolchin.
Among their recommendations, the authors suggest that medical advisory boards should conduct individualized risk assessments for people with seizures and require a seizure-free period of three months or longer before driving. In addition, they make the case that health practitioners should be allowed but not required to report drivers who pose an elevated risk, since mandatory reporting has not been found to reduce accidents or fatalities but in fact increases the likelihood that people will drive without a license and withhold information about seizures.
Ultimately, the authors say, the paper strikes a balance between promoting the personal independence and well-being of people with epilepsy and public safety.
“Most people with epilepsy can drive safely when seizures are controlled by medication, and for some, seizures stop over time,” said Tolchin, an associate professor of neurology at Yale School of Medicine who specializes in non-epileptic seizures. “This position statement aims to improve the management of this complex personal, medical, governmental and societal issue.”
Benjamin Tolchin
In an interview, Tolchin, who is also a fellow of the American Academy of Neurology and the American Epilepsy Society, describes the known risks associated with driving and seizures, how the new recommendations protect the rights of individuals with epilepsy, and the importance of providing alternative methods for transportation for those whose driving privileges are restricted due to these health conditions.
The interview has been edited for length and clarity.
Why was there a need for a new consensus statement on driving and seizures?
Benjamin Tolchin: There was a recognition by all three organizations [American Academy of Neurology, the American Epilepsy Society, and the Epilepsy Foundation of America] that the consensus statement published in 1994, as well as the 2007 AAN position statement, needed to be updated. A substantial amount of evidence relating to driving and seizures and the risk of motor vehicle accidents had been collected over the intervening decades. And there were also a few gaps and issues that were not addressed in those statements that all three organizations agreed it was important to consider and address.
What were some of those gaps? And how do the findings of the past three decades help to address them?
Tolchin: Research has shown real but modest increases in the risk of motor vehicle accidents after epileptic seizures — in particular, that higher seizure frequency is associated with a higher risk of accidents. But there have also been findings that the risk of fatal motor vehicle accidents associated with epileptic seizures was not higher than in the general population of drivers — and that it is actually significantly lower than the risk of fatal accidents associated with alcohol use disorder, young drivers, or distracted drivers.
Placing that level of risk in context with other comparable risks, there’s evidence that the risk of recurrent seizures and the risk of motor vehicle accidents for individuals who have had seizures actually declines with longer seizure-free intervals. The longer a person waits and doesn’t drive while not having seizures after having had a seizure, the lower the risk of having a recurrent seizure becomes for that individual, and the lower the risk of a motor vehicle accident. But at the same time, other studies suggest that requiring across-the-board prolonged seizure-free intervals before individuals are allowed to drive may not actually reduce the risks compared with shorter seizure-free intervals. Further, they find that individualized seizure-free intervals [periods tailored for individuals] may be an effective way of reducing the risk of motor vehicle accident after seizure.
There’s also another growing body of evidence which shows that mandatory reporting by clinicians is not effective in reducing the risk of motor vehicle accidents or of motor vehicle accident fatalities when clinicians caring for patients with seizures are mandated to report those; in fact, mandatory reporting increases the occurrence of individuals driving without being licensed and also increases the occurrence of patients withholding information [about their condition] from their clinicians.
The position statement also argues for the adoption of more consistent guidelines and policies nationally. Why is that important?
Tolchin: There’s a significant variation of driving regulations from state to state which can affect whether there is any seizure-free interval required before somebody who has had a seizure can resume driving and what the duration of that interval should be.
There is also some variation in regard to whether individuals receive an individualized assessment by a medical advisory board. Many states do not require individualized assessment by a medical advisory board in setting that seizure-free interval, but rather have an across-the-board seizure-free interval that is required for anybody who has had a seizure, regardless of the specific factors in their case. Different states also have different regulations regarding whether clinicians are required to report seizures to state authorities and the extent to which clinicians are subject to legal liability if they report seizures or unsafe driving situations to the state. I think this can lead to some confusion and uncertainty, both for patients and for clinicians.
Greater uniformity of these regulations could be achieved through a mechanism like the Uniform Law Commission, which helps to coordinate different state legislatures in advancing similar regulations around a uniform model or framework.
The authors argue for the importance of such individualized assessments for people with epilepsy and seizures. Why is that important?
Tolchin: The statement really focuses on the benefits of having individualized assessment of cases by a medical advisory board — which ideally would include clinicians who are experienced and expert in the diagnosis and management of seizure disorders. We suggest that recommendations on a seizure-free interval should be based on an individualized assessment by the medical advisory board, rather than the treating clinicians — with a minimum of three months of seizure-freedom prior to driving — and that that interval may be extended based on the individual circumstances of the case.
And another key recommendation that this position statement really focuses on is the recommendation that treating clinicians should be allowed, but not mandated, to report seizures and unsafe driving, and that they should be protected from legal liability whether they make a clinical decision to report or not to report. The goal there is to empower clinicians to make clinical judgments based on whether they think they can be more helpful by disclosing information to the medical advisory board and the DMV or whether they can be most helpful by counseling the patient in confidence.
That’s not to say that clinicians should not report seizures or unsafe driving conditions to the Department of Motor Vehicles or to the medical advisory board, but rather that there should be a clinical judgment by the clinician about when that should happen and if that should happen.
You also recommend accommodations for individuals who are unable to drive because of these conditions.
Tolchin: Yes, over the past three decades we have seen that the ability to drive is a key factor in quality of life for individuals with seizures. When that ability is restricted, it significantly affects an individual’s autonomy and their ability to work, to care for their families, and their overall quality of life. So one key recommendation is that governments — including the federal government, state governments, and municipalities — really need to make provisions to provide alternate transportation and accommodations for individuals who are restricted from driving for medical reasons.
You talked about how the risks associated with driving and seizures compares with some other public health threats. Is there data to quantify specifically how much of a public health threat it presents?
Tolchin: I don’t think we have great numbers on the overall number of motor vehicle accidents caused by seizures. But we do have some relevant information. We know, for instance, that about one 1 in 10 people will have a seizure at some point in their life, and that 1 in 100 will go on to have epilepsy, meaning a risk of having recurrent seizures. So, these are regulations that affect a broad minority of Americans. And there is a slightly increased risk for motor vehicle accidents among individuals who have epileptic seizures compared with the general population, but the risk of fatal motor vehicle accidents does not appear to be higher than among the general population. We know it’s significantly lower than the risk for individuals with alcohol use disorder, for young drivers, for distracted drivers.
In terms of raw numbers, there was a study in Maryland that looked at the number of seizure-related motor vehicle accidents reported in the state over a seven-year period [that involved persons with] an individualized assessment by a medical advisory board and a minimum three-month seizure free interval (which could be prolonged at the discretion of the medical advisory board on the basis of that individualized assessment). They found that over that period there were two motor vehicle accidents associated with seizures reported in the state of Maryland. So, I think that suggests that, despite the relatively large number of individuals with seizures and relatively large numbers of people with epilepsy, with individualized assessment by a medical advisory board with a minimum seizure-free interval of three months (and with the possibility of expanding that seizure-free interval to a longer period), the risk of a motor vehicle accident associated with seizures can be kept to a very small number.
The bigger takeaway here, I think, is that with appropriate medications and appropriate medical care, the overwhelming majority of individuals with seizures and with epilepsy can drive safely.
