Driving and Social Issues in Epilepsy

Joseph F. Drazkowski

Joseph I. Sirven

A person with epilepsy faces many social concerns that are taken for granted by those without the disorder (1,2). A recent quality-of-life (QOL) survey identified driving a motor vehicle as the number one concern for a person with epilepsy (1). In addition to driving, other important social issues for a person with epilepsy include obtaining and maintaining employment, and participating in athletic and recreational activities (2). This chapter explores important social issues that can influence the QOL of a person with epilepsy.

EVALUATION OF THE RISK OF ENGAGING IN A DESIRED ACTIVITY

Although on some level everyone must balance the risks of engaging in a desired activity against the potential benefits derived from that activity, this cost-to-benefit analysis assumes added significance for the person with epilepsy. A person with epilepsy must conduct the analysis in the context of a specific situation, with the consideration that a seizure-related injury might occur during the specific activity. To determine potential risk, a person with epilepsy needs to understand all aspects of the specific activity and must try to predict the potential exposure to injury should a seizure occur during participation. The risk of seizure recurrence will determine, at least in part, how safe it is to participate in a desired activity. Factors that influence seizure recurrence have been reported (3) and may provide important insight into determining the risks associated with a desired activity. These factors include the presence of an abnormal electroencephalogram (EEG), initial seizure type, and etiology of the seizure. Symptomatic seizures are twice as likely as idiopathic seizures to recur (4, 5, 6). Partial seizures are also more likely to recur compared with an initial major motor seizure (4,7). If the etiology of a seizure disorder is head injury, the risk for recurrence may be higher. In patients with severe head injury, the recurrence rates for seizures are 7.1% and 11.5% at 1 and 5 years, respectively, (8) with severe head injury defined as amnesia and/or loss of consciousness for more than 24 hours, or the presence of an intracranial hematoma. Structural lesions, such as brain tumors, stroke, abscesses, and penetrating head wounds, all carry an increased risk for recurrent seizures. Seizures caused by alcohol use, on the other hand, are unlikely to recur if abstinence is maintained. After a new-onset major motor seizure in a patient with a normal examination and work-up, including magnetic resonance imaging (MRI), electroencephalography, and blood tests, seizure recurrence is estimated to range between 25% (5) and approximately 70% (9) at 3 years. Another review suggested a recurrence risk of 50%, also at 3 years (7). If one remains in remission (i.e., seizure free) for 2 years or longer, a good prognosis is possible (10).

The danger period for a particular activity should also be considered when evaluating potential risk. The person with epilepsy is exposed to less risk when the danger period for an activity is brief. For example, target shooting with a lethal weapon likely poses little risk to the shooter or people in close proximity except for that very short period of time when squeezing the trigger. In contrast, such activities as motorbike riding or hang gliding might present a relatively high risk for the person with epilepsy as danger periods encompass the entire time they are involved in the activity. Activities with inherent danger must also be factored into the decision of whether to participate. For example, table tennis is certainly less dangerous than bullfighting. Finally, other factors, such as medication compliance, medication side effects, age, concomitant medical problems, use of safety equipment, and
a prolonged and consistent aura, can all influence the risks faced by a person with epilepsy when engaging in a specific activity.

DRIVING AND THE PERSON WITH EPILEPSY

The Risks

A person with epilepsy faces a risk of injury and a risk of causing injury if a seizure should occur while operating a motor vehicle. Driving is a privilege, not a right. This privilege is governed by individual country, state, or territorial governments (11). There are approximately 225 million registered vehicles in the United States. In 2002, an estimated 6.7 million motor vehicle crashes occurred in the United States (12). These crashes resulted in approximately 3 million injuries and more than 42,000 deaths (12). It is estimated that approximately 0.5% to 1.0% of the U.S. population has epilepsy (3), potentially placing more than 2.5 million drivers with epilepsy on the roads of the United States. However, the actual number of persons with epilepsy who drive with or without a valid license is unknown. Applicants for a motor vehicle license must answer questions about their medical status and affirm that they are healthy and fit to drive before they are allowed to operate a motor vehicle. One study suggested that only 14% of individuals had answered truthfully on their driving application when asked about the presence of epilepsy (13). In a prospective survey of 367 patients with localization-related epilepsy pooled from a consortium of comprehensive epilepsy programs, approximately 30% of the respondents had operated a motor vehicle in the previous 12 months (14). The paucity of available data makes it difficult to definitively establish the number of automobile crashes caused by persons with epilepsy who have a seizure while driving. Reports suggest that persons with epilepsy account for approximately 0.02% to 0.04% of all reported automobile car crashes (15,16). In contrast, alcohol-related crashes comprise approximately 7% of car crashes but account for approximately 40% of all fatalities nationwide (17).

TABLE 89.1 CHANGES IN THE INCIDENCE RATES OF CRASHES (/10⁹ MILES DRIVEN) AFTER REDUCING THE RESTRICTION ON DRIVERS WITH EPILEPSY FROM 12 TO 3 MONTHS, 3 YEARS BEFORE AND AFTER LAW CHANGE

	Before	After	Incidence^a
Type/Cause	95% CI		Rate		95% CI	RR^b
Total
Seizure	1.1	1.1	-0.028	-0.30-0.24	0.98	0.77-1.24
Other medical	2.6	2.6	-0.092	-0.51-0.33	0.97	0.82-1.13
Not seizure (103)	2.6	2.8	0.20	0.19-0.22	1.08	1.07-1.08
Injury
seizure	0.58	0.76	0.18	-0.03-0.39	1.31	0.95-1.80
Other medical	1.6	1.3	-0.21	-0.52-0.10	0.87	0.70-1.07
Not seizure (103)	1.0	1.1	0.045	0.037-0.053	1.04	1.04-1.05
Fatal^c
Seizure	0.046	0.016	-0.029	-0.076-0.017	0.36	0.07-1.85
Other medical	0.055	0.099	0.043	-0.027-0.11	1.79	0.67-4.8
Not seizure	20	21	1.6	0.39-2.7	1.08	1.02-1.14
Abbreviations: CI, confidence interval; RR, relative risk.
^aIncidence rate difference (before versus after). ^bRelative risk (before versus after). ^cFatal crashes are a subset of the injury category and are segregated for separate analysis.
Modified from Drazkowski JF, Fisher RS, Sirven JI, et al. Seizure-related motor vehicle crashes in Arizona before and after reducing the driving restriction from 12 to 3 months. Mayo Clin Proc 2003;78:819-825, with permission.

Seizures are unpredictable, and the presumption is that longer seizure-free intervals translate into a decreased likelihood of seizure-related crashes. Verifying this is difficult, however, as individual driving records are generally not available for review. A recent retrospective survey of patients in several Maryland outpatient epilepsy clinics suggested that the risk of motor vehicle crashes was reduced by 85% and 93% if the patient did not have a seizure at 6 months and 12 months, respectively (18). This survey relied on self-reported crashes.

It has been suggested that self-reporting of crashes by respondents in surveys is unreliable (19,20). Drazkowski and colleagues (16) reviewed actual accident reports in Arizona from crashes caused by seizures before and after the seizure-free interval was reduced from 12 to 3 months (Table 89.1). Although no significant increases in seizure-related crashes were reported, the retrospective study provided some objective
data on these crashes. To date, no controlled prospective data are available to guide regulating authorities as to the optimum seizure-free interval for the protection of both the person with epilepsy and the public.

The Regulatory Requirements

The first seizure-related car crash was reported near the turn of the 19th century. Since then, regulatory authorities have placed restrictions on driving for the person with epilepsy. Almost a decade ago, the American Academy of Neurology, the American Epilepsy Society, and the Epilepsy Foundation of America convened a conference of thought leaders to issue guidelines on the topic of driving and the person with epilepsy (21). Recommendations from the conference included (a) a seizure-free interval of 3 months, (b) allowances for purely nocturnal seizures, and (c) a provision allowing driving when there is an established pattern of a prolonged and consistent aura (21).

Determining the risk of a crash caused by the driver with epilepsy is difficult. Traditionally, the duration of seizure freedom is used by authorities to determine when it is safe for a person with epilepsy to drive. Seizure-free intervals adopted by jurisdictions vary widely and have many unique exceptions (22) (Tables 89.2 and 89.3). State regulatory agencies and the Epilepsy Foundation of America website (www.efa.org) can be contacted for current laws governing driving and epilepsy (23). In an editorial, Krumholz suggested that it is time to consider uniform laws governing epilepsy and driving throughout the United States (24). International rules on driving have been reviewed, and because of the high variability among individual countries, it has been suggested that the appropriate national authority be consulted to determine current local laws regarding driving before traveling to these nations (25).

Six states currently have laws that require health care providers to report persons with epilepsy to the appropriate state driving authorities. The rationale behind the reporting requirement is that a person with epilepsy will not reliably self-report the presence of active or recurrent seizures to the proper authority. Laws that require a health care provider to report a person with epilepsy to authorities are criticized as impairing the physician-patient relationship and thus compromising optimal medical care. The premise is that when physicians are required to report epilepsy to driving authorities, persons with epilepsy may conceal information about their seizures to avoid being reported and potentially losing their license (19). Of persons with epilepsy who had been counseled about driving laws, only 27% reported their condition to the appropriate authorities (26). This is assuming that the health care professional knows the proper laws, but in one survey, only 13% of providers knew the appropriate requirements (27). In California, which is the most populous state requiring physician reporting, a survey again suggested that the physician reporting requirement impaired medical care and the doctor-patient relationship (28). There are no available studies showing that physician reporting reduces seizure-related automobile crashes. In Canada, a conference of invited experts concluded that the laws requiring health care professionals to report persons with epilepsy to authorities should be abolished and suggested that driving laws be uniform across Canada (29). An editorial by emergency department physicians suggested that mandatory reporting of seizures be abolished in the United States (30). This editorial highlighted several other medical conditions and situations that are associated with a similar or higher relative risk of a car crash compared with epilepsy, such as sleep, apnea, diabetes, dementia, and cell phone use (distraction) (30).

EMPLOYMENT AND THE PERSON WITH EPILEPSY

QOL surveys have identified employment issues and concerns of persons with epilepsy as significant (1,2). The economic impact that epilepsy has on society is huge (more than $10.8 billion per year) and is largely attributable to indirect employment-related costs, which account for 85% of all epilepsy costs (31). Persons with epilepsy are reported to have lower household incomes, which are estimated to be 93% of the U.S. median income (32), compared with the general population.

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