Visual inattention and driving
What Is Visual Inattention And Can You Drive?
The brain works in mysterious ways
One of the hardest things to do after a brain injury such as a stroke is to regain enough function to drive. This can be significantly harder with visual inattention. But what is inattention and how does it relate to driving???
As a driver trained occupational therapist we look for the functional implications of medical conditions and how they affect the everyday task driving. But as our clients would attest too, driving is sometimes not as every-day as it would seem.
A stroke or cardiovascular accident (CVA) stops blood flow to parts of the brain through a blockage or through a leak in the system (bleed/haemorrhage/aneurysm). Most people would recognise a change in movement or slurring of speech as a result of a stroke. But one of the more debilitating effects of a CVA is the changes to thinking and changes to how the brain process information. Cognitive and perceptual issues following a stroke can be evident or can hide under the surface and be more subtle. My past work experience was working on the stroke rehabilitation ward and in outpatient rehabilitation at a government hospital. Here we worked with patients to help them overcome many changes to their brain function for thinking and processing. Executive changes to the brain can be as evident as being unable to hold a conversation or add numbers through to more hidden differences such as a mild inattention.
Visual inattention is a condition experienced by people who have had a stroke or head injury. It can be as severe as where a person ignores everything on one side of their visual world. It usually affects people who have had a right
sided stroke and impacts on peoples ability to process visual information on their left side. Right sided visual inattention is less common and tends to affect people in different ways.
Visual inattention is also known as visual neglect or spatial inattention. A neglect is the most severe form where they ignore or do not attend to one-half of their body, and again is mainly the left side. But visual inattention can vary from being very mild to very severe. As well as visual inattention some people may also have a hemianopia, which is the loss of vision to the same side. This can be very debilitating as the person has extreme difficulties relating to their world. Hemianopia and inattention together rarely related to a return to safe driving. I have not gone into a hemianopia here, but you can read Tania’s story here.
People who have visual inattention can be unaware of anything or anyone on their affected side, or less subtly, they can be slower to respond to information presented on their affected side. In more severe cases, the person may hear you but will not look at you or acknowledge you until you move around to their non-affected side. They may only eat one-half of the food on their plate, struggle to read because half of the page is missing, bump into people and
objects on their affected side. If issues are this significant, most cases won’t present for a driving assessment.
But what happens if it is more subtle? What happens if the person does their rehab on the wards and they are no longer bumping into things on the affected side at walking speed? What if they are attending to most of the information in their world? Can they drive?????
Can a person drive with a visual inattention?
The issue is with inattention is that the majority of people, with visual inattention, tend to be symptom-free. The brain is unaware that the affected side is affected and the patient is unaware that anything is wrong, so they deny that they have a problem. That means that unless issues are pointed out to them, they live in a state of unknown.
Obviously, if the inattention is as bad as a neglect or a significant inattention where the person can only occasionally attend to the affected side, and the person does not process issues on the affected side at all well, this is bad for driving. When driving, the information to process could be a small child crossing the road or a car pulling out of a side street. If it is not seen, the issues are now a life or death situation.
The same issues present if the inattention is mild. You only have to miss the information from the affected side once for it to be a significant and life threatening issue. And just because the person does not bump into things at walking pace, moving at up to 100km an hour in a car can pose as a completely different set of challenges. So, it would be very very rare that a person with inattention can get straight into a car and drive safely.
So the question now is:
Can you teach a driver to overcome an inattention and be a safe driver???
The mechanism for recovery of visual inattention is complex and still not fully understood. In many people, there is
frequently good recovery from visual inattention. However, when it is present, continued input from healthcare
professionals and carers is important to promote awareness of the affected side.
Visual inattention is described as a disorder in ‘looking’ rather than ‘seeing’. The eyes work, but the brain is not processing what it sees, or the brain does not ask the eyes to look to the affected side. Orthoptic treatment involves getting the patient to look to their affected side. This is done using eye exercises and encouraging the patient to ‘look’ or scan for objects on their affected side. It also involves processing the information seen.
At Williams OT, with our driver trained Occupational Therapists that hold driving instructor qualifications, we take our medical knowledge and rehab strategies and apply this to the task of driving.
Driver and driving retraining can be difficult.
Edna has very graciously agreed to allow us to video her and share her story. Edna suffered a stroke prior to 2011 when I first met her. I completed her very first driver assessment at this time. This was an assessment that did not last more than 3 or 4 corners. She was unable to attend to the left-hand side. She drifted onto the wrong side of the road frequently and had extreme difficulty passing parked cars. She did not look to the left at intersections and the assessment needed to be terminated due to significant safety concerns. As with inattention issues, Edna was unaware of the issues at the time and that she had missed information to the left, despite it being evident to all involved. She was gutted.
Fast forward to 2017, some 6 years later. Edna has been adamant that she can get back to driving and overcome this issue. She has learnt a lot about inattention and tried repeated times to have assessments to prove that she has overcome the issues. She has also tried alternative treatment options to aid her recovery. However, through all of this period, she was unable to have any rehabilitation specific to driving.
Below are two videos (direct from the car, so the quality is a bit rough). These videos were taken after 12 hours of training with Williams OT.
Edna had to face some hard truths in the rehabilitation phase. She had to receive lots of feedback, and sometimes it came as a bit of a shock to her. She has been highlighted over and over again to the issues that were present. This included road positioning and scanning for cars on the left. It included passing parked cars. It then proceeded to included scanning into every driveway on the left and scanning every footpath on the left at intersections. to look for potential dangers. we tried and tried to build new routines and create new habits.
It was fatiguing work, and unfortunately the more she fatigued, the more errors she made and old habits ruled by the inattention rose back to the surface. Despite this, she presented for a licence test with the local authorities.
Unfortunately, Edna did not pass her test. This was heartbreaking for us both considering the efforts she had put in. A lapse in concentration meant that she made a critical error and law breach. She also had multiple minor infringements for lane positioning.
However, this is the issue that faces drivers with an inattention. It takes another person to highlight when you have made an oversight or error. You don’t know what you haven’t seen if you haven’t seen it. it also takes 100% concentration all of the time to compensate for the deficit. there is no time or room to relax. Even if Edna had scraped through her licence assessment, her level of concentration would need to stay at 100% for every meter that she drove.
Edna is very keen to keep trying to rehabilitate herself in the hope that she can drive again one day. And with the NDIS coming to her area soon, maybe funding will allow a more intense and longer rehabilitation program to build that stamina. But at this stage, the road to recovery is currently out of reach for Edna.
We thank Edna for being so brave and sharing this story.
Check out some more articles regarding stroke and visual inattention below
- Visual Attention and Action: How cueing, direct mapping, and social interactions drive orienting
- Stroke Survivor’s view and experience on impact of visual impairment