New Guidance on Seizures, Driving, and Medical Reporting

The first updated guidelines for seizures, driving licensure, and medical reporting in nearly two decades reflect a shift toward medical advisory boards to determine driver licensing for individuals with epilepsy and greater physician flexibility and immunity in reporting unsafe drivers.

The consensus position statement was developed by experts from the American Academy of Neurology (AAN), the American Epilepsy Society, and the Epilepsy Foundation of America. 

This is the first joint position statement on this issue from all three organizations since 1994, updating the AAN’s consensus positions published in 2007. 

“There’s been a lot of different pieces of evidence have come in since that time and that growth of evidence most motivated the AAN and the other organizations that an update needed to be issued,” Benjamin Tolchin, MD, MS, lead author and associate professor of neurology, Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News.

The updated statement was published online March 12 in Neurology.

Reliance on Empirical Data, Not Anecdotes

The position statement includes 10 key consensus positions based on the unanimous agreement of the author panel, followed by review and approval by all three organizations. 

The update recommends that regulations around driving and epilepsy should be based on empirical evidence rather than tragic individual cases or anecdotes, which in the past have unfortunately driven some driving regulations, Tolchin said.

The evidence has established there is a modest but real increased risk of motor vehicle accidents (MVAs) for individuals with epileptic seizures compared with the general population.

The risk of fatal MVAs, however, is not higher than in the general population and is significantly lower than for individuals with alcohol use disorder, young drivers, and distracted drivers.

“That’s important in terms of putting the risk to public safety in context with other comparable risks,” he said.

The risk of recurrent seizures and MVAs also goes down with longer seizure-free intervals, with progressively reduced risks after 6-12 months of seizure freedom.

New evidence, however, shows that universal legal requirements for seizure-free intervals longer than 3 months do not necessarily reduce MVAs or fatalities, as was demonstrated when Arizona cut its seizure-free interval from 12 months to 3 months, Tolchin said.

New Role for Medical Advisory Boards.

A key new recommendation calls for a minimum 3-month seizure-free interval, extended based on individualized consideration of favorable and unfavorable factors, assessed by a medical advisory board with input from treating practitioners.

The position statement includes a number of factors for the advisory board to consider in setting the seizure-free interval. It also suggests the medical advisory board in every state should include at least one clinician with experience in treating epilepsy and other alterations in consciousness.

Since the state of Maryland implemented this strategy in 2003, just two MVAs associated with seizures have been reported, the consensus document notes. 

Tolchin acknowledged the new recommendation will require an investment in public safety by states — many of which still have a single blanket seizure-free interval, often longer than 3 months — but “is the best way to balance the very legitimate concerns of public safety, while at the same time protecting patient autonomy and welfare.”

Mandated Reporting Nixed

Another key recommendation is that practitioners should not be mandated to report seizure activity. Instead, they should have the discretion to notify licensing authorities, especially when they believe a patient is driving unsafely against medical advice. 

“There is now a growing body of evidence that mandated reporting by clinicians does not in fact reduce motor vehicle accidents or motor vehicle fatalities but does undermine the therapeutic alliance and increase the likelihood of patients withholding information from their clinicians and the likelihood of patients driving without a license,” Tolchin said. 

“This has really raised a lot of concern about the idea of mandated reporting, which fortunately is only present in six states,” he added.

The consensus document also recommends that practitioners exercising their clinical judgement in good faith should be shielded from legal liability for either reporting or not reporting seizures or unsafe driving practices. 

However, practitioners should counsel patients about state regulations regarding driving with seizures and document these conversations in the medical record.

Psychogenic Seizures Now Included

New to the updated document is the consideration of functional seizures, also known as psychogenic nonepileptic seizures, which are caused by severe stress, other strong emotions, or other psychological factors, Tolchin said. 

Limited preliminary available evidence suggests that individuals with functional seizures may have a higher rate of MVAs, though a lower rate of severe injuries, compared with individuals with epileptic seizures.

“There are now documented cases in which functional seizures have caused motor vehicle accidents, and, for that reason, the position statement recommends the same individualized assessment with a minimum of 3 months of seizure freedom that can be extended by the medical advisory board should hold for functional seizures as well as epileptic seizures,” Tolchin said.

He acknowledged that more research is needed in this area and that research is also ongoing into the effect of interictal epileptiform discharges in the brain that do not rise to the level of a full-blown epileptic seizure and whether they may impact driving safety.

The authors report no targeted study funding or relevant financial relationships.