Introduction

Driving capacity can be affected by many medical conditions, including kidney disease, stroke, diabetes, concussion, migraine and inner-ear vestibular disorders,^{Reference Cohen, Wells, Kimball and Owsley1–Reference MacDougall, Moore, Black, Jolly and Curthoys6} and by medications.^{Reference Hetland and Carr7–11} Patients with dizziness, vertigo or balance disorders, especially younger patients, women, and patients with Ménière's disease, regularly experience limitations related to driving. This means people are often unable to work,^{Reference Wei and Agrawal12–Reference McKiernan and Jonathan15} and it has a significant impact on their lifestyle.^{Reference Chihuri, Mielenz, DiMaggio, Betz, DiGuiseppi and Jones16–Reference Van Leeuwen, Schermer, Colijn and Bruintjes19} It is surprising that there is a reported lack of knowledge at patient and practitioner level.^{Reference Evans and Eng17,Reference Sinnott, Mahoney, Wilkinson and Broomfield18} Consequently, driving was not considered in 92 per cent of patients attending a centre for dizziness and balance disorders.^{Reference Van Leeuwen, Schermer, Colijn and Bruintjes19} However, given its importance, the topic of driving and dizziness or vertigo should always be addressed in those presenting with these symptoms,²⁰ and in patients taking medication that causes dizziness or drowsiness,²⁰ as data are consistent regarding the effects of medications used for dizziness and vertigo on driving ability.^{Reference MacDougall, Moore, Black, Jolly and Curthoys6–Reference Pergolizzi, Taylor, LeQuang, Bisney, Raffa and Pergolizzi10,Reference Uwents, Jorissen, Van Ombergen, Dobbels, van de Berg and de Varebeke21–Reference Zwergal, Grill, Lopez and Dieterich23}

Vestibular disorders have been shown to negatively affect driving ability in most studies, with a low risk of bias,^{Reference Chihuri, Mielenz, DiMaggio, Betz, DiGuiseppi and Jones16,Reference Evans and Eng17,Reference Van Rompaey, Somers, Deggouj, de Varebeke S, Lefebvre and Topsakal22} and any associated anxiety or mood disorders – prevalent in vestibular disorders – may also affect driving.^{Reference Chihuri, Mielenz, DiMaggio, Betz, DiGuiseppi and Jones16} A systematic review revealed a significant heterogeneity in studies reporting driving performance, with contradictory results,^{Reference Uwents, Jorissen, Van Ombergen, Dobbels, van de Berg and de Varebeke21} which makes giving accurate, condition-specific advice more challenging.^{Reference Van Rompaey, Somers, Deggouj, de Varebeke S, Lefebvre and Topsakal22–Reference Sindwani, Parnes, Goebel and Cass24} Furthermore, there can be a fear of implications where legislation appears over-cautious.^{Reference Zwergal, Grill, Lopez and Dieterich23,Reference Sindwani, Parnes, Goebel and Cass24} There are similarities in findings for those with benign paroxysmal positional vertigo (BPPV), who can resume driving following successful repositioning manoeuvres. These individuals report significant degrees of controllability and predictability; for example, dizziness only comes on when getting in or out of a lying-flat position, which is not related to driving a car.^{Reference Cohen, Wells, Kimball and Owsley1,Reference Wei and Agrawal12,Reference Wei and Agrawal13,Reference McKiernan and Jonathan15,Reference Van Leeuwen, Schermer, Colijn and Bruintjes19} However, one study did suggest that almost as many people with BPPV had problems that limited driving as those who did not,^{Reference Van Rompaey, Somers, Deggouj, de Varebeke S, Lefebvre and Topsakal22} emphasising the importance of communication during consultations.

This is a neglected area of assessment. Providing a driving capacity leaflet facilitated only marginally improved levels of documented discussion of driving and dizziness in people with vestibular disorders attending ENT or neuro-otology clinics.^{Reference Sinnott, Mahoney, Wilkinson and Broomfield18} It is therefore of value to audit and collect data on the accuracy of assessment and advice given regarding dizziness and driving. Medical records need to be accurate considering the legal implications, and there is a need for conversations in order to increase awareness about driving with dizziness. It is noteworthy that people without vestibular disorders are in fact more likely to be involved in traffic offences and road traffic accidents.^{Reference Cohen, Wells, Kimball and Owsley1,Reference Sindwani and Parnes25,Reference Redelmeier, Yarnell, Thiruchelvam and Tibshirani26} It has been highlighted that drivers with vestibular conditions modify their driving habits to compensate.^{Reference Wei and Agrawal13,Reference Pyykkö, Manchaiah, Zou, Levo and Kentala14,Reference Van Leeuwen, Schermer, Colijn and Bruintjes19,Reference Van Rompaey, Somers, Deggouj, de Varebeke S, Lefebvre and Topsakal22}

A survey of otolaryngologists^{Reference Sindwani and Parnes25} indicated that 64 per cent believed that patients stopped driving when warned it was dangerous, and patients were more likely to be advised to stop if dizziness was constant and/or severe.^, Conversely, patients did not always take the advice, with 52 per cent reporting they would continue to drive but more safely, 4 per cent would continue as usual, and only 11 per cent would not drive and consequently became more aware leading to fewer accidents.^{Reference Sindwani, Parnes, Goebel and Cass24–Reference Redelmeier, Yarnell, Thiruchelvam and Tibshirani26}

Guidelines concerning dizziness and driving vary worldwide, and even within the European Union where a common driving licence is used but each country produces different guidance.^{Reference Huppert, Straumann, Magnusson, Pyykkö and Brandt27} Within the UK, there are specific recommendations for conditions such as Ménière's disease, migraine and vestibular schwannoma;²⁸ however, the advice regarding symptom characteristics for many other conditions, such as vestibulopathy and BPPV, is more generic (i.e. based on predictability, controllability or three months of no symptoms).^{28,Reference Eggers, Bisdorff, Von Brevern, Zee, Kim and Perez-Fernandez29} Other factors impacting driving capacity associated with dizziness and vestibular disorders relate to the environment (e.g. weather, traffic and road distractions), the characteristics of the individual concerned (e.g. physical, cognitive and spatial abilities, self-awareness, and age) and the needs of the person (e.g. related to work, social life, shopping, leisure activities).

The Driver and Vehicle Licensing Agency in the UK requires dizziness to be controllable or predictable, or requires three months without dizziness outside of this criteria, to drive a car.^20,28 In order to drive a heavy goods vehicle or passenger transport vehicles (bus or coach), there are stricter regulations.^20,28 A self-declaration of fitness to drive system is in place for all UK drivers, and clinicians can report directly to the Driver and Vehicle Licensing Agency UK if they become aware of drivers who are neglecting to inform the Driver and Vehicle Licensing Agency after being advised it would be unsafe or illegal to drive.²⁸ Therefore, appropriate information-gathering in patient records (in line with current best practice) should be patient-orientated, and include best practice assessment of dizziness and balance, as outlined in clinical practice guidelines and as recommended for the assessment of the dizzy patient.^{Reference Burrows, Lesser, Kasbekar, Roland and Billing30–33} This typically includes: patient-orientated medical records, audiological examination (audiogram, tympanogram, otoscopy and tinnitus screening), cranial nerve examination, visuo-ocular motor screening, head impulse testing, positional tests, falls risk assessment, strength, sensation and co-ordination testing of postural stability, and, where necessary, vestibular function tests, blood tests and imaging.^{Reference Burrows, Lesser, Kasbekar, Roland and Billing30–33}