Physician's Guide to Assessing and Counseling Older Drivers

PHYSICIAN’S GU IDE TO

Assessing and Counseling

Older Drivers

2nd edition

The information in this guide is provided to assist physicians in evaluating

the ability of their older patients to operate motor vehicles safely as part of

their everyday, personal activities. Evaluating the ability of patients to operate

commercial vehicles or to function as professional drivers involves more

stringent criteria and is beyond the scope of this publication.

This guide is not intended as a standard of medical care, nor should it be used

as a substitute for physicians’ clinical judgement. Rather, this guide reects the

scientic literature and views of experts as of December 2009, and is provided

for informational and educational purposes only. None of this guide’s materials

should be construed as legal advice nor used to resolve legal problems. If legal

advice is required, physicians are urged to consult an attorney who is licensed to

practice in their state.

Material from this guide may be reproduced. However, the authors of this

guide strongly discourage changes to the content, as it has undergone rigorous,

comprehensive review by medical specialists and other experts in the eld of

older driver safety.

The American Medical Association is accredited by the Accreditation Council

for Continuing Medical Education to provide continuing medical education

(CME) for physicians.

The American Medical Association designates this educational activity for a

maximum of 6.25 AMA PRA Category 1 Credits™. Physicians should only claim

credit commensurate with the extent of their participation in the activity.

Additional copies of the guide can be downloaded or ordered online at the

AMA’s Older Driver’s Project Web site: www.ama-assn.org/go/olderdrivers.

For further information about the guide,

please contact:

Joanne G. Schwartzberg, MD

Director, Aging and Community Health

American Medical Association

515 N. State Street

Chicago, IL 60654

Physician’s Guide

to Assessing and

Counseling Older Drivers

An AMA Continuing Education Program

First Edition Original Release Date–7/30/2003

Second Edition–2/3/2010

Expiration Date–2/3/2012

Accreditation Statement

The American Medical Association is accredited

by the Accreditation Council for Continuing

Medical Education to provide continuing medical

education for physicians.

Designation Statement

The American Medical Association designates

this educational activity for a maximum of 6.25

AMA PRA Category 1 Credits

. Physicians

should only claim credit commensurate with the

extent of their participation in the activity.

Disclosure Statement

The content of this activity does not relate to

any product of a commercial interest as dened

by the ACCME; therefore, there are no relevant

nancial relationships to disclose.

Educational Activity Objectives

• Increase physician awareness of the safety risks

of older drivers as a public health issue

• Identify patients who may be at risk for unsafe

driving

• Use various clinical screens to assess patients’

level of function for driving tness

• Employ referral and treatment options for

patients who are no longer t to drive

• Practice counseling techniques for patients who

are no longer t to drive

• Demonstrate familiarity with State reporting

laws and legal/ethical issues surrounding

patients who may not be safe on the road

Instructions for claiming AMA PRA

Category 1 Credits™

To facilitate the learning process, we encourage

the following method for physician participation:

Read the material in the Physician’s Guide to

Assessing and Counseling Older Drivers, complete

the CME Questionnaire & Evaluation, and then

mail both of them to the address provided. To

earn the maximum 6.25 AMA PRA Category 1

Credits™ , 70 percent is required to pass and

receive the credit.

IV Acknowledgements

Acknowledgements

This Physician’s Guide to Assessing and

Counseling Older Drivers is the product

of a cooperative agreement between

the American Medical Association and

the National Highway Trafc Safety

Administration.

First edition: Primary Authors

Claire C. Wang, MD

American Medical Association

Catherine J. Kosinski, MSW

American Medical Association

Joanne G. Schwartzberg, MD

American Medical Association

Anne Shanklin, MA

American Medical Association

Second edition:

Principal Faculty Authors

Editor: David B. Carr, MD

Associate Professor of Medicine and

Neurology Washington University at

St. Louis Clinical Director

Planning Committee:

David B. Carr, MD;

Associate Professor of Medicine and

Neurology Washington University at

St. Louis Clinical Director

Joanne G. Schwartzberg, MD

Director, Aging and Community Health,

American Medical Association

Lela Manning, MPH, MBA

Project Coordinator, American Medical

Association

Jessica Sempek, MS

Program Administrator, American Medical

Asscoiation

Citation

Carr DB; Schwartzberg JG; Manning

L; Sempek J; Physician’s Guide to

Assessing and Counseling Older

Drivers, 2nd edition, Washington,

D.C. NHTSA. 2010.

This guide beneted signicantly

from the expertise of the following

individuals who served as reviewers

in this project.

Second edition: Content Consultants

Lori C. Cohen

AARP

Senior Project Manager, Driver Safety

Jami Croston, OTD

Washington University at St. Louis

T. Bella Dinh-Zarr, PhD, MPH

Road Safety Director, FIA Foundation

North American Director, MAKE

ROADS SAFE–The Campaign for Global

Road Safety

John W. Eberhard, PhD

Consultant, Aging and Senior

Transportation Issues

Camille Fitzpatrick, MSN, NP

University of California Irvine

Clinical Professor Family Medicine

Mitchell A. Garber, MD,

MPH, MSME

National Transportation Safety Board

Medical Ofcer

Anne Hegberg, MS, OTR/L

Marionjoy Rehabilitation Hospital

Certied Driver Rehabilitation Specialist

Patti Y. Horsley, MPH

Center for Injury Prevention

Policy and Practice

SDSU EPIC Branch

California Department of Public Health

Linda Hunt, OTR/L, PhD

Pacic University

School of Occupational Therapy

Associate Professor

Jack Joyce

Maryland Motor Vehicle Administration

Driver Safety Research Ofce

Senior Research Associate

Karin Kleinhans OTR/L

Sierra Nevada Memorial Hospital

Center for Injury Prevention Policy &

Practice

Occupational Therapy Association of

California

Kathryn MacLean, MSW

St. Louis University

Mangadhara R. Madineedi, MD, MSA

Harvard Medical School

Instructor in Medicine

VA Boston Healthcare System

Director, Geriatrics & Extended Care

Service Line

Richard Marottoli, MD, MPH

American Geriatrics Society

John C. Morris

Professor of Neurology

Washington University School of Medicine

Germaine L. Odenheimer, MD

VAMC

Donald W. Reynolds Department of

Geriatric Medicine

Associate Professor

Alice Pomidor, MD, MPH

Florida State University College of

Medicine

Associate Professor, Department of

Geriatrics

Kanika Mehta Rankin

Loyola University Chicago School of Law

(2nd year) Juris Doctorate Candidate,

2011

Yael Raz, MD

American Academy of Otolaryngology

William H. Roccaforte, MD

American Association for Geriatric

Psychiatry

Nebraska Medical Center

Department of Psychiatry

Gayle San Marco, OTR/L, CDRS

Northridge Hospital Medical Center

Project Consultation, Center for Injury

Prevention Policy & Practice

Freddie Segal-Gidan, PA-C, PhD

American Geriatrics Society

William Shea, OTR/L

Fairlawn Rehabilitation Hospital

VAcknowledgements

Patricia E. Sokol, RN, JD

Senior Poilcy Analyst, Patient Safety

American Medical Association

Esther Wagner, MA

National Highway Trafc Safety

Administration

First edition: Advisory Panel

Sharon Allison-Ottey, MD

National Medical Association

Joseph D. Bloom, MD

American Psychiatric Association

Audrey Rhodes Boyd, MD

American Academy of Family Physicians

David B. Carr, MD

Washington University School of Medicine

Bonnie M. Dobbs, PhD

University of Alberta

Association for the Advancement of

Automotive Medicine

John Eberhard, PhD

National Highway Trafc Safety

Administration

Laurie Flaherty, RN, MS

National Highway Trafc Safety

Administration

Arthur M. Gershkoff, MD

American Academy of Physical

Medicine and Rehabilitation

Brian Greenberg, MEd

American Association of Retired Persons

Lynne M. Kirk, MD, FACP

American College of Physicians –

American Society of Internal Medicine

Marian C. Limacher, MD, FACC,

FSGC

American College of Cardiology

Society of Geriatric Cardiology

Richard Marottoli, MD, MPH

American Geriatrics Society

Lylas G. Mogk, MD

American Academy of Ophthalmology

John C. Morris, MD

American Academy of Neurology

Alzheimer’s Association

James O’Hanlon, PhD

Tri-Counties Regional Center

Cynthia Owsley, PhD, MSPH

University of Alabama at Birmingham

Robert Raleigh, MD

Maryland Department of Transportation

William Roccaforte, MD

American Association for Geriatric

Psychiatry

Jose R. Santana Jr., MD, MPH

National Hispanic Medical Association

Melvyn L. Sterling, MD, FACP

Council on Scientic Affairs

American Medical Association

Jane Stutts, PhD

University of North Carolina Highway

Safety Research Center

First edition: Review Committee

Geri Adler, MSW, PhD

Minneapolis Geriatric Research Education

Clinical Center

Reva Adler, MD

American Geriatrics Society

Elizabeth Alicandri

Federal Highway Administration

Paul J. Andreason, MD

Food and Drug Administration

Mike Bailey

Oklahoma Department of Public Safety

Robin Barr, PhD

National Institute on Aging

Arlene Bierman, MD, MS

Agency for Healthcare Research

and Quality

Carol Bodenheimer, MD

American Academy of Physical Medicine

and Rehabilitation

Jennifer Bottomley, PhD, MS, PT

American Physical Therapy Association

Thomas A. Cavalieri, DO

American Osteopathic Association

Lori Cohen

American Association of Motor Vehicle

Administrators

Joseph Coughlin, PhD

Gerontological Society of America

T. Bella Dinh-Zarr, PhD, MPH

AAA

Barbara Du Bois, PhD

National Resources Center on Aging

and Injury

Leonard Evans, PhD

Science Serving Society

Connie Evaschwick, ScD., FACHE

American Public Health Association

Jeff Finn, MA

American Occupational Therapy

Association

Jaime Fitten, MD

UCLA School of Medicine

Marshall Flax, MA

Association for the Education and

Rehabilitation of the Blind and

Visually Impaired

Linda Ford, MD

Nebraska Medical Association

Barbara Freund, PhD

Eastern Virginia Medical School

Mitchell Garber, MD, MPH, MSME

National Transportation Safety Board

Andrea Gilbert, COTA/L

Rehabilitation Institute of Chicago

Claudia Grimm, MSW

Oregon Department of Transportation

Kent Higgins, PhD

Lighthouse International

VI Acknowledgements

Linda Hunt, PhD, OTR/L

Maryville University

Mary Janke, PhD

California Department of Motor Vehicles

Gary Kay, PhD

Washington Neuropsychological Institute

Shara Lynn Kelsey

Research and Development

California Department of Motor Vehicles

Susan Kirinich

National Highway Trafc Safety

Administration

Donald Kline, PhD

University of Calgary

Philip LePore, MS

New York State Ofce for the Aging

Sandra Lesikar, PhD

US Army Center for Health Promotion

and Preventive Medicine

William Mann, OTR, PhD

University of Florida

Dennis McCarthy, MEd, OTR/L

University of Florida

Gerald McGwin, PhD

University of Alabama

Michael Mello, MD, FACEP

American College of Emergency Physicians

Barbara Messinger-Rapport, MD, PhD

Cleveland Clinic Foundation

Alison Moore, MD, MPH

American Public Health Association

David Geffen School of Medicine,

University of California

Anne Long Morris, EdD, OTR/L

American Society on Aging

Germaine Odenheimer, MD

Center for Assessment and Rehabilitation

of Elderly Drivers

Eli Peli, M.Sc., OD

Schepens Eye Research Institute

Alice Pomidor, MD, MPH

Society of Teachers of Family Medicine

George Rebok, MA, PhD

Johns Hopkins School of Hygiene and

Public Health

Selma Sauls

Florida Department of Highway Safety and

Motor Vehicles

Susan Samson

Pinellas/Pasco Area Agency on Aging

Steven Schachter, MD

Epilepsy Foundation

Frank Schieber, PhD

University of South Dakota

Freddi Segal-Gidan, PA, PhD

American Geriatrics Society

Melvin Shipp, OD, MPH, DrPh

University of Alabama at Birmingham

Richard Sims, MD

American Geriatrics Society

Kristen Snyder, MD

Oregon Health & Science University

School of Medicine

Susan Standfast, MD, MPH

American College of Preventative Medicine

Holly Stanley, MD

American Geriatrics Society

Loren Staplin, PhD

Transanalytics and Texas Transportation

Institute

Wendy Stav, PhD, OTR, CDRS

American Occupational Therapy

Association

Cleveland State University

Donna Stressel, OTR, CDRS

Association of Driver Rehabilitation

Specialists

Cathi A. Thomas, RN, MS

Boston University Medical Center

American Parkinson Disease Association

John Tongue, MD

American Academy of Orthopedic Surgery

Patricia Waller, PhD

University of Michigan

Lisa Yagoda, MSW, ACSW

National Association of Social Workers

Patti Yanochko, MPH

San Diego State University

Richard Zorowitz, MD

National Stroke Association

VIITable of Contents

Table of Contents

Preface .................................................................................................................................. IX

Chapter 1 .................................................................................................................................1

Safety and the Older Driver With Functional or Medical Impairments: An Overview

Chapter 2 ...............................................................................................................................11

Is the Patient at Increased Risk for Unsafe Driving?

Red Flags for Further Assessment

Chapter 3 ...............................................................................................................................19

Assessing Functional Ability

Chapter 4 ...............................................................................................................................33

Physician Interventions

Chapter 5 ...............................................................................................................................41

The Driver Rehabilitation Specialist

Chapter 6 ...............................................................................................................................49

Counseling the Patient Who is no Longer Safe to Drive

Chapter 7 ...............................................................................................................................59

Ethical and Legal Responsibilities of the Physician

Chapter 8 ...............................................................................................................................69

State Licensing and Reporting Laws

Chapter 9 .............................................................................................................................145

Medical Conditions and Medications That May Affect Driving

Chapter 10 ...........................................................................................................................187

Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

Appendix A ..........................................................................................................................197

CPT

Codes

VIII Table of Contents

Table of Contents (continued)

Appendix B ..........................................................................................................................201

Patient and Caregiver Educational Materials

Am I a Safe Driver? ....................................................................................................................... 203

Successful Aging Tips .................................................................................................................. 205

Tips for Safe Driving ...................................................................................................................... 207

How to Assist the Older Driver ...................................................................................................... 209

Getting By Without Driving ............................................................................................................ 213

Where Can I Find More Information? ............................................................................................. 215

Appendix C ..........................................................................................................................221

Continuing Medical Education Questionnaire and Evaluation

Physicians Guide to Assessing and Counseling Older Drivers ....................................................... 221

Continuing Medical Education Evaluation Form ............................................................................. 224

Index ....................................................................................................................................229

IXPreface

Preface

The science of public health and the practice of medicine are often deemed two

separate entities. After all, the practice of medicine centers on the treatment of

disease in the individual, while the science of public health is devoted to preven-

tion of disease in the population. However, physicians can actualize public health

priorities through the delivery of medical care to their individual patients.

One of these priorities is the prevention of injury. More than 400 Americans

die each day as a result of injuries sustained from motor vehicle crashes, rearms,

poisonings, suffocation, falls, res, and drowning. The risk of injury is so great

that most people sustain a signicant injury at some time during their lives.

The Physician’s Guide to Assessing and Counseling Older Drivers was created by

the American Medical Association (AMA), with support from the National

Highway Trafc and Safety Administration (NHTSA), to help physicians

address preventable injuries—in particular, those incurred in motor vehicle

crashes. Currently, motor vehicle injuries are the leading cause of injury-related

deaths among 65- to 74-year-olds and are the second leading cause (after falls)

among 75- to 84-year-olds. While trafc safety programs have reduced the fatal-

ity rate for drivers under age 65, the fatality rate for older drivers has consistently

remained high. Clearly, additional efforts are needed.

Physicians are in a leading position to address and correct this health disparity.

By providing effective health care, physicians can help their patients maintain

a high level of tness, enabling them to preserve safe driving skills later in life

and protecting them against serious injuries in the event of a crash. By adopting

preventive practices—including the assessment and counseling strategies outlined

in this guide—physicians can better identify drivers at risk for crashes, help

enhance their driving safety, and ease the transition to driving retirement if

and when it becomes necessary.

Through the practice of medicine, physicians have the opportunity to promote

the safety of their patients and of the public. The AMA and NHTSA urge you

to use the tools in this Physician’s Guide to Assessing and Counseling Older Drivers

to forge a link between public health and medicine.

The project was supported by cooperative agreement number DTNH22-08-H-00185

from the National Highway Trafc Safety Administration (NHTSA) of the Department

of Transportation. While this guide was reviewed by NHTSA, the contents of this guide

are those of the authors and do not represent the opinions, policies or ofcial positions

of NHTSA.

CHAPTER 1

Safety and the Older Driver

With Functional or Medical

Impairments: An Overview

Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

Patients like Mrs. Simon and Mr. Evans

are becoming more common in physi-

cians’ practices. Buoyed by the large

ranks of “baby boomers” and increased

life expectancy, the U.S. older adult

population is growing nearly twice as

fast as the total population.

1,2

Within

this cohort of older adults, an increasing

proportion will be licensed to drive, and

it is expected that these license-holders

will drive more miles than older drivers

do today.

As the number of older drivers with

medical conditions expands, patients

and their families will increasingly

turn to physicians for guidance on safe

driving. Physicians will have the chal-

lenge of balancing their patients’ safety

against their transportation needs and

the safety of society.

This guide is intended to help you

answer the questions, “At what level of

severity do medical conditions impair

safe driving?” “What can I do to help

my patient drive more safely?”

, and if

necessary to help you counsel patients

1. National Center for Statistics & Analysis.

Trafc Safety Facts 2000: Older Population.

DOT HS 809 328. Washington, DC: National

Highway Trafc Safety Administration.

2. Population Projections of the United States by

Age, Sex, Race, Hispanic, Origin, and Nativity:

1999 to 2100. Population Projections Program,

Population Division, Census Bureau Internet

release date: January 13, 2000. Revised date:

February 14, 2000. Suitland, MD: U.S.

Census Bureau.

3. Eberhard, J. Safe Mobility for Senior Citizens.

International Association for Trafc and Safety

Services Research. 20(1):29–37.

Mrs. Simon, a 67-year-old woman

with type 2 diabetes mellitus and

hypertension, mentions during a

routine check-up that she almost

hit a car while making a left-hand

turn when driving two weeks ago.

Although she was uninjured, she

has been anxious about driving since

that episode. Her daughter has

called your ofce expressing concern

about her mother’s driving abilities.

Mrs. Simons admits to feeling less

condent when driving and wants

to know if you think she should stop

driving. What is your opinion?

Mr. Evans, a 72-year-old man

with coronary artery disease and

congestive heart failure, arrives for

an ofce visit after fainting yesterday

and reports complaints of “light-

headedness” for the past two weeks.

When feeling his pulse, you notice

that his heartbeat is irregular. You

perform a careful history and physi-

cal examination, and order some

laboratory tests to help determine the

cause of his atrial brillation. When

you ask Mr. Evans to schedule a

follow-up appointment for the next

week, he tells you he cannot come

at that time because he is about to

embark on a two-day road trip to

visit his daughter and newborn

grandson. Would you address the

driving issue and if so, how?

What would you communicate to

the patient?

CHAPTER 1

Safety and the Older

Driver With Functional

or Medical Impairments

An Overview

about driving cessation and alternate

means of transportation. Mobility

counseling and discussing alternative

modes of transportation need to take a

more prominent role in the physician’s

ofce. To these ends, we have reviewed

the scientic literature and collaborated

with clinicians and experts in this eld

to produce the following physician tools:

• An ofce-based assessment of

medical tness to drive. This

assessment is outlined in the

algorithm, Physician’s Plan for

Older Drivers’ Safety (PPODS),

presented later in this chapter.

• A functional assessment battery,

the Assessment of Driving Related

Skills (ADReS). This can be found

in Chapter 3.

• A reference table of medical

conditions and medications that

may affect driving, with specic

recommendations for each, can

be found in Chapter 9.

In addition to these tools, we also

present the following resources:

• Information to help you navigate

the legal and ethical issues regarding

patient driving safety. Information

* Please be aware that the information in this

guide is provided to assist physicians in evaluat-

ing the ability of their older patients to operate

motor vehicles safely as part of their everyday,

personal activities. Evaluating the ability of

patients to operate commercial vehicles or to

function as professional drivers involves more

stringent criteria and is beyond the scope of this

guide.

2 Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

on patient reporting, with a state-by-

state list of licensing criteria, license

renewal criteria, reporting laws,

and Department of Motor Vehicles

(DMV) contact information, can be

found in Chapters 7 and 8.

• Recommended Current Procedural

Terminology (CPT

) codes for

assessment and counseling procedures.

These can be found in Appendix A.

• Handouts for your patients and their

family members. These handouts,

located in Appendix B, include a self-

screening tool for driving safety, safe

driving tips, driving alternatives, and

a resource sheet for concerned family

members. These handouts can be

removed from the guide and photo-

copied for distribution to patients

and their family members.

We understand that physicians may

lack expertise in communicating with

patients about driving, discussing the

need for driving cessation (delivering

bad news), and being aware of viable

alternative transportation options to

offer. Physicians also may be concerned

about dealing with the patient’s anger,

or even losing contact with the patient.

Driving is a sensitive subject, and the

loss of driving privileges can be stressful.

While these are reasonable concerns,

there are ways to minimize the impact

on the doctor-patient relationship when

discussing driving. We provide sample

approaches in subsequent chapters in

the areas of driving assessment, rehabili-

tation, restriction, and cessation.

We want this information to be

readily accessible to you and your

ofce staff. You can locate this guide

on the Internet at the AMA Web site

(www.ama-assn.org/go/olderdrivers).

Additional printed copies may also

be ordered through the Web site.

Before you read the rest of the guide,

you may wish to familiarize yourself

with key facts about older drivers.

Older drivers: Key facts

Fact #1: The number of older adult

drivers is growing rapidly and they

are driving longer distances.

Life expectancy is at an all-time high

and the older population is rap-

idly increasing. By the year 2030, the

population of adults older than 65 will

more than double to approximately 70

million, making up 20 percent of the

total U.S. population.

In many States,

including Florida and California, the

population of those over age 65 may

reach 20 percent in this decade The

fastest growing segment of the popula-

tion is the 80-and-older group, which

is anticipated to increase from about 3

million this year to 8 to 10 million over

the next 30 years. We can anticipate

many older drivers on the roadways

over the next few decades, and your

patients will likely be among them.

Census projections estimate that by

the year 2020 there will be 53 million

persons over age 65 and approximately

40 million (75%) of those will be

licensed drivers.

The increase in the

number of older drivers is due to many

factors. In addition to the general aging

of the population that is occurring in

all developed countries, many more

female drivers are driving into advanced

age. This will likely increase with aging

cohorts such as the baby boomers.

In addition, the United States has

become a highly mobile society, and

older adults are using automobiles for

volunteer activities and gainful employ-

ment, social and recreational needs,

and cross country travel. Recent studies

suggest that older adults are driving

4. Centers for Disease Control and Prevention.

2008. National Center for Health Statistics.

Accessed on December 14, 2008 at;

www.cdc.gov/nchs/PRESSROOM/

07newsreleases/lifeexpectancy.htm

5. U.S. Census Bureau, Healthy Aging, 2008.

Accessed on December 14, 2008 at; www.cdc.

gov/NCCdphp/publications/aag/aging.htm

6. U.S. Census Bureau. Projection of total resident

population by 5-year age groups and sex with

special age categories; middle series, 2016–2020.

Washington, DC: Population Projections

Program, Population Division, U.S. Census

Bureau; 2000.

more frequently, while transportation

surveys reveal an increasing number of

miles driven per year for each successive

aging cohort.

Fact #2: Driving cessation is inevi-

table for many and can be associated

with negative outcomes.

Driving can be crucial for performing

necessary chores and maintaining social

connectedness, with the latter having

strong correlates with mental and physi-

cal health.

Many older adults continue

to work past retirement age or engage in

volunteer work or other organized ac-

tivities. In most cases, driving is the pre-

ferred means of transportation. In some

rural or suburban areas, driving may be

the sole means of transportation. Just as

the driver’s license is a symbol of inde-

pendence for adolescents, the ability to

continue driving may mean continued

mobility and independence for older

drivers, with great effects on their qual-

ity of life and self-esteem.

In a survey of 2,422 adults 50 and older,

86 percent of survey participants report-

ed that driving was their usual mode of

transportation. Within this group, driv-

ing was the usual method of transporta-

tion for 85 percent of participants 75 to

79, 78 percent of participants 80 to 84,

and 60 percent of participant’s 85 and

older.

This data also indicates that the

probability of losing the ability to drive

increases with advanced age. It is esti-

mated that the average male will have

6 years without the functional ability to

drive a car and the average female will

have 10 years.

However, our society

has not prepared the public for driving

7. Berkman, L. F., Glass, T., Brissette, I., & See-

man, T. E. From social integration to health:

Durkheim in the new millennium. Soc Sci Med.

51:843–857.

8. Stutts, J. C. Do older drivers with visual and

cognitive impairments drive less? J Am Geriatr

Soc. 46(7):854–861.

9. Ritter, A. S., Straight, A., & Evans, E.

Understanding Senior Transportation: Report

and Analysis of a Survey of Consumers Age

50+. American Association for Retired Persons,

Policy and Strategy Group, Public Policy

Institute, p. 10–11.

10. Foley, D. J., Heimovitz, H. K., Guralnik, J., &

Brock, D. B. Driving life expectancy of persons

aged 70 years and older in the United States.

Am J Public Health. 92:1284–1289

3Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

cessation, and patients and physicians

are often ill-prepared when that time

comes.

Studies of driving cessation have noted

increased social isolation, decreased

out-of-home activities,

and an in-

crease in depressive symptoms.

These

outcomes have been well documented

and represent some of the negative con-

sequences of driving cessation. It is im-

portant for health care providers to use

the available resources and professionals

who can assist with transportation to

allow their patients to maintain inde-

pendence. These issues will be discussed

further in subsequent chapters.

Fact #3: Many older drivers

successfully self-regulate their

driving behavior.

As drivers age, they may begin to

feel limited by slower reaction times,

chronic health problems, and effects

from medications. Although transporta-

tion surveys over the years document

that the current cohort of older driv-

ers is driving farther, in later life many

reduce their mileage or stop driving

altogether because they feel unsafe or

lose condence. In 1990, males over 70

drove on average 8,298 miles, compared

with 16,784 miles for men 20 to 24; for

women, the gures were 3,976 miles

and 11,807 miles, respectively.

Older

drivers are more likely to wear seat belts

and are less likely to drive at night,

speed, tailgate, consume alcohol prior

to driving, and engage in other risky

behaviors.

Older drivers not only drive substan-

tially less, but also tend to modify

11. Marottoli, R. A., de Leon, C. F. M., & Glass,

T. A., et al. Consequences of driving cessation:

decreased out-of-home activity levels. J Gerontol

Series B Psychol Sci Soc Sci. 55:S334–340.

12. Ragland, D. R., Satariano, W. A,. & MacLeod,

K. E. Driving cessation and increased depressive

symptoms J Gerontol Series A Bio Sci Med Sci.

60:399–403.

13. Evans, L. How safe were today’s older drivers

when they were younger? Am J Epidemiol.

1993;137(7);769–775.

14. Lyman, J. M., McGwin, G., &Sims, R.V. Factors

related to driving difculty and habits in older

drivers. Accid Anal Prev. 33:413–421.

when and how they drive. When they

recognize loss of ability to see well after

dark, many stop driving at night. There

are data that suggest older women are

more likely to self-regulate than men.

Others who understand the complex

demands of left turns at uncontrolled

intersections and their own diminished

capacity forgo left-hand turns, and

make a series of right turns instead. Self-

regulating in response to impairments

is simply a continuation of the strategy

we all employ daily in navigating this

dangerous environment—driving. Each

of us, throughout life, is expected to

use our best judgment and not operate

a car when we are impaired, whether

by fatigue, emotional distress, physical

illness, or alcohol. Thus, self-awareness,

knowledge of useful strategies, and

encouragement to use them may be

sufcient among cognitively intact

older adults; however, this remains an

important area for further study.

Older drivers may reduce their mile-

age by eliminating long highway trips.

However, local roads often have more

hazards in the form of signs, signals,

trafc congestion, and confusing inter-

sections. Decreasing mileage, then, may

not always proportionately decrease

safety risks.

In fact, the “low mileage”

drivers (e.g., less than 3,000 miles per

year) may actually be the group that is

most “at-risk.”

Despite all these self-regulating mea-

sures, motor vehicle crash rates per mile

driven begin to increase at age 65.

a case-by-case level, the risk of a crash

depends on whether each individual

driver’s decreased mileage and behavior

15. Kostyniuk, L. P., & Molnar, L. J. Self-regulatory

driving practices among older adults: health, age

and sex effects. Accid Anal Prev. 40: 1576–1580.

16. Janke, M. K. Accidents, mileage, and the exag-

geration of risk. Accid Anal Prev. 1991;23:183–

188.

17. Langford, J., Methorst, R., & Hakamies-

Blomqvist, L. Older drivers do not have a high

crash risk—a replication of low mileage bias.’

Accid Anal Prev. 38(3):574–578.

18. Li, G., Braver, E. R., & Chen, L. H. Exploring

the High Driver Death Rates per Vehicle-Mile

of Travel in Older Drivers: Fragility versus

Excessive Crash Involvement. Presented at the

Insurance Institute for Highway Safety; August

2001.

modications are sufcient to counter-

balance any decline in driving ability.

In some cases, decline—in the form of

peripheral vision loss, for example—

may occur so insidiously that the driver

is not aware of it until he/she experi-

ences a crash. In fact, a recent study

indicated that some older adults do not

restrict their driving despite having

signicant visual decits.

Reliance on

driving as the sole available means of

transportation can result in an unfortu-

nate choice between poor options. In

the case of dementia, drivers may lack

the insight to realize they are unsafe

to drive.

In a series of focus groups conducted

with older adults who had stopped

driving within the past ve years, about

40 percent of the participants knew

someone over age 65 who had problems

with his/her driving but was still behind

the wheel.

Clearly, some older drivers

require outside assessment and interven-

tions when it comes to driving safety.

Fact #4: The crash rate for older

drivers is in part related to physical

and/or mental changes associated

with aging and/or disease.

Compared with younger drivers whose

car crashes are often due to inexperi-

ence or risky behaviors,

older driver

crashes tend to be related to inattention

or slowed speed of visual processing.

Older driver crashes are often multiple-

vehicle events that occur at intersections

and involve left-hand turns. The crash is

usually caused by the older driver’s failure

to heed signs and grant the right-of-way.

At intersections with trafc signals, left-

19. Okonkwo, O. C., Crowe, M., Wadley, V. G.,

& Ball, K. Visual attention and self-regulation

of driving among older adults. Int Psychogeriatr.

20:162–173.

20. Persson, D. The elderly driver: deciding when to

stop. Gerontologist. 1993;33(1):88–91.

21. Preusser, D. F., Williams, A. F., Ferguson, S. A.,

Ullmer R. G., & Weinstein, H.B. Fatal crash

risk for older drivers at intersections. Accid Anal

Prev. 30(2):151–159.

22. Williams, A. F., & Ferguson, S. A. Rationale

for graduated licensing and the risks it should

address. Inj Prev. 8:ii9–ii16.

23. Eberhard, J. W. Safe Mobility for Senior

Citizens. International Association for Trafc

and Safety Sciences Research. 20(1):29–37.

4 Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

hand turns are a particular problem for

the older driver. At stop-sign-controlled

intersections, older drivers may not know

when to turn.

These driving behaviors indicate that

visual, cognitive, and/or motor factors

may affect the ability to drive in older

adults. Research has not yet determined

what percentage of older adult crashes

are due to driving errors that are also

common among middle-aged drivers,

what proportion are due to age-related

changes in cognition (such as delayed

reaction time), or how many could be

attributed to age-related medical illness-

es. However, it is believed that further

improvements in trafc safety will likely

result from improving driving perfor-

mance or modifying driving behavior.

The identication and management

of diseases has a potential to maintain

or improve driving abilities and

road safety.

Fact #5: Physicians can inuence

their patients’ decisions to modify

or stop driving. They can also help

their patients maintain safe

driving skills.

Although older drivers believe that

they should be the ones to make the

nal decision about driving, they also

agree that their physicians should advise

them. In a series of focus groups con-

ducted with older adults who had given

up driving, all agreed that the physi-

cians should talk to older adults about

driving, if a need exists. As one panelist

put it, “When the doctor says you can’t

drive anymore, that’s denite. But when

you decide for yourself, there might be

questions.” While family advice had

limited inuence on the participants,

most agreed that if their physicians

advised them to stop and their family

concurred, they would certainly retire

from driving.

This is consistent with a

24. Preusser, D. F., Williams, A. F., Ferguson, S. A.,

Ullmer, R. G., & Weinstein, H. B. Fatal crash

risk for older drivers at intersections. Accid Anal

Prev. 30(2):151–159.

25. Lee, J. D. Fifty years of driving safety research.

Hum Factors. 50: 521–528.

26. Persson, D. The elderly driver: deciding when to

stop. Gerontologist. 1993;33(1):88–91.

recent focus group study with caregivers

of demented drivers, who stated that

physicians should be involved in this

important decision-making process.

Physicians assist their older patients

to maintain safe mobility in two ways.

They provide effective treatment and

preventive health care, and they play a

role in determining the ability of older

adults to drive safely. Also, improved

cardiovascular and bone health has

the potential to reduce serious injuries

and improve the rate of recovery in the

event of a crash.

In many cases, physicians can keep

their patients on the road longer by

identifying and managing diseases, such

as cataracts and arthritis, or by discon-

tinuing sedating medications. Many

physicians are aware of the literature on

fall prevention, and that clinicians can

reduce future risks of falls and fractures

by addressing certain extrinsic (envi-

ronmental) and intrinsic factors.

Driv-

ing abilities share many attributes that

are necessary for successful ambulation,

such as adequate visual, cognitive, and

motor function. In fact, a history of falls

has been associated with an increased

risk of motor vehicle crash.

Brief physician intervention on topics

such as smoking and seat belt use has

been shown to be effective. There is

an assumption that doctors can and do

make a difference by evaluating older

individuals for medical tness to drive.

Furthermore, there is a crucial need to

have this hypothesis studied systemati-

cally. To date, little organized effort in

the medical community has been made

to help older adults improve or main-

tain their driving skills. Research and

clinical reviews on the assessment

27. Perkinson, M., Berg-Weger, M., Carr, D.,

Meuser, T., Palmer, J., Buckles, V., Powlishta,

K., Foley, D., & Morris, J. Driving and dementia

of the Alzheimer type: beliefs and cessation

strategies among stakeholders. Gerontologist.

45(5):676–685.

28. Tinetti, M. E. Preventing falls in elderly persons.

N Engl J Med. 348(1):42–49.

29. Margolis, K. L., Kerani, R. P., McGovern, P.,

et al. Risk factors for motor vehicle crashes in

older women. J Gerontol Series A Bio Sci Med Sci.

57:M186–M191.

of older drivers have focused on screen-

ing methods to identify unsafe drivers

and restrict older drivers. Physicians are

in a position to identify patients at risk

for unsafe driving or self-imposed driv-

ing cessation due to functional impair-

ments, and address and help manage

these issues to keep their patients driv-

ing safely for as long as possible.

Physicians must abide by State report-

ing laws. While the nal determination

of an individual’s ability to drive lies

with the driver licensing authority,

physicians can assist with this deter-

mination. Driver licensing regulations

and reporting laws vary greatly by State.

Some State laws are vague and open to

interpretation; therefore, it is impor-

tant for physicians to be aware of their

responsibilities for reporting unsafe

patients to the local driver licensing

authority. Information on State laws is

provided in Chapter 8.

Thus, physicians can play a more active

role in preventing motor vehicle crashes

by assessing their patients for medical

tness to drive, recommending safe

driving practices, referring patients to

driver rehabilitation specialists, advising

or recommending driving restrictions,

and referring patients to State authori-

ties when appropriate.

5Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

To achieve these ends, primary care

physicians can follow the algorithm,

Physician’s Plan for Older Drivers’ Safety

(PPODS) (see Figure 1.1), which

recommends that physicians:

• Screen for red ags such as medical

illnesses and medications that may

impair driving safety;

• Ask about new-onset impaired

driving behaviors (see Am I a Safe

Driver and How to Help the Older

Driver in the appendices);

• Assess driving-related functional

skills in those patients who are at

increased risk for unsafe driving; for

the functional assessment battery,

Assessment of Driver Related Skills

(ADReS), see Chapter 3;

• Treat any underlying causes of

functional decline;

• Refer patients who require a driving

evaluation and/or adaptive training to

a driver rehabilitation specialist;

• Counsel patients on safe driving

behavior, driving restrictions, driving

cessation, and/or alternate transporta-

tion options as needed; and

• Follow-up with patients who should

adjust their driving to determine if

they have made changes, and evalu-

ate those who stop driving for signs of

depression and social isolation.

While primary care physicians may

be in the best position to perform the

PPODS, other clinicians have a re-

sponsibility to discuss driving with their

patients as well. Ophthalmologists,

neurologists, psychiatrists, physiatrists,

orthopedic surgeons, emergency depart-

ment and trauma center physicians,

and other specialists all treat condi-

tions, prescribe medications, or perform

procedures that may have an impact on

driving skills. When counseling their

patients, physicians may wish to

consult the reference list of medical

conditions in Chapter 9.

In the following chapters, we will guide

you through the PPODS and provide

the tools you need to perform it. Before

we begin, you may wish to review the

AMA’s policy on impaired drivers (see

Figure 1.2).This policy can be applied

to older drivers with medical conditions

that impair their driving skills and

threaten their personal driving safety.

Fact #6: Trafc safety for older

drivers is a growing public

health issue.

Older drivers are the safest drivers as

an age group when using the absolute

number of crashes per 100 licensed

drivers per year.

However, the crash

rate per miles driven reveals an increase

at about age 65 to 70 in comparison to

middle-aged drivers.

In 2000, 37,409

Americans died in motor vehicle

crashes.

Of this number, 6,643 were 65

and older.

Accidental injuries are the

seventh leading cause of death among

older people and motor vehicle crashes

are not an uncommon cause.

As the

number of older drivers continues to

grow, drivers 65 and older are expected

to account for 16 percent of all crashes

and 25 percent of all fatal crashes.

Motor vehicle injuries are the leading

cause of injury-related deaths among

65- to 74-year-olds and are the second

leading cause (after falls) among 75- to

84-year-olds.

Compared to other driv-

30. CDC. (1997). Behavioral Risk Factor Surveil-

lance System Survey Data. Atlanta: Centers for

Disease Control and Prevention

31. Ball, K., Owsley, C., Stalvey, B., Roenker, D.

L., & Sloane, M. E. Driving avoidance and

functional impairment in older drivers. Accid

Anal Prev. 30:313–322.

32. NHTSA. FARS. Web-Based Encyclopedia.

www-fars.nhtsa.dot.gov.

33. Insurance Institute for Highway Safety. (2001).

Fatality Facts: Elderly (as of October 2001).

(Fatality Facts contains an analysis of data from

U.S. Department of Transportation Fatality

Analysis Reporting System.) Arlington, VA:

Insurance Institute for Highway Safety.

34. Staats, D. O. Preventing injury in older adults.

Geriatrics. 63:12–17.

35. Eberhard, J. Older drivers up close: they aren’t

dangerous. Insurance Institute for Highway Safety

Status Report (Special Issue: Older Drivers).

36(8):1–2.

36. CDC. (1999). 10 Leading Causes of Injury

Deaths, United States, 1999, All Races, Both

Sexes. Ofce of Statistics and Programming,

National Center for Injury Prevention and Con-

trol, Centers for Disease Control and Preven-

tion. Data source: National Center for Health

Statistics Vital Statistics System. Atlanta:

Centers for Disease Control and Prevention.

ers, older drivers have a higher fatality

rate per mile driven than any other age

group except drivers under 25.

On the

basis of estimated annual travel, the

fatality rate for drivers 85 and older is

9 times higher than the rate for drivers

25 to 69.

By age 80, male and female

drivers are 4 and 3.1 times more likely,

respectively, than 20-year-olds to die

as a result of a motor vehicle crash.

There is a disproportionately higher rate

of poor outcomes in older drivers, due

in part to chest and head injuries.

Old-

er adult pedestrians are also more likely

to be fatally injured at crosswalks.

There may be several reasons for this

excess in fatalities. First, some older

drivers are considerably more fragile.

For example, the increased incidence

of osteoporosis, which can lead to

fractures, and/or atherosclerosis of the

aorta which can predispose individuals

to rupture with chest trauma from an

airbag or steering wheel. Fragility begins

to increase at age 60 to 64 and

increases steadily with advancing age.

A recent study noted that chronic

conditions are determinants of mortality

and even minor injury.

As noted above,

older drivers are also overrepresented in

37. NHTSA. Driver fatality rates, 1975-1999.

Washington, DC: National Highway Trafc

Safety Administration.

38. NHTSA. National Center for Statistics &

Analysis. Trafc Safety Facts 2000: Older

Population. DOT HS 809 328. Washington,

DC: National Highway Trafc Safety

Administration.

39. Evans, L. Risks older drivers face themselves

and threats they pose to other road users.

Int J Epidemiol. 29:315–322.

40. Bauza, G., Lamorte, W. W., Burke, P., &

Hirsch, E. F. High mortality in elderly drivers is

associated with distinct injury patterns: analysis

of 187,869 drivers. J Trauma Inj Infect Crit Care.

64:304–310.

41. FHWA. (2007). Pedestrian Safety Guide and

Countermeasres. PEDSAFE. 2007. Washington,

DC: Federal Highway Administration. www.

walkinginfo.org/pedsafe/crashstats.cfm. Accessed

November 21, 2007.

42. Li, G., Braver, E., & Chen, L-H. Fragility versus

excessive crash involvement as determinants of

high death rates per vehicle mile of travel for

older drivers. Accid Anal Prev. 35, 227–235.

43. Camiloni, L., Farchi, S., Giorgi Rossi, P., Chini,

F., et al. Mortality in elderly injured patients:

the role of comorbidities. Int J Inj Control Safety

Prom. 15:25–31.

(Continues on page 7)

6 Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

Figure 1.1 Physician’s Plan for Older Drivers’ Safety (PPODS)

Is the patient at increased risk for unsafe driving?

Perform initial screen—

• Observe the patient

• Be alert to red ags

¤ Medical conditions

¤ Medications and polypharmacy

¤ Review of systems

¤ Patient’s or family member’s concern/

impaired driving behaviors

At risk

Formally assess function

• Assess Driving Related Skills (ADReS)

¤ Vision

¤ Cognition

¤ Motor and somatosensory skills

Medical interventions

• For diagnosis and

treatment

Counsel and follow up

• Explore alternatives to driving

• Monitor for depression and social isolation

• Adhere to state reporting regulations

Deﬁcit not resolved

Refer to Driver Rehabilitation Specialist:

Is the patient safe to drive?

No Yes

Deﬁcit resolved

Not at risk

Health maintenance

• Successful Aging Tips

• Tips for Safe Driving

• Mature Driving classes

• Periodic follow-up

If screen is positive—

• Ask health risk assessment/social history questions

• Discuss alternatives to driving early in the process

• Gather additional information

left-hand-turn collisions, which cause

more injury than more injury than

rear-end collisions.

Finally, preliminary

data from a Missouri study of medically

impaired drivers who were in crashes

indicate that the average age of the

vehicle was more than 10 years and the

cars often did not have air bags (personal

communication, Tom Meuser, University

of St. Louis-Missouri). If this latter obser-

vation is a contributing factor, improve-

ment should occur as future cohorts of

aging drivers purchase newer vehicles

with improved crashworthiness.

44. IIHS. (2003). Fatality Facts: Older People as

of November 2002. Arlington, Va: Insurance

Institute for Highway Safety.

Chapter 1—Safety and the Older Driver With Functional or Medical Impairments: An Overview

Figure 1.2

AMA ethical opinion

E-2.24 Impaired drivers and their physicians

The purpose of this policy is to articulate physicians’ responsibility to recognize

impairments in patients’ driving ability that pose a strong threat to public safety and

which ultimately may need to be reported to the Department of Motor Vehicles. It

does not address the reporting of medical information for the purpose of punish-

ment or criminal prosecution.

1. Physicians should assess patients’ physical or mental impairments that might

adversely affect driving abilities. Each case must be evaluated individually since

not all impairments may give rise to an obligation on the part of the physician.

Nor may all physicians be in a position to evaluate the extent or the effect of an

impairment (e.g., physicians who treat patients on a short-term basis). In mak-

ing evaluations, physicians should consider the following factors: (a) the physi-

cian must be able to identify and document physical or mental impairments

that clearly relate to the ability to drive; and (b) the driver must pose a clear risk

to public safety.

2. Before reporting, there are a number of initial steps physicians should take.

A tactful but candid discussion with the patient and family about the risks of

driving is of primary importance. Depending on the patient’s medical condition,

the physician may suggest to the patient that he or she seek further treatment,

such as substance abuse treatment or occupational therapy. Physicians also

may encourage the patient and the family to decide on a restricted driving

schedule, such as shorter and fewer trips, driving during non-rush-hour trafﬁc,

daytime driving, and/or driving on slower roadways if these mechanisms would

alleviate the danger posed. Efforts made by physicians to inform patients and

their families, advise them of their options, and negotiate a workable plan may

render reporting unnecessary.

3. Physicians should use their best judgment when determining when to report

impairments that could limit a patient’s ability to drive safely. In situations where

clear evidence of substantial driving impairment implies a strong threat to

patient and public safety, and where the physician’s advice to discontinue driv-

ing privileges is ignored, it is desirable and ethical to notify the Department of

Motor Vehicles.

4. The physician’s role is to report medical conditions that would impair safe driv-

ing as dictated by his or her State’s mandatory reporting laws and standards of

medical practice. The determination of the inability to

drive safely should be made by the State’s Department of Motor Vehicles.

5. Physicians should disclose and explain to their patients this responsibility to

report.

6. Physicians should protect patient conﬁdentiality by ensuring that only the mini-

mal amount of information

is reported and that reasonable security measures are used in handling that

information.

7. Physicians should work with their State medical societies to create statutes

that uphold the best interests of patients and community, and that safeguard

physicians from liability when reporting in good faith. (III, IV, VII) Issued June

2000 based on the report “Impaired Drivers and Their Physicians,” adopted

December 1999.

CHAPTER 2

Is the Patient at

Increased Risk for

Unsafe Driving?

11Chapter 2—Is the Patient at Increased Risk for Unsafe Driving?

Mr. Phillips, a 72-year-old man with

a history of hypertension, congestive

heart failure, type 2 diabetes mel-

litus, macular degeneration, and

osteoarthritis comes to your ofce for

a routine check-up. You notice that

Mr. Phillips has a great deal of trou-

ble walking to the examination room,

is aided by a cane, and has difculty

reading the labels on his medication

bottles, even with his glasses. While

taking a social history, you ask him

if he still drives, and he states that

he takes short trips to run errands,

reach appointments, and meet

weekly with his bridge club.

Mr. Bales, a 60-year-old man with

no signicant past medical history,

presents at the emergency department

with an acute onset of substernal

chest pain. He is diagnosed with

acute myocardial infarction. Follow-

ing an uneventful hospital course, he

is stable and ready to be discharged.

On the day of discharge, he mentions

that he had driven himself to the

emergency department and would

now like to drive himself home, but

cannot nd his parking voucher.

CHAPTER 2

Is the Patient at Increased

Risk for Unsafe Driving?

This chapter discusses the rst steps of

the Physician’s Plan for Older Drivers’

Safety (PPODS). In particular, we

provide a strategy for answering the

question, “Is the patient at increased

risk for unsafe driving?” This part of the

evaluation process includes your clinical

observation, identifying red ags such

medical illnesses and medications that

may impair safe driving, and inquiring

about new onset driving behaviors that

may indicate declining trafc skills.

To answer this question, rst—

Observe the patient

throughout the ofﬁce visit.

Careful observation is often an impor-

tant step in diagnosis. As you observe

the patient, be alert to:

• Impaired personal care such as poor

hygiene and grooming;

• Impaired ambulation such as difculty

walking or getting into and out of

chairs

• Difculty with visual tasks; and

• Impaired attention, memory, language

expression or comprehension.

In the example above, Mr. Phillips

has difculty walking and reading his

medication labels. This raises a question

as to whether he can operate vehicle

foot pedals properly or see well enough

to drive safely. His physical limitations

would not preclude driving, but may

be indicators that more assessment

is indicated.

Be alert to conditions in the

patient’s medical history,

examine the current list of

medications, and perform

a comprehensive review

of systems.

When you take the patient’s history, be

alert to “red ags,”

that is, any medical

condition, medication or symptom that

can affect driving skills, either through

acute effects or chronic functional

decits (see Chapter 9). For example,

Mr. Evans, as described in Chapter 1,

presents with lightheadedness associated

with atrial brillation. This is a red ag,

and he should be counseled to cease

driving until control of heart rate and

symptoms that impair his level of con-

sciousness have resolved. Similarly, Mr.

Bales’ acute myocardial infarction is a

red ag. Prior to discharge from the

hospital, his physician should counsel

him about driving according to the

recommendations in Chapter 9 (see

Figure 2.1).

Mr. Phillips does not have any acute

complaints, but his medical history

identies several conditions that place

him at potential risk for unsafe driving.

His macular degeneration may prevent

him from seeing well enough to drive

safely. His osteoarthritis may make it

difcult to operate vehicle controls or it

may restrict his neck range of motion,

thereby diminishing visual scanning

in trafc. Questions in regard to his

45. Dobbs, B. M. (2005) Medical Conditions and

Driving: A Review of the Literature (1960-

2000). Report # DOT HS 809 690. Wahington,

DC: National Highway Trafc Safety Adminis-

tration. Accessed October 11, 2007.

at www.nhtsa.dot.gov/people/injury/research/

Medical_Condition_Driving/pages/TRD.html.

12 Chapter 2—Is the Patient at Increased Risk for Unsafe Driving?

diabetes include: Does he have any

end-organ damage such as sensory neu-

ropathies, chronic cognitive decline, or

uctuations from stroke that may affect

his ability to operate a motor vehicle?

Could any of his medications impair

driving performance?

Most older adults have at least one

chronic medical condition and many

have multiple conditions. The most

common medical conditions in older

adults include arthritis, hypertension,

hearing impairments, heart disease,

cataracts, dizziness, orthopedic impair-

ments, and diabetes.

Some of these

conditions have been associated with

driving impairment and will be dis-

cussed in more detail in subsequent

chapters. Additionally, keep in mind

that many prescription and nonpre-

scription medications have the po-

tential to impair driving skills, either

by themselves or in combination with

other drugs. (See Chapter 9 for a more

in-depth discussion on medications and

driving.) Older patients generally take

more medications than their younger

counterparts and are more susceptible

to their central nervous system effects.

Whenever you prescribe one of these

medications or change its dosage, coun-

sel your patient on its potential to affect

driving safety. You may also recommend

that your patient undergo formal

assessment of function (see Chapter 3)

while he/she is taking a new medication

that may cause sedation. Concern may

be heightened if there are documented

difculties in attention or visuospatial

processing speed (e.g., such as the Trails

B test [see Chapters 3 and 4]).

The review of systems can reveal

symptoms that may interfere with the

patient’s driving ability. For example,

loss of consciousness, confusion, falling

sleep while driving, feelings of faintness,

memory loss, visual impairment, and

muscle weakness all have the potential

to endanger the driver.

46. Health United States: 2002; Current Population

Reports, American with Disabilities, p. 70–73.

Figure 2.1

Counseling the driver in the

inpatient setting

When caring for patients in the inpatient

setting, it can be all too easy for physi-

cians to forget about driving. In a survey

of 290 stroke survivors who were inter-

viewed 3 months to 6 years post-stroke,

fewer than 35% reported receiving advice

about driving from their physicians, and

only 13% reported receiving any type of

driving evaluation. While it is possible that

many of these patients suffered such ex-

tensive deﬁcits that both the patient and

physician assumed that it was unlikely for

the patient to drive again, patients should

still receive driving recommendations from

their physician.

Counseling for inpatients may include

recommendations for permanent driving

cessation, temporary driving cessation,

or driving assessment and rehabilita-

tion when the patient’s condition has

stabilized. Such recommendations are

intended to promote the patient’s safety

and, if possible, help the patient regain

his/her driving abilities.

Figure 2.2

Health risk assessment

A health risk assessment is a series of

questions intended to identify potential

health and safety hazards in the patient’s

behaviors, lifestyle, and living environment.

A health risk assessment may include

questions about, but not limited to:

• Physical activity and diet;

• Use of seat belts;

• Presence of smoke detectors and ﬁre

extinguishers in the home;

• Presence of ﬁrearms in the home; and

• Episodes of physical or emotional

abuse.

The health risk assessment is tailored to

the individual patient or patient population.

For example, a pediatrician may ask the

patient’s parents about car seats, while a

physician who practices in a warm-climate

area may ask about the use of hats and

sunscreen. Similarly, a physician who sees

older patients may choose to ask about

falls, injuries, and driving.

At times, patients themselves or family

members may raise concerns. If the fam-

ily of your patient asks, “Is he or she safe

to drive?” (or if the patient expresses

concern), identify the reason for the

concern. Has the patient had any recent

crashes or near-crashes, or is he/she los-

ing condence due to declining

functional abilities? Inquiring about

specic driving behaviors may be more

useful than asking global questions

about safety. A list of specic driving

behaviors that could indicate concerns

for safety is listed in the Hartford guide,

“At the Crossroads.”

Physicians can

request family members or spouses to

monitor and observe skills in trafc

with full disclosure and permission from

the patient. Another tactic might be

identifying a family member who refuses

to allow other family members such

as the grandchildren to ride with the

patient due to trafc safety concerns.

Please note that age alone is not a red

ag! Unfortunately, the media often

emphasize age when an older driver is

involved in an injurious crash. This

“ageism” is a well-known phenomenon

in our society.

While many people

experience a decline in vision, cognition,

or motor skills as they get older, people

age at different rates and experience

functional changes to different degrees.

The focus should be on functional abili-

ties and medical tness-to-drive and

not on age per se.

Inquire about driving during

the social history/health risk

assessment.

If a patient’s presentation and/or the

presence of red ags lead you to suspect

that he/she is potentially at risk for

unsafe driving, the next step is to ask

whether he/she drives. You can do this

by incorporating the following ques-

tions into the social history or health

risk assessment (see Figure 2.2):

47. The Hartford. At the Crossroads. Hartford, CT.

www.thehartford.com/alzheimers/brochure.html.

Accessed December 12, 2007.

48. Nelson, T. (2002). Ageism: Stereotyping and

Prejudice Against Older Persons. Cambridge,

MA: MIT Press.

13Chapter 2—Is the Patient at Increased Risk for Unsafe Driving?

• “How did you get here today?” or

“Do you drive?”; and

• “Are you having any problems while

operating a motor vehicle?”;

• “Have others expressed concern

about your driving?”; and

• “What would you do if you had to

stop driving?”

If your patient drives, then his/her driv-

ing safety should be addressed. For acute

illness, this generally involves counsel-

ing the patient. For example, Mr. Bales

should be counseled to temporarily

cease driving for a certain period of

time after his acute myocardial infarc-

tion (see Chapter 9). If Mr. Phillips is

started on a new medication, he should

be counseled about the side effects and

their potential to impair driving perfor-

mance, if appropriate.

For chronic conditions, on the other

hand, driving safety is addressed by

formally assessing the functions that are

important for driving. This assessment

will be discussed further in the

next chapter.

Please note that some chronic medical

conditions may have both chronic and

acute effects. For example, a patient

with insulin-dependent diabetes may

experience acute episodes of hypogly-

cemia, in addition to having chronic

complications such as diabetic retinopa-

thy and/or peripheral neuropathy.

In this case, the physician should

counsel the patient to avoid driving

until acute episodes of hypoglycemia

are under control and to keep candy

or glucose tablets within reach in the

car at all times. The physician should

also recommend formal assessment of

function if the patient shows any signs

of chronic functional decline. (See

Chapter 9 for the full recommendation

on diabetes and driving.)

If your patient does not drive, you may

wish to ask if he/she ever drove, and if

so, what the reason was for stopping. If

your patient voluntarily stopped driving

due to medical reasons that are poten-

tially treatable, you may be able to

help her or him return to safe driving.

In this case, formal assessment of

function can be performed to identify

specic areas of concern and serve as

a baseline to monitor the patient’s

improvement with treatment. Referral

to a driver rehabilitation specialist in

these cases is strongly encouraged (see

Chapter 5).

Gather additional information.

To gain a better sense of your patient as

a driver, ask questions specic to driving.

The answers can help you determine the

level of intervention needed.

If a collateral source such as a family

member is available at the appointment

or bedside, consider addressing your

questions to both the patient and the

collateral source with the patient’s

permission. If this individual has had

the opportunity to observe the patient’s

driving, his/her feedback may be

valuable.

Questions to ask the patient and/or

family member:

• “How much do you drive?” (or

“How much does [patient] drive?”)

• “Do you have any problems when you

drive?” (Ask specically about day

and night vision, ease of operating

the steering wheel and foot pedals,

confusion, and delayed reaction to

trafc signs and situations.)

• “Do you think you are a safe driver?”

• “Do you ever get lost while driving?”

• “Have you received any trafc viola-

tions or warnings in the past two years?”

• “Have you had any near-crashes or

crashes in the past two years?”

Understand your patient’s

mobility needs.

At this time you can also ask about your

patient’s mobility needs and encourage

him/her to begin exploring alternative

transportation options before it be-

comes imperative to stop driving. Even

if alternative transportation options

are not needed at this point, it is wise

for the patient to plan ahead in case it

ever becomes necessary.

Some questions you can use to initiate

this conversation include:

• “How do you usually get around?”

• “If your car ever broke down, how

would you get around? Is there any-

one who can give you a ride? Can you

use a public train or bus? Does your

community offer a shuttle service or

volunteer driver service?”

Encourage your patients to plan a safety

net of transportation options. You might

want to say, “Mobility is very impor-

tant for your physical and emotional

health. If you were ever unable to drive

for any reason, I’d want to be certain

that you could still make it to your ap-

pointments, pick up your medications,

go grocery shopping, and visit your

friends.”

Sources for educational materials are

listed in Appendix B like the Hart-

ford insurance company’s “We need to

talk,” AARP materials, or University

of Michigan Transportation Research

Institute’s materials

, which could be

invaluable in planning for maintaining

out-of-home activities.

In the event

that your patient must cease driving,

the transition from driver to non-driver

status will be less traumatic if he/she has

already created a transportation plan.

In addition the handout in Appendix B,

Getting By Without Driving, can help

your patient get started.

49. University of Michigan Transportation

Research Institute. UMTRI Library; 2007.

www.umtri.umich.edu/pubsdata.php.

Accessed November 21, 2007.

50. The Hartford. Family Conversations With

Older Drivers. Hartford, CT. www.thehartford.

com/talkwitholderdrivers/. Accessed October 11,

2007.

14 Chapter 2—Is the Patient at Increased Risk for Unsafe Driving?

Red Flags for Further Assessment

Acute events

Prior to hospital or emergency department discharge, patients

and appropriate caregivers should be counseled as needed

regarding temporary driving cessation:

• Acute myocardial infarction;

• Acute stroke and other traumatic brain injury;

• Arrhythmia;

• Lightheadedness and pre-syncope;

• Syncope and vertigo;

• Seizure;

• Surgery;

• Delirium from any cause; and

• New sedating medications.

Patient’s or family member’s concern

Has your patient approached you with the question, “Am I

safe to drive?” (Alternatively, a family member may express

concern about the patient’s driving safety.) If so, nd out

the cause of concern. Note that age alone does not predict

driving tness—function, not age, is the determining factor.

Ask for specic causes of concern, such as recent crashes,

near-misses, trafc tickets, becoming lost, poor night vision,

forgetfulness, and confusion. Evaluate for function using the

Assessment of Driver Related Skills (ADReS) battery (Chap-

ters 3 and 4).

Medical history: Chronic medical conditions

Patients may require formal assessment to determine the

impact of these conditions on their level of function:

• Diseases affecting vision, including cataracts, diabetic retin-

opathy, macular degeneration, glaucoma, retinitis pigmen-

tosa, eld cuts, and low visual acuity even after correction;

• Cardiovascular disease, especially when associated with pre-

syncope, syncope or cognitive decits, including unstable

coronary syndrome, arrhythmias, palpitations, congestive

heart failure, hypertrophic obstructive cardiomyopathy, and

valvular disease;

• Neurologic disease, including dementia, multiple sclerosis,

Parkinson’s disease, peripheral neuropathy, brain injury,

spinal cord injury, and residual decits from stroke;

• Psychiatric disease, including mood disorders, depression,

anxiety disorders, psychotic illness, personality disorders,

and alcohol or other substance abuse;

• Metabolic disease, including type 1 and type 2 diabetes mel-

litus especially with hypoglycemic attacks or severe swings

in blood sugars, and hypothyroidism;

• Musculoskeletal disabilities, including arthritis and foot

abnormalities;

• Chronic renal failure;

• Respiratory disease, including chronic obstructive pulmonary

disease and obstructive sleep apnea; and

• Cancer and chemotherapy.

15Chapter 2—Is the Patient at Increased Risk for Unsafe Driving?

Medical history: Medical conditions with

unpredictable/episodic events

The patient should be counseled not to drive during any of

the following acute events until they have discussed this issue

with their physician:

• Pre-syncope or syncope;

• Angina;

• Seizure;

• Transient ischemic attacks;

• Hypoglycemic attacks;

• Vertigo;

• Alcoholism and hospitalization for detoxication; or

• Sleep attacks or cataplexy.

Medications

Many nonprescription and prescription medications have the

potential to impair driving ability, either by themselves or

in combination with other drugs. Combinations of drugs may

affect drug metabolism and excretion, and dosages may need

to be adjusted accordingly. (See Chapter 9 for a discussion of

each medication class.) Medications with strong potential to

affect the patient’s driving ability include:

• Anticholinergics;

• Anticonvulsants;

• Antidepressants;

• Antiemetics;

• Antihistamines;

• Antihypertensives;

• Antiparkinsonians;

• Antipsychotics;

• Benzodiazepenes and other sedatives/anxiolytics;

• Muscle relaxants;

• Narcotic analgesics; and

• Stimulants.

Review of systems

The review of systems can reveal symptoms or conditions

that may impair driving performance. In addition to further

work-up, driving safety should be addressed.

• General: fatigue, weakness;

• Head Ears Eyes Nose Throat (HEENT): headache, head

trauma, double vision, visual changes, vertigo;

• Respiratory: shortness of breath, use of oxygen;

• Cardiac: chest pain, dyspnea on exertion, palpitations,

sudden loss of consciousness;

• Musculoskeletal: muscle weakness, muscle pain, joint

stiffness or pain, decreased range of motion;

• Neurologic: loss of consciousness, feelings of faintness,

seizures, weakness/paralysis, tremors, loss of sensation,

numbness, tingling; and

• Psychiatric: depression, anxiety, memory loss, confusion,

psychosis, mania.

Assessment and plan

As you formulate a diagnosis/treatment plan for your patient’s

medical conditions, remember to address driving safety as

needed. You may need to counsel your patients about driving

when you:

• Prescribe a new medication, or change the dosage of a

current medication; and

• Work up a new-onset disease presentation or treat an

unstable medical condition. This includes many of the

medical conditions listed above.

Dobbs, B. M. (2005) Medical Conditions and Driving: A

Review of the Literature (1960-2000). Report # DOT HS

809 690. Washington, DC: National Highway Trafc Safety

Administration. www.nhtsa.dot.gov/people/injury/research/

Medical_Condition_Driving/pages/TRD.html.

Charlton, J., Koppel, S., O’Hare, M., Andrea, D., Smith, G.,

Khodr, B., Langford, J., Odell, M., & Fildes, B. (2004) Inu-

ence of chronic illness on crash involvement of motor vehicle

drivers, Monash University Accident Research Centre, Re-

port No. 213. www.monash.edu/muarc/reports/muarc213.html

For recent reviews please consult the following two extensive reviews on these topics, both available on-line:

CHAPTER 3

Assessing Functional

Ability

license,” you may nd it helpful to offer

reassurance that physicians do not have

that type of legal authority. Explain that

you may advise evaluation of driving if

needed and/or refer him/her to a driver

rehabilitation specialist or the Depart-

ment of Motor Vehicles (DMV).

Here is an example of how you could

suggest an evaluation to Mr. Phillips:

“Mr. Phillips, I’m concerned about your

safety when you drive. Your son tells me

that you were in a car crash recently and

that you’ve had several near crashes in the

past two years. Even though your medical

conditions are well managed, they can still

cause problems that can affect your driving

ability. I’d like you to do a few things for

me, such as walking down the hall while I

time you. These tests will help me decide

if there are areas we need to work on to

improve your driving safety.

“This is how it works: Based on what I

know about your health and how you do on

these tasks, we’ll do our best to identify any

potential treatable or reversible conditions.

For example, if you’re not seeing as well

as you should, then we’ll do what we can

to improve your vision. If there’s something

we can’t improve, then we can consult a

driver rehabilitation specialist. This type

of instructor, typically an occupational

therapist, will go out on the road with you

to watch you drive, then recommend ways

to make your driving safer. The goal is to

keep you on the road for as long as you are

safe to drive.”

As revealed in the PPODS algorithm

(Figure 1.1), the next step to managing

Mr. Phillips’ driving safety is a formal

assessment of the key functional abilities

related to driving. Specic information

in Mr. Phillips’ driving history—namely,

the crash, moving violations, or near

crashes—in addition to his medical

conditions, further support the need for

an assessment.

In this chapter, we discuss the functions

related to driving and present a brief

ofce test battery, the Assessment of

Driving Related Skills (ADReS). Each

test in ADReS assesses a key area of

function. Although not all functional

domains that are necessary or relevant

to driving are tested by the ADReS

battery, many key areas are and have

been validated with driving outcomes.

How do you broach the issue

of a driving assessment to

your patient?

Your patient may feel defensive about

being assessed and may even refuse

assessment for fear of being told that

he/she can no longer drive. After all,

driving is not only the primary form

of transportation for most Americans,

it also represents freedom and

independence.

In suggesting assessment to your patient,

it is best to use a direct but nonconfron-

tational approach. Reassure your patient

that you have his/her safety in mind

and emphasize that you would like to

assist him/her to drive safely for as long

as possible. If your patient expresses

fear that you will “take away my driver’s

Mr. Phillips, whom you met in

Chapter 2, has been accompanied

to the clinic by his son, who is in

the examination room with him.

Mr. Phillips tells you that he is a

safe driver. You request and obtain

permission to interview the son who

voices his concern. Four months ago,

Mr. Phillips was involved in a minor

car crash, in which he was found to

be at fault. He has also had several

near-crashes in the past two years.

However, he has never gotten lost

while driving.

In discussing Mr. Phillips’ trans-

portation options, you learn that he

drove himself to this appointment.

Driving is Mr. Phillips’ main mode

of transportation, and he drives

almost every day. Although Mr.

Phillips is certain—and his son

conrms—that family members and

neighbors would be willing to drive

him wherever he needs to go, he has

never asked for rides. “Why should

I ask for rides when I can just drive

myself around? Besides, I don’t want

to impose on my family or friends.”

CHAPTER 3

Assessing Functional

Ability

20 Chapter 3—Assessing Functional Ability

• Follow-up at the patient’s next ap-

pointment: Would he/she be willing

to complete the self-screening? Has

the patient put any of the tips into

practice? Does the patient have any

questions or concerns? Would he/she

be willing to undergo ADReS?

• If family members are concerned

about the patient’s driving safety,

you can give them a copy of How

to Assist the Older Driver, found in

Appendix B. Especially if the patient

has dementia, he/she will probably

lack insight and it will likely not

be fruitful to belabor the point. It is

important here to enlist family mem-

bers and obtain their aid in creating

a transportation plan for the patient

and encouraging the patient to be

evaluated by ADReS.

• If you are urgently concerned about

your patient’s driving safety, you may

wish to forego ADReS and refer your

patient directly to a driver rehabilita-

tion specialist (see Chapter 5) or to

your state DMV for a focused driving

assessment. Depending on your

State’s reporting laws, you may be

legally responsible for reporting

“unsafe” drivers to the DMV. (A

detailed discussion of the physician’s

legal responsibilities can be found in

Chapter 7. A reference list of report-

ing laws is provided in Chapter 8.)

In any case, the patient should be

referred with his/her knowledge.

At this point, the patient and/or

family might relent and be willing

to consider an evaluation from a

driving rehabilitation specialist.

Assessment of Driving-Related

Skills (ADReS)

The three key functions for safe driving

are (1) vision, (2) cognition, and (3)

motor/somatosensory function. ADReS

assesses some aspects of these three

important functions to help you identify

specic areas of concern.

Please note that ADReS does not pre-

dict crash risk! While many researchers

are working to create an easy-to-use

test battery that predicts crash risk,

further research is needed. However,

• Suggest that the patient take the

SAFER Driving survey. Also devel-

oped at the University of Michigan

Transportation Research Institute,

this is a Web-based tool (available at

um-saferdriving.org) that requires users

to answer questions about the severity

of health concerns they are expe-

riencing due to medical conditions

and medications. The Web site then

calculates the effects of these health

concerns on critical driving skills and

gives users individualized feedback on

how their driving may be declining;

what to do to continue driving safely

given these declines; and, if appro-

priate, recommendations for more

in-depth assessment. Research has

shown that feedback from the Web

site correlates positively with on-road

driving scores and an assessment from

an occupational therapist. Users also

report that the site is easy to use, the

information is helpful, and that they

discovered declines in themselves

of which they were not previously

aware.

• In the patient’s chart, document your

concern regarding his/her driving

ability, and support this with relevant

information from the patient’s presen-

tation, medical history, medications,

and reported driving history. Docu-

ment the patient’s refusal for further

assessment, along with any counseling

you have provided. (Current Proce-

dural Terminology [CPT

] codes for

counseling can be found in Appendix

A.) Not only will this remind you

to follow-up at the next visit, but

it could potentially protect you in

the event of a lawsuit. (A detailed

medicolegal discussion can be found

in Chapter 7.) In cases where the risk

is very high and the patient drives

despite your recommendations, you

might consider referral of the patient

to the DMV for further testing.

54. Eby, D. W., Molnar, L. J., Shope, J.T., & Del-

linger, A.M. Development and pilot testing of

an assessment battery for older drivers. J Safety

Res 38: 535-43.

What do you do if your patient

refuses assessment?

Despite your best efforts, your patient

may refuse to have his/her functional

abilities that are key to driving assessed.

If this occurs, you have several options:

• Encourage your patient to complete

the self-screening tool (Am I a Safe

Driver?) found in Appendix B. This

may help raise your patient’s level of

awareness and make him/her more

open to ADReS.

• Counsel your patient on the Success-

ful Aging Tips and Tips for Safe

Driving, both found in Appendix B.

These may raise your patient’s level

of awareness and encourage safe

driving habits.

• Suggest enrolling in a driving course

designed to improve trafc safety,

such as the Trafc Safety Course

offered by AARP

or those offered

by the AAA.

Roadwise Review is

a CD available from the AAA that

assesses important functional abili-

ties for driving and provides feedback

to older adults on the presence of

impairment.

Roadwise Review does

require the older adult to have a

computer and an assistant during the

playing of the CD. Give the patient a

copy of the Driving Decisions Work-

book. Developed by the University

of Michigan Transportation Research

Institute, this is a paper-and-pencil

workbook that provides users with

individualized feedback based on how

they answer questions. Research has

shown that workbook scores are posi-

tively correlated with on-road driving

scores and several clinical tests of

functional ability. The workbook can

be downloaded free of charge at:

http://deepblue.lib.umich.edu/bitstream/

2027.42/1321/2/94135.0001.001.pdf.

51. AARP Trafc Safety Course. www.aarp.org/

families/driver_safety/driver_safety_online_course.

html. Accessed October 14, 2007.

52. AAA Foundation for Trafc Safety Senior

Driver Web site. www.seniordrivers.org/home/

index.cfm. Accessed October 14, 2007.

53. AAA Exchange. Checking Your Driving Abili-

ties. www.aaapublicaffairs.com/Main/Default.as

p?SectionID=&SubCategoryID=38&CategoryID

=3&ContentID=315&. Accessed October 14,

2007.

21Chapter 3—Assessing Functional Ability

ptosis, which is more common in the

older population. Drivers with loss of

peripheral vision (e.g., glaucoma) may

have trouble noticing trafc signs or

cars and pedestrians that are about to

cross their path. Although earlier stud-

ies examining the relationship between

visual eld loss and driving performance

were equivocal, more recent studies

have found signicant relationships.

In ADReS, visual elds are measured

through confrontation testing.

Aspects of vision that are important for

safe driving

but are not included in

ADReS are:

• Contrast sensitivity: Older adults

require about three times more con-

trast than young adults to distinguish

targets against their background. This

decit in contrast sensitivity is further

exacerbated by low light levels. Thus,

older drivers may have problems

distinguishing cars or pedestrians

against background scenery, and this

may be much worse at night or during

storms.

While contrast sensitivity

has been found to be a valid predictor

of crash risk among older drivers,

most vision care specialists are not

familiar with measures of contrast

sensitivity, nor is it routinely mea-

sured in eye examinations. Further

research must be performed to produce

standardized, validated cut-off points

for contrast sensitivity, and further

work must be done to introduce

this concept to professionals in

eye care centers.

57. Dobbs, B. M. (2001). Medical Conditions and

Driving: Current Knowledge. Association for

the Advancement of Automotive Medicine/

National Highway Trafc Safety Administra-

tion, p. 24 Project DTNH22-94-G-05297.

Washington, DC: National Highway Trafc

Safety Administration

58. Walgreens. https://webapp.walgreens.com/ceP-

harmacy/programsHTML/transportation-tech.pdf.

Accessed October 14, 2007.

59. Owsley, C., & Ball, K. Assessing visual

function in the older driver. Clin Geriatr Med.

1993;9(2):389–401.

60. Dobbs, B. M. Medical Conditions and Driving:

Current Knowledge. Association for the Ad-

vancement of Automotive Medicine/ National

Highway Trafc Safety Administration, Project

DTNH22-94-G-05297. Washington, DC:

National Highway Trafc Safety Administra-

tion. 2001: p. 15–16.

To perform ADReS, you will need a

Snellen chart, tape to mark distances

on the oor, a stopwatch, and a pencil.

There are two paper-and-pencil tests in

ADReS, one of which requires a pre-

printed form. This is included on pages

28–29 and may be photocopied.

Vision

Vision is the primary sense utilized in

driving in comparison to other modali-

ties like hearing and proprioception,

and it is responsible for the majority

of driving-related sensory input.

In most States, candidates are required

to undergo vision testing to obtain

a driver’s license. Several States (see

Chapter 8) also require vision testing

at the time of license renewal.

Aspects of vision that are important for

safe driving and can be readily assessed

by a physician include:

• Visual acuity, and

• Visual elds.

Numerous studies show that visual

acuity declines between early and late

adulthood, although no consensus exists

on the rate of decline or decade of

onset. Decline in acuity is related to

physiologic changes of the eye that

occur with age and the increased

incidence of diseases such as cataracts,

glaucoma, and macular degeneration.

While far visual acuity is crucial to

many driving-related tasks, declines

in near visual acuity may be associ-

ated with difculty seeing or reading

maps, or gauges and controls inside the

vehicle. In ADReS, far visual acuity is

measured with a Snellen chart.

Visual elds may decline as a result of

the natural aging process and medical

conditions such as glaucoma, retinitis

pigmentosa, and stroke. In addition,

upper visual elds may be obstructed by

55. Shinar, D., & Schieber, F. (1991). Visual

requirements for safety and mobility of older

drivers. Hum Factors. 33(5):507-519.

56. Carr, D. B. Assessing older drivers for

physical and cognitive impairment. Geriatrics.

1993;48(5):46-51.

until physicians are able to test their

patients directly for crash risk, they can

test them indirectly by assessing the func-

tions that are necessary for safe driving.

Any impairment in these functions has

the potential to increase the patient’s

risk for crash. Once they are identied,

the physician is in a good position to

determine if the patient requires referral

to a specic subspecialist (e.g., ophthal-

mologist). Although cut-off scores are

provided for these tests (see Chapter 4),

the ADReS battery is a tool for identify-

ing areas of concern that require addi-

tional evaluation. The physician should

use his/her clinical judgment regardless

of the scores by utilizing all available

information (driving history, medical

history, and functional assessment). In

addition, not all important functions

are tested on the ADReS battery; rather

specic items were chosen for their

applicability and feasibility in the ofce

setting, along with their correlates with

impaired driving outcomes.

The tests in ADReS were selected by a

consensus panel of driving safety experts

who worked with the AMA, and were

chosen from among the many available

functional tests based on their ease of

use, availability, amount of time required

for completion, and quality of informa-

tion provided by the patient’s test perfor-

mance. The individual tests in ADReS

have been validated as measures of their

particular function and in some cases

have been studied with relation to driv-

ing. Although we are still awaiting more

evidenced-based medical studies to link

these tests with crash risk, these screens

can detect new-onset visual, cognitive,

or motor problems that may be amenable

to an intervention.

The tests are presented below by

function, following a discussion of the

function and how it relates to driving.

An accompanying score sheet on pages

28–29 can be photocopied and placed

in the patient’s chart. On the score

sheet, the tests are presented in the

recommended order of execution. CPT

codes for components of ADReS are

provided in Appendix A, and the score

sheet can serve as documentation for

these codes.

22 Chapter 3—Assessing Functional Ability

• Accommodation and adaptation:

Accommodation is the change in

the shape of the lens that assists with

bringing objects into focus. This is

an important skill for reading the

instrument panel in a car or viewing

objects in the mirror. Adaptation is

the ability to perceive objects when

levels of illumination are changing, as

might occur during nighttime driving

or in parking garages. Older adults

require more time than young adults

to adjust to abrupt changes in light

or darkness. As a result, older drivers

often report difculties dealing with

the sudden onset of bright lights, such

as the headlights of an oncoming car.

Glare may also play a role in their

visual difculties.

• Angular movement, dynamic visual

acuity, and depth perception. Older

adults must be able to detect objects

in motion such as judging the speed

of cars coming across their path dur-

ing left hand turns. This ties in with

the concept of dynamic visual acuity,

which may also require the detection

of letters or images (such as reading

trafc signs) while in motion. Depth

perception is important for near ob-

jects, but apparently becomes less of

an issue at further distances. A more

pertinent task is the ability to detect

changes in visual image size, such

as judging the speed of approaching

vehicles.

• Color. Many reviews on visual

abilities that are necessary for driving

tend to downplay the importance of

color detection, based on the current

level of evidence. Trafc lights in the

United States typically have mixed

colors embedded in the lights to

compensate for the small percentage

of the population that is red-green

color blind. However, the ability

to recognize trafc signs, which are

given specic colors based on a spe-

cic regulatory area, is important. In

addition, vehicle color may enhance

or diminish detection under certain

trafc conditions (e.g., a white car in

snowy weather, or a grey car in rainy

or foggy conditions).

61. Owsley, C., & Ball, K. Assessing visual func-

tion in the older driver. Clin Geriatr Med.

1993;9(2):389–401.

Assessment of Driving-Related Skills (ADReS)

Snellen E chart

The Snellen chart is used to test far visual acuity. The standard chart measures

9” x 23” and is printed on a durable, tear-resistant latex sheet, with eyelets for

easy hanging. Letters are printed on one side, and tumbling “E” symbols are

printed on the reverse.

With the chart hanging on a wall, the patient is instructed to stand 20 feet away.

Wearing his/her usual glasses or contact lenses, the patient reads the smallest line

possible with both eyes open. The patient’s visual acuity is based on the lowest full

row that he/she successfully reads. For example, if the best the patient can see is

20/40, then his/her acuity is 20/40 OU (oculus uterque). This process is repeated

for each eye individually (right eye: OD or oculus dexter; left eye: OS or oculus

sinister).

This test is best performed in a hallway with good lighting. Tape can be used to

mark a distance of 20 feet.

If you prefer, far visual acuity can be measured using the chart of your choice, such

as the Snellen chart for a 10-foot distance or the Sloan low vision letter chart for 6

meters (20 feet).

Near visual acuity can also be tested with commercially available charts, and

should be considered whenever a patient complains of difﬁculty seeing or reading

maps, or gauges and controls within the vehicle. Although not part of the ADReS

battery, many clinicians will check near vision using a Rosenbaum pocket chart.

Some limitations have been noted in testing using the Snellen chart. These

include—but are not limited to—the different number of letters per line, differ-

ent spacing between lines, the speciﬁc use of letters, and the spacing between

letters.

A trend in the ﬁeld of eye care has been to use a newer chart called the

ETDRS (Early Treatment Diabetic Retinopathy Study) that in some studies of eye

diseases appears to be more accurate.

The ETDRS chart improves on the Snellen

test by having a similar number of letters per line and standard spacing between

the letters. Although it has not yet become the standard, it is possible that eye

clinics will eventually migrate toward this eye chart. For physicians ofﬁces that are

interested, ETDRS eye charts can be obtained from several sources and the stimuli

presented in a variety of formats (e.g., wall chart, computer).

1. Staplin, L., Lococo, K. H., Stewart, J., & Decina, L. E. (1999, April). Safe Mobility for Older People

Notebook. NHTSA Report No. DOT HS 808 853. Washington, DC: National Highway Trafc Safety

Administration.

2. Vector Vision. ETDRS Acuity Testing. www.vectorvision.com/html/educationETDRSAcuity.html. Accessed

October 14, 2007.

3. Falkenstein, I. A., Cochran, D. E., Azen, S. P., et al. Comparison of visual acuity in macular

degeneration: patients measured with Snellen and early treatment diabetic retinopathy study charts.

Ophthalmology. 10:319–23.

23Chapter 3—Assessing Functional Ability

Cognition

Driving is a complex activity that

requires a variety of high-level cognitive

skills. Among the cognitive skills that

are useful for driving

are:

• Memory—short-term, long-term,

and working memory;

• Visual perception, visual processing,

visual search, and visuospatial skills;

• Selective and divided attention;

• Executive skills (sequencing, plan-

ning, judgment, decision making);

• Language; and

• Vigilance.

Both crystallized memory and working

memory are necessary for driving. Not

only must drivers remember how to

operate their vehicle and what signs and

signals mean, they must also remember

their current destination and how to

get there.

In addition, drivers must be

able to retain certain information while

simultaneously processing other infor-

mation—a skill called working memory.

Working memory (and the other cogni-

tive skills to which it contributes) tends

to decline with age, while crystallized

memory remains relatively intact across

the life span. It is unclear at present

whether age-related memory impair-

ments reect only preclinical forms of

age-related diseases or whether these

occur independent of disease processes.

Visual perception, visual processing,

and visuospatial skills are necessary for

the driver to organize visual stimuli into

recognizable forms and know where

they exist in space. Without these skills,

the driver would be unable to recognize

a stop sign and determine its distance

from the car. In general, visual process-

62. Walgreens. https://webapp.walgreens.com/

cePharmacy/programsHTML/transportation-tech.

pdf. Accessed October 14, 2007.

63. Colsher, P. L., & Wallace R. B. Geriatric assess-

ment and driver functioning. Clin Geriatr Med.

1993;9(2):365–375.

64. Goetz, C. G. (1999). Textbook of Clinical

Neurology, 1st ed. Philadelphia: W.B. Saunders

Company.

ADReS (continued)

Visual ﬁelds by confrontation testing

The examiner sits or stands three feet in front of the patient, at the patient’s eye

level. The patient is asked to close his/her right eye, while the examiner closes his/

her left eye. Each ﬁxes on the other’s nose.

The examiner then holds up a hand in each visual ﬁeld simultaneously with a ran-

dom number (usually one or two) of ﬁngers in each of the four quadrants, and asks

the patient to state the total number of ﬁngers. With the ﬁngers held slightly closer

to the examiner, the patient has a wider ﬁeld of view than the examiner. Provided

that the examiner’s visual ﬁelds are within normal limits, if the examiner can see

the ﬁngers, then the patient should be able to see them unless he/she has a visual

ﬁeld defect.

The process is repeated for the other eye (patient’s left eye and examiner’s right

eye closed). The examiner indicates any visual ﬁeld defects by shading in the area

of defect on a visual ﬁeld representation.

Trail-making test, part B

This test of general cognitive function also speciﬁcally assesses working memory,

visual processing, visuospatial skills, selective and divided attention, and psycho-

motor coordination. In addition, numerous studies have demonstrated an associa-

tion between poor performance on the Trail-Making Test, Part B, and poor driving

performance.

(See Chapter 4 for further discussion.)

Part B involves connecting, in alternating order, encircled numbers (1–13) and

encircled letters (A–L) randomly arranged on a page. This test is scored by overall

time (seconds) required to complete the connections accurately. The examiner

points out and corrects mistakes as they occur; the effect of mistakes, then, is to

increase the time required to complete the test. This test usually takes

3 to 4 minutes to administer.

The examiner administers the test to the patient, stating, “Now I will give you a

paper and pencil. On the paper are the numbers 1 through 13 and the letters A

through L, scattered across the page. Starting with 1, draw a line to A, then to 2,

then to B, and so on, alternating back and forth between numbers and letters until

you ﬁnish with the number 13. I’ll time how fast you can do this. Are you ready?

Go.” The examiner records time-to-complete.

Although not recommended in the previous version of the ADReS battery, many

neuropsychologists recommend giving the Trails A test (connecting just numbers)

prior to giving the Trails B test. The rationale is at least twofold: (1) Trails A provides

an appropriate warm-up to Trails B, and allows the older adult some practice on a

simpler concept; and (2) in many of the driving studies that validated Trails B, Trails

A was given ﬁrst. For clinicians who prefer to conduct both tests, collaborating with

a psychologist who uses the Trails A test (stimuli) can assist with administration

and oversight in the ofﬁce setting. However, the recent Maryland Pilot Older Driver

Study (MaryPODS) that found an association with Trails B performance and at-fault

crashes in a cohort of older adults utilized only the practice trial of Trails B prior to

the full test. We have now included the practice trial of Trails B in the current stimuli

of the ADReS battery.

1. Staplin, L., Gish, K. W., & Wagner, E. K. (2003). MaryPODS revisited: updated crash analysis and

implications for screening program implementation. J Safety Res. 34:389–397.

2. Staplin, L., Lococo, K. H., Stewart, J., & Decina, L. E. (1999, April). Safe Mobility for Older People

Notebook. NHTSA Report No. DOT HS 808 853. Washington, DC: National Highway Trafc Safety

Administration.

24 Chapter 3—Assessing Functional Ability

ing may slow

and complex visuospatial

skills may decline with age, while visual

perception remains stable.

During driving, many demands are

made on attention. In particular, drivers

must possess selective attention—the

ability to prioritize stimuli and focus

on only the most important—in order

to attend to urgent stimuli (such as

trafc signs) while not being distracted

by irrelevant ones (such as roadside

ads). In addition, drivers must possess

divided attention in order to focus on

the multiple stimuli required by most

driving tasks. Attentional functioning

may decline with age,

with divided

attention showing more pronounced

changes than selective attention.

The most widely studied instrument

for detection of impairment in divided

attention and selective attention that

has been correlated with crash risk in

older adult drivers has been the Useful

Field of View (UFOV).

This test is

available for purchase and information is

available on the Visual Awareness Web

site.

Cost, time, and ability to bill,

as well as limited studies in a primary

care setting, might be potential barriers

to utilization in a physician’s ofce.

Another computerized set of tests that

assesses key functional abilities for driv-

ing is the Driving Health

Inventory

65. Owsley, C., & Ball K. Assessing visual

function in the older driver. Clin Geriatr Med.

1993;9(2):389–401.

66. Beers, M. H., & Berkow, R. (eds). (2000). The

Merck Manual of Geriatrics. Section 4, Chapter

32: Aging and mental health. Whitehouse

Station, NJ: Merck & Co., Inc..

67. Hartley, A. A. (1992). Attention. In: Craik, F.

I. M., & Salthouse, T.A. (eds). The Handbook

of Aging and Cognition. Pp. 3–50. Hillsdale, NJ:

Erlbaum.

68. Madden, D. J., Turkington, T. G., Provenzale, J.

M., Hawk, T. C., Hoffman, J. M., Coleman, R.

E. (1997). Selective and divided visual atten-

tion: age-related changes in regional cerebral

blood ow measured by H215O PET. Hum Brain

Mapp. 5:389–409.

69. Ball, K., Roenker, D.L., Wadley, V.G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting? J Am

Geriatr Soc. 54:77–84.

70. Visual Awareness.com. http://visualawareness.

com/Pages/request.html. Accessed October 14,

2007.

ADReS (continued)

Clock drawing test

Depending on the method of administration and scoring, the clock drawing

test (CDT) may assess a patient’s long-term memory, short-term memory, visual

perception, visuospatial skills, selective attention, abstract thinking, and executive

skills. Preliminary research indicates an association between speciﬁc scoring

elements of the clock drawing test and poor driving performance.

(See Chapter 4 for a further discussion.)

In this form of the CDT, the examiner gives the patient a pencil and a blank sheet

of paper and says, “I would like you to draw a clock on this sheet of paper. Please

draw the face of the clock, put in all the numbers, and set the time to ten minutes

after eleven.” This is not a timed test, but the patient should be given a reasonable

amount of time to complete the drawing. The examiner scores the test by examin-

ing the drawing for each of seven speciﬁc elements found on the ADReS score

sheet (see page 28 for score sheet).

Rapid pace walk

This is a measure of lower limb strength, endurance, range of motion, and bal-

ance. A 10-foot path is marked on the ﬂoor with tape. The subject is asked to

walk the 10-foot path, turn around, and walk back to the starting point as quickly

as possible. If the patient normally walks with a walker or cane, he/she may use it

during this test. The total walking distance is 20 feet.

The examiner begins timing the patient when he/she picks up the ﬁrst foot, and

stops timing when the last foot crosses the ﬁnish mark. This test is scored by the

total number of seconds it takes for the patient to walk 10 feet and back.

In addition, the examiner should indicate on the scoring sheet whether the patient

used a walker or cane. Scores greater than 9 seconds are associated with an

increased risk of at-fault motor vehicle tasks.

1. Freund, B., Gravenstein, S., & Ferris, R. Use of the Clock Drawing Test as a Screen for Driving Compe-

tency in Older Adults. Presented at the American Geriatrics Society Annual Meeting, Washington, DC;

May 9, 2002; and Personal correspondence with B. Freund dated September 16, 17 and 19, 2002.

2. Ibid.

3. Staplin, L., Lococo, K. H., Stewart, J., & Decina, L. E. (1999, April). Safe Mobility for Older People

Notebook. NHTSA Report No. DOT HS 808 853. Washington, DC: National Highway Trafc Safety

Administration.

4. Staplin, L., Gish, K. W., & Wagner, E. K. (2003). MaryPODS revisited: updated crash analysis and

implications for screening program implementation. J Safety Res. 34:389–397.

25Chapter 3—Assessing Functional Ability

(DHI).

Similar to the ADReS battery,

the program has not yet been validated

in a large cohort of older adult drivers,

but the subcomponents have been

found to correlate with at-fault crash

risk.

Furthermore, the DHI did appear

to discriminate drivers with a history of

a crash from those without crashes in a

small cohort of drivers. In addition, this

battery of tests appears feasible and

acceptable to older drivers as a screen

for functional impairments.

Additional cognitive domains that have

been linked with driving impairment

include vigilance or sustained attention.

Although many older drivers may make

only short trips, some illnesses such as

untreated obstructive sleep apnea cause

persistent sleepiness or impaired atten-

tion. This risk would be present in this

example regardless of the duration of

the driving episode. In addition, many

older adults travel long distances for

vacations and to visit relatives, making

the ability to sustain attention over

time critical.

Language skills are necessary to read

trafc signs and are critical in knowing

the speed limit, identifying construc-

tion zones, and comprehending other

important informational cues along the

roadway. Geographic orientation refers

to the skill of nding unfamiliar routes

(e.g., map reading or using MapQuest)

or knowing the way to familiar places.

This skill likely involves executive

function, short- and long-term memory,

and language abilities. Impairment in

these cognitive domains have not been

well studied in regard to driving out-

comes, but could play a role in accident

causation in selected groups of medically

impaired drivers.

71. DrivingHealth.com. DrivingHealth Inventory.

www.drivinghealth.com/screening.htm, Accessed

October 14, 2007.

72. Ball, K., Roenker, D.L., & Wadley, V.G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting? J Am

Geriatr Soc. 54:77–84.

73. Edwards J. D., Leonard K. M., & Lunsman M.,

et al. (2008). Acceptability and validity of

older driver screening with the DrivingHealth,

Inventory. Accid Anal Prev. 40: 1157–1163.

ADReS (continued)

Manual test of range of motion

The examiner tests the patient’s range of motion by asking him/her to perform the

requested motions bilaterally:

• Neck rotation: “Look over your shoulder like you’re backing up or parking. Now

do the same thing for the other side.”

• Shoulder and elbow ﬂexion: “Pretend you’re holding a steering wheel. Now pre-

tend to make a wide right turn, then a wide left turn.”

• Finger curl: “Make a ﬁst with both of your hands.”

• Ankle plantar ﬂexion: “Pretend you’re stepping on the gas pedal. Now do the

same for the other foot.”

• Ankle dorsiﬂexion: “Point your toes towards your body.”

The examiner scores the test by choosing the appropriate description of test

performance: (1) Within normal limits; or (2) not within normal limits: good range of

motion with excessive hesitation/pain or very limited range of motion.

Manual test of motor strength

The examiner tests the patient’s motor strength by manually ﬂexing/extending the

patient’s limbs, and asking him/her to resist the examiner’s movements. The exam-

iner should test bilateral:

• Shoulder adduction, abduction and ﬂexion;

• Wrist ﬂexion and extension;

• Hand-grip strength;

• Hip ﬂexion and extension; and

• Ankle dorsiﬂexion and plantar ﬂexion.

Motor strength should be recorded on a scale of 0 to 5, as stated below:

Grade Deﬁnition

5/5 Normal strength: movement against gravity with full resistance

4/5 Movement against gravity and some resistance

3/5 Movement against gravity only

2/5 Movement with gravity eliminated

1/5 Visible/palpable muscle contraction, but no movement

0/5 No contraction

Strength that is slightly less than grade 5/5 but still greater than 4/5 may

be recorded as 5

–

/5. Similarly, strength that is slightly greater than 4/5 but

still less than 5/5 may be recorded as 4

/5. This applies to all other grades

of strength as well.

1. Messinger-Rapport, B. J., & Rader E. (2000). High risk on the highway: how to identify and treat the

impaired older driver. Geriatrics. 55(10):32–45.

2. Maxwell, R. W. (1996). Maxwell Quick Medical Reference, 3rd ed. Tulsa, OK: Maxwell Publishing

Company, Inc.

26 Chapter 3—Assessing Functional Ability

ties, such as range of motion and muscle

function, with driving. Driving impair-

ment has been associated with the

inability to reach above the shoulder.

Older adults with physical frailty may

be at increased risk for a motor vehicle

crash,

80,81

and studies have indicated

they appear to be more vulnerable to

injury.

Walking less than one block a

day, impaired left knee exion, and foot

abnormalities have been associated with

an adverse driving event.

Another

study revealed that more difculty

walking one-quarter mile in comparison

to a control group was associated with

increase crash risk.

In ADReS, motor

function is measured through the Rapid

Pace Walk, Manual Test of Range of

Motion, and Manual Test of Motor

Strength measures.

79. Hu Hu, P. S., Trumble, D. A., & Foley, D. J., et

al. (1998). Crash risks of older drivers: a panel

data analysis Accid Anal Prev. 30:569–581.

80. Sims, R. V., McGwin, G., & Allman, R. M., et

al. (2000). Exploratory study of incident vehicle

crashes among older drivers. J Gerontol Series A

Bio Sci Med Sci. 55: M22–27.

81. Marottoli, R. A., Wagner, D. R., Cooney, L. M.,

& Tinetti, M. E. (1994). Predictors of crashes

and moving violations among elderly drivers.

Ann Intern Med; 121:842–846.

82. Kent, R., Funk, J., & Crandall, J. (2003). How

future trends in societal aging, air bag avail-

ability, seat belt use, and eet composition will

affect serious injury risk and occurrence in the

United States. Traff Inj Prev. 4: 24–32.

83. Marottoli, R. A., Wagner, D. R., Cooney, L. M.,

& Tinetti, M. E. (1994). Predictors of Crashes

and Moving Violations Among Elderly Drivers.

Annals of Internal Medicine, 121, 842–846.

84. Sims, R. V., McGwin, G., Pulley, L., et al.

(2001). Mobility Impairments in Crash

Involved Drivers. J Aging Health. 12:430.s.

Executive skills are required to analyze

driving-related stimuli and formulate

appropriate driving decisions. Executive

skills allow a driver to appropriately

make the decision to stop at a red light

or at a green light if a pedestrian is in

the path of the vehicle. The capacity

for this kind of logical analysis tends to

decline with age.

Dementia and some medications’ side

effects in the older population may

impact cognition. The fact that crashes

involving older drivers commonly occur

in complex situations in which task

demand exceeds performance suggests

that cognitive limitations may play a

signicant role in crash causation.

In the ADReS battery, cognition is

measured through the Trail-Making

Test, Part B, and the Clock Drawing

Test using Freund Scoring Criteria.

74. Beers M. H., & Berkow R. (eds). (2000). The

Merck Manual of Geriatrics. Section 4, Chapter

32: Aging and mental health. Whitehouse

Station, NJ: Merck & Co., Inc.

75. Lundberg C., Hakamies-Blomqvist L., Almkvist

O., & Johansson K. (1998). Impairments

of some cognitive functions are common in

crash-involved older drivers. Accid Anal Prev.

30(3):371–377.

Motor and Somatosensory Function

Driving is a physical activity that

requires motor and somatosensory

abilities such as:

• Muscle strength and endurance;

• Range of motion of the extremities,

trunk, and neck; and

• Proprioception.

Motor abilities are necessary for operat-

ing vehicle controls appropriately and

consistently and turning to view trafc.

Even before driving, motor abilities are

needed to enter the car safely and fasten

the seat belt. The natural process of

aging may involve a decline in muscle

strength, muscle endurance, exibility,

and joint stability. (Whether proprio-

ception changes appreciably with age

has not been solidly established.

)

Furthermore, osteoarthritis and other

musculoskeletal problems are common

in the elderly. Patients who suffer pain

and limitations from these conditions

may not only experience direct effects on

their driving ability, but also decrease

their physical activity, causing further

decline in motor function.

Most of the difculty in driving an

automobile for patients with muscle

or arthritic disorders involves difcul-

ties with the use of seat belts and keys,

adjusting seats and mirrors, using the

pedals, steering, and transferring in and

out of the car.

Several efforts have

been made to correlate functional abili-

76. Marottoli, R. A., & Drickamer M. A. (1993).

Psychomotor mobility and the elderly driver.

Clin Geriatr Med. 9(2):403–411.

77. Ibid.

78. Jones, J. G., McCann, J., & Lassere, M. N.

(1991). Driving and arthritis. Br J Rheumatol. 30

361–364.

27Chapter 3—Assessing Functional Ability

ADReS score sheet

When administering the ADReS

battery, you may nd it helpful to use

the ADReS Score Sheet which can be

found at the end of this chapter. This

form may be photocopied, lled out,

and placed in the patient’s chart. The

ADReS Score Sheet presents the tests in

the simplest order of administration and

provides space for recording test results.

We also recognize that these tests may

not necessarily be performed by the

physician but assigned to ofce staff

such as the nurse or physician extender.

CPT

codes for components of the

ADReS battery are provided in Appen-

dix A, and the ADReS Score Sheet can

serve as documentation for these codes.

Although you may administer the tests

in the order you prefer, we recommend

the following sequence:

• Visual Fields by Confrontation

Testing;

• Snellen E Chart—If your ofce has

a long hallway, hang the chart at the

end of the hallway and mark a 20-foot

distance on the oor with tape. Have

the patient stand at the tape.

• Rapid Pace Walk—Mark a 10-foot

distance on the oor. With the

patient already standing at the

20-foot mark, have him/her walk

to the 10-foot mark, then back.

• Manual Test of Range of Motion—

This is performed when the patient

has returned to the examination

room.

• Manual Test of Motor Strength;

• Clock Drawing Test—Ask the patient

to turn over the Trail Making Test

sheet and draw a clock on the

blank side.

• Trail Making Test, Part B.

A discussion of these tests’ efcacy,

scoring, and recommended interven-

tions based on performance is included

in the next chapter.

28 Chapter 3—Assessing Functional Ability

Assessing Driving Related Skills (ADReS) Score Sheet

Patient’s name: ______________________________________________________ Date: __________________________

1. Visual elds: Shade in any areas of decit.

2. Visual acuity: _________ OU __________ OS _________OU

Was the patient wearing corrective lenses? If yes, please specify: ______________________________________________

If either eye acuity worse than 20/40, consider referral to ophthalmologist.

3. Rapid pace walk: ____________ seconds

(>10 secs, abnormal and consider referral for driving evaluation and/or evaluation of gait disorder) Was this performed

with a walker or cane? If yes, please specify: ______________________________________________________________

4. Range of motion: Specify ‘Within Normal Limits’ or ‘Not WNL.’ If not WNL, describe.

Right Left

Neck rotation

Finger curl

Shoulder and elbow exion

Ankle plantar exion

Ankle dorsiexion

Plan for any deciencies (consider referral to OT/PT, address pain management, if indicated, and/or referral to driving

clinic for vehicle modication)

5. Motor strength: Provide a score on a scale of 0–5.

Right Left

Shoulder adduction

Shoulder abduction

Shoulder exion

Wrist exion

Wrist extension

Hand grip

Hip exion

Hip extension

Ankle dorsiexion

Ankle plantar exion

Plan for any deciencies: (consider referral to OT/PT or driving clinic for vehicle modication)

LPatient’s R

29Chapter 3—Assessing Functional Ability

ADReS Score Sheet (continued)

Patient’s name: ______________________________________________________ Date: __________________________

6. Trail-Making Test, Part B: ____ seconds

(score greater than 180 secs abnormal, consider referral to driving evaluation clinic and/or work-up for

cognitive/visual/motor impairment )

7. Clock drawing test: Please check ‘yes’ or ‘no’ to the following criteria

Yes No

Only the numbers 1-12 are included (no duplicates or omissions)

The numbers are drawn inside the clock circle

The numbers are spaced equally or nearly equally from each other

The numbers are spaced equally or nearly equally from the edge of the circle

One clock hand correctly points to 2

There are only two clock hands

There are no intrusive marks, writing or hands indicating incorrect time

(any abnormal elements consider referral to driving evaluation clinic and/or work-up for cognitive/visual/

motor impairment)

Assessment/Plan:

Trail-Making Test, Part B Patient’s name: _________________________ Date: __________________________

End

Begin

CHAPTER 4

Physician Interventions

33Chapter 4—Physician Interventions

Visual acuity

Although many States currently require

far visual acuity of 20/40 for an unre-

stricted license, there is a paucity of

evidence that links static visual acuity

to crash risk. In fact, studies undertaken

in some States have demonstrated that

there is no increased crash risk between

20/40 and 20/70, resulting in several

new State requirements.

However,

some studies have found that those

States that require visual testing during

license renewal for older adults have

lower crash rates.

89,

General recommendations on visual

acuity and driving are stated below.

Please note that these recommenda-

tions are subject to each State’s

licensing requirements.

For visual acuity greater than

20/40 (e.g., more impaired), the

physician should:

• Ensure that the underlying cause of

vision loss is adequately treated, if

treatment is possible. If the patient

is not currently under the care of an

ophthalmologist or optometrist,

referral is recommended.

• Recommend that the patient has and

uses the appropriate glasses or contact

lenses. Again, if the patient is not

currently under the care of a special-

ist, referral is recommended.

88. American Academy of Ophthalmology. Policy

Statement: Vision Requirements for Driving.

Approved by Board of Trustees, October 2001.

89. Levy, D. T. (1995). The relationship of age

and State license renewal policies to driving

licensure rates. Accid Anal Prev. 27(4):461–467.

90. Shipp, M. D. (1998). Potential human eco-

nomic cost-savings attributable to vision testing

policies for driver license renewal, 1989–1991.

Optom Vis Sci. 75:103–118.

On the ADReS battery, Mr. Phillips

takes 11 seconds to perform the

Rapid Pace Walk. His visual acu-

ity is 20/50 OD and 20/70 OS. His

motor strength is 4-/5 in both lower

extremities, and 4/5 in both upper

extremities. He has limited range

of motion on neck rotation; ankle

plantar exion and dorsiexion are

within normal limits. It takes him

182 seconds to complete the Trail-

Making Test, Part B, and his clock

drawing is scored as “normal” for

all seven criteria.

Now that Mr. Phillips has undergone

ADReS, what does his performance

indicate? In this chapter, we help you

interpret your patient’s test performance

by providing you with scoring cut-offs.

We have also provided examples of

interventions to help you manage and

treat any functional decits that are

identied through ADReS. Recently, the

ADReS battery has been shown to have

high levels of inter-rater reliability.

As you review the recommended in-

terventions, remember that the goal of

physician evaluation is to identify, cor-

rect, or stabilize any functional decits

that may impair the patient’s driving

performance and refer to a driver reha-

bilitation specialist (DRS), if appropri-

ate (for more details, see Chapter 5).

86. Please be aware that the recommendations

stated in this chapter are subject to your State’s

reporting laws and DMV requirements.

87. Posse, C., McCarthy, D. P., & Mann, W. C.

(2006). A pilot study of interrater reliability of

the assessment of driving-related skills: Older

Driver Screening Tool. Top Geriatr Rehab The

Older Driver, Part 2. 22: 113–120.

Despite your encouragement, Mr.

Phillips (introduced in Chapter 2)

hesitates to take the Assessment

of Driver Related Skills (ADReS)

battery because he says, “I don’t

see the need for it.” You reiterate

your concerns for his safety, and

give him a copy of the Am I a Safe

Driver? self-assessment handout to

take home. In addition, you counsel

Mr. Phillips on the Successful Aging

Tips and Tips for Safe Driving hand-

outs. Mr. Phillips agrees to allow

his son to observe his driving, and

you give the son the How to Assist

the Older Driver handout (see Ap-

pendices). You document all of this

in Mr. Phillips’ chart and schedule

a follow-up visit. Alternatively, the

Hartford guide “At the Crossroads”

has a driving behavior checklist that

could be lled out by family members

(p.11).

Although not systemati-

cally studied, this type of objective

evaluation could also be revealing.

At Mr. Phillips’ next visit, you ask

him if he has tried putting any of the

Tips for Safe Driving into practice.

He admits that he had another close

call, and his son states he observed

several driving errors. These moti-

vated Mr. Phillips to complete the

self-assessment. He claims that the

self-assessment was an eye-opening

experience, and he is now willing to

undergo ADReS.

85. The Hartford. Alzheimers, Dementia &

Driving. Hartford, CT. www.thehartford.com/

alzheimers/brochure.html. Accessed October

24, 2007.

CHAPTER 4

Physician Interventions

34 Chapter 4—Physician Interventions

• Recommend that the patient reduce

the impact of decreased visual acuity

by restricting travel to low risk areas

and conditions (e.g., familiar sur-

roundings, non-rush hour trafc,

low speed areas, daytime, and good

weather conditions).

• Be aware that the patient may require

more frequent (e.g., yearly) assessment

of visual acuity to detect further

visual decline caused by chronic,

progressive diseases.

For visual acuity less than

20/70 (e.g., more impaired),

the physician should:

• Follow the recommendations stated

above, and

• Recommend an on-road assessment

performed by a DRS to evaluate the

patient’s performance in the actual

driving task, where permitted and

available (see Chapter 5).

For visual acuity less than

20/100 (e.g., more impaired),

the physician should:

• Follow the recommendations stated

above, and

• Recommend that the patient not

drive unless safe driving ability can be

demonstrated in an on-road assess-

ment performed by a DRS, where

permitted and available.

Visual ﬁelds

Research shows that visual eld loss

can signicantly affect driving safety. In

examining 10,000 volunteer California

license applicants, Johnson and Keltner

found signicant deterioration in visual

elds among drivers over age 60. In

addition, they found that drivers with

binocular visual eld loss had driving

crash and conviction rates more than

twice as high as age- and gender-

matched drivers with normal elds.

Recently, studies focused on a more

homogenous group of older adults with

a specic disease (e.g., glaucoma) that

91. Johnson, C. A., & Keltner, J. L. (1983).

Incidence of visual eld loss in 20,000 eyes

and its relationship to driving performance.

Arch Ophthalmol. 101:371–375.

is known to impair visual elds have

found correlation with increased crash

risk in patients with moderate to severe

eld defects.

92, 93

While it is known that an adequate

visual eld is important for safe driv-

ing, there is no conclusive evidence

to dene what is meant by “adequate.”

Most likely, this varies widely from

patient to patient and may depend on

the presence of other co-morbidities.

For example, a driver with a restricted

visual eld but excellent scanning

ability may drive as safely as a driver

with an unrestricted visual eld but

poor neck rotation.

General recommendations on visual

eld and driving are stated below. Physi-

cians should be aware of their States’

specic visual eld requirements, if any,

and adhere to them.

For visual eld defects noted on

clinical examination, the physician

should:

• Ensure that the underlying cause of

visual eld loss is adequately treated,

if treatment is possible. If the patient

is not currently under the care of an

ophthalmologist or optometrist,

referral is recommended.

• Automated visual eld testing may

help dene the extent of the defect,

and ophthalmologists have a number

of useful instruments for measuring

visual elds.

• For binocular visual eld of question-

able adequacy (as deemed by clinical

judgment), an on-road assessment

performed by a DRS is strongly rec-

ommended. Through driving rehabili-

tation, the patient may learn how to

92. Szlyk, J. P., Mahler, C. L., Seiple, W., et al.

(2005). Driving performance of glaucoma

patients correlates with peripheral visual eld

loss. J Glaucoma. 14:145–150.

93. McGwin, G., Jr., Mays, A., Joiner, W., et al.

(2004). Is glaucoma associated with motor

vehicle collision involvement and driving

involvement and driving avoidance? Invest

Ophthalmol Vis Sci. 45: 3934–3939.

94. American Academy of Ophthalmology. Policy

Statement: Vision Requirements for Driving.

Approved by Board of Trustees, October 2001.

compensate for decreased visual elds.

In addition, the DRS may prescribe

enlarged side- and rear-view mirrors

as needed and train the patient in

their use.

• Be aware that the patient may require

re-testing of visual elds in the future

for visual eld defects caused by

chronic, progressive diseases.

Cognition

Although the following cognitive tests

are scored separately, interventions are

recommended if the patient reaches

designated cut-off values (as described

below) on either of them.

Trail-Making Test, Part B

A time for completion of greater than

3 minutes (180 seconds) signals a need

for intervention,

such as a review of

causes for the abnormal result (e.g.,

dementia, sedating medication) and/or

referral to a DRS.

Numerous studies have demonstrated

an association between performance on

the Trail-Making Test, Part B (TMT-B),

and cognitive function and/or driving

performance. In a study of 1,700 drivers

65 and older who were applying for

renewal of their North Carolina driver’s

license, TMT-B test results were strong-

ly associated with recent prior crash

involvement.

A study of 105 drivers

in Nebraska 65 to 88 years old showed

that on-road driving performance sig-

nicantly correlated to TMT-B perfor-

mance (correlation coefcient -0.42).

Most recently, data from the Maryland

95. Staplin, L., Lococo K.H., Gish K.W., &

Decina L.E. (2003). Model driver screening

and evaluation program & Maryland pilot older

driver study. NHTSA Report Number DOT HS

809 581. Washington, DC: National Highway

Trafc Safety Administration.

96. Stutts, J. C., Stewart, J. R., & Martell C.

(1998). Cognitive test performance and

crash risk in an older driver population.

Accid Anal Prev. 30(3):337–346.

97. Tarawneh, M. S., McCoy, P. T., Bishu, R. R.,

Ballard, J. L. (1993). Factors associated

with driving performance of older drivers.

Transportation Res Record. 1405:64–71.

35Chapter 4—Physician Interventions

Your patients may be unaware of the

potential effects of polypharmacy on

cognitive ability and driving.

• If possible, treat the underlying

disorder and/or adjust the medica-

tion regimen as needed. Remember,

it is critical that every patient have a

complete evaluation to identify the

underlying cause or causes and receive

proper treatment.

• Refer the patient to a neurologist,

psychiatrist, or neuropsychologist

for diagnosis or treatment as needed.

If the patient has a degenerative

dementia, such as Alzheimer’s disease,

begin treatment with appropriate

medications as indicated.

• Recommend an on-road assessment

performed by a DRS to assess the

patient’s performance in the actual

driving task. An initial comprehensive

on-road assessment with retesting at

regular intervals is particularly useful

for progressive dementing illnesses.

Strongly recommend that the patient

begin exploring alternative forms of

transportation now, and encourage

him/her to involve family members/

caregivers in these discussions.

It is again emphasized that these tests

should not be the sole determinant as

to whether an older adult should drive,

and this was the conclusion of a recent

review on this subject.

103

However,

impairments on these tests are associated

with increased risk, and referral for

further evaluation, such as performance-

based road testing, should be consid-

ered. In addition, it is unlikely that

future tness-to-drive evaluations will

rely on one test but likely will employ

a battery of tests.

104

If the patient’s performance

warrants interventions, the

physician should:

• Gather (or refer for) more informa-

tion to include detailed history

and examination of cognitive and

functional abilities, as needed;

• Identify or interview a reliable

informant (e.g., family member or

caregiver) who can assist with the

evaluation;

• Identify the cause of the

cognitive decline;

¤ Check for reversible causes

of cognitive decline;

105

¤ Screen for depression;

106

¤ Review the patient’s medication

regimen and the side effects of

the medications, and question the

patient about the onset of cognitive

decline in conjunction with new

medications or dosage changes.

103. Langford, J. (2008). Usefulness of off-road

screening tests to licensing authorities when

assessing older driver tness to drive. Trafc Inj

Prev. 9:328–335.

104. Stave, W. B., Justiss, M. D., McCarthy, D. P., et

al. (2008). Predictability of clinical assessments

for driving performance. J Safety Res. 39:1–7.

105. Based on history, examination, and cogni-

tive testing, order laboratory tests as needed

to evaluate for causes of cognitive decline:

CBC for anemia or infection; comprehensive

metabolic prole for electrolyte imbalance and

renal function; nger stick for blood sugar, pulse

oximetry for hypoxia, TSH for hypothyroidism;

liver function tests; vitamin B12 and folate

for vitamin deciency, and based on the prior

probability, noncontrast CT or MRI scan.

106. Knopman, D. S. (2001). Practice parameter: di-

agnosis of dementia (an evidence-based review).

Report of the Quality Standards Subcommittee

of the American Academy of Neurology.

Neurology. 56(9):1143–1153.

Pilot Older Driver Study

demonstrated

a signicant correlation between TMT-

B performance and future at-fault crash

in the license renewal sample.

Clock Drawing Test, Freund Clock

Scoring for Driving Competency

Any incorrect or missing element on

the Freund Clock Scoring Criteria

signals a need for intervention, such

as a review of causes for the abnormal

result (e.g., dementia) and/or referral

to a DRS.

Clock Drawing Tests (CDT) have been

found to correlate signicantly with

traditional cognitive measures, and to

discriminate healthy individuals from

those with dementia.

Of all the mea-

sures that have correlated with impaired

driving performance in older adults

with dementia, tests of visuospatial

skill ability have had the highest level

of prediction.

100

Several versions of the

CDT are available, each varying slightly

in the method of administration and

scoring.

101

The Freund Clock Scoring is

based on seven “principal components”

(as outlined on the ADReS Score

Sheet), which were derived by analyz-

ing the clock drawings of 88 drivers 65

and older against their performance on

a driving simulator.

102

Errors on these

principal components correlated signi-

cantly with specic hazardous driving

errors, signaling the need for formal

driving evaluation.

98. Ball, K. K., Roenker, D. L., Wadley, V. G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting?

J Am Geriatr Soc. 54:77–84.

99. Royall, D. R., Cordes, J. A., & Polk, M. J.

(1998). Clox: An executive clock drawing task.

J Neurol Neurosurg Psychiatry. 64:588–594.

100. Reger, M. A., Welsh, R. K., Watson, G. S., et al.

(2004). The relationship between neuropsy-

chological functioning and driving ability in

dementia: a meta-analysis. Neuropsychology.

18:85–93.

101. Royall, D. R., Mulroy, A R., Chiodo, L K.,

Polk, M J. (1999). Clock drawing is sensitive to

executive control: a comparison of six methods.

J Gerontol Psychol Sci. 54B(5):328–333.

102. Freund, B., Gravenstein, S., Ferris, R., et al.

(2005). Drawing clocks and driving cars. J Gen

Intern Med. 20:240–244.

36 Chapter 4—Physician Interventions

Motor ability

Although the following tests are scored

separately, interventions are recom-

mended if the patient reaches designated

cut-off values (as described below) on

any of the individual tests.

Rapid Pace Walk

A time for completion of greater than 9

seconds signals a need for intervention,

107

such as determination of the cause for

slowed gait speed (e.g., Parkinson’s dis-

ease) and/or referral to a DRS.

The Rapid Pace Walk assesses lower

limb mobility, trunk stability, and

balance. In a prospective cohort study

of 283 drivers 72 and older, subjects

who took longer than 7 seconds to

complete the test were twice as likely

to experience an adverse trafc event

(crash, violation, or being stopped by

the police) in the year following the

test.

108

More recently, data from the

Maryland Pilot Older Driver Study—a

study of almost 2,000 drivers over age

55 who were license renewal applicants-

-demonstrated a correlation between

performance on the Rapid Pace Walk

and future at-fault crash in the license

renewal sample (odds ratio 1.70).

109

Manual Test of Motor Strength

Less than grade 4/5 strength in either

upper extremity or the right lower ex-

tremity signals a need for intervention,

such as vehicle modication. (If the

patient drives a vehicle with manual

transmission or reports using both feet

to operate the brake and accelerator

pedals,

110

this applies to the left lower

extremity as well.)

107. Staplin, L., Gish, K. W., & Wagner, E. K.

(2003). MaryPODS revisited: updated crash

analysis and implications for screening program

implementation. J Safety Res. 34:389–397.

108. Marottoli, R. A., Cooney, L. M., Wagner, R.,

Doucette, J., & Tinetti, M. E. (1994). Predictors

of automobile crashes and moving viola-

tions among elderly drivers. Ann Intern Med.

121(11):842–846.

109. Ibid.

110. Although this is not considered the recom-

mended way of driving, many older drivers

initially learned to drive using both feet to

operate the pedals.

(Continues on next page)

Figure 4.1: Dementia and driving

We encourage all physicians to pursue a diagnosis of dementia. Dementia is one

of the most serious disorders in the older population, and affects 4 to 5 million

persons in the United States.

However, it is frequently unrecognized and undocu-

mented by primary care physicians

—a situation that is particularly unfortunate

since early treatment and planning may stabilize or slow the course of the disease,

improve the safety and comfort of the patient, and reduce caregiver stress.

With regard to driving, patients with progressive dementia ultimately become

unsafe to drive, yet often lack the cognitive abilities to be aware of their limitations.

When it becomes unsafe for these patients to drive, it frequently falls on family

members and caregivers to enforce driving cessation and arrange alternative

forms of transportation. With early diagnosis, patients and their families have

the opportunity to plan ahead for a smooth transition from driving to non-driving

status. Valuable information about an individual’s driving ability may come from

observations of informants. (For a more detailed discussion of driving cessation

and the dementia patient, see Chapter 6. Several recent reviews in the literature

on this topic also may be helpful to the clinician.

3, 4

)

Figure 4.2: The copilot phenomenon

Copiloting refers to a situation in which an individual drives with the assistance of a

passenger who provides navigational directions and instructions on how to drive.

Patients with dementia may rely on passengers to tell them where to drive and

how to respond to driving situations, while patients with vision deﬁcits may ask

passengers to alert them to trafﬁc signs and signals.

The use of copilots is not rare. In a study of the prevalence and cessation of driving

among older men with dementia, about 10 percent of the 59 subjects who were

still driving relied on copilots.

Patients should be advised to not continue driving

unless they are capable of driving safely without the use of a copilot. In many trafﬁc

situations, there is insufﬁcient time for the copilot to detect a hazard and alert the

driver, and for the driver to then respond quickly enough to avoid a crash. In such

situations, the driver places not only him/herself in danger, but also the copilot and

other passengers. Furthermore, the use of copilots to meet standards for licen-

sure raises questions of who, exactly, is licensed to drive; how the presence of the

copilot can be ensured; and what standards for medical ﬁtness-to-drive should be

applied to the copilot.

Patients who are not safe to drive should be recommended to stop driving, regard-

less of their need or use of a copilot. Copilots should never be recommended to

unsafe drivers as a means to continue driving. Instead, efforts should focus on

helping the patient ﬁnd safe transportation for him/herself and the family members

who may depend on them. Conversely, some safe drivers feel more comfortable

driving with a passenger to give them company and help with navigation. While

using a passenger to assist as a copilot with navigation is an acceptable practice,

use of a copilot to provide instruction on how to drive is not recommended.

As long as these drivers have the ability to drive safely on their own, passenger

assistance is an acceptable and advisable practice.

1. Beers, M.H., &Berkow, R. (2000). The Merck Manual of Geriatrics. Section 5, Chapter 40. Whitehouse

Station, NJ: Merck & Co., Inc.

2. Valcour, C. G., Masaki, K. H., Curb, J. D., & Blanchette, P. L. The detection of dementia in the primary

care setting. Arch Intern Med. 160:2964–2968.

3. Brown, L. B., & Ott, B. R. (2004). Driving and dementia: a review of the literature. J Geriatr Psychiatry

Neurol. 17:232–240.

4. Carr, D. B., Duchek, J. M., Meuser, T. M., et al. (2006). Older adult drivers with cognitive impairment.

Am Fam Physician. 73:1029–1034.

5. Foley, D. J., Masaki, K. H., Ross G. W., &Whwite L. R. (2000). Driving cessation in older men with

dementia. J Am Geriatr Soc. 48(8):928–930.

6. Fox, G. F., & Bashford, G. M. (1997). Dementia and driving: balancing

personal independence and public safety. Med J Australia. 167:406–407.

37Chapter 4—Physician Interventions

The manual test of motor strength

evaluates separate muscle groups in

both the upper and lower limbs. The

U.S. Public Health Service guidelines

on musculoskeletal ability and driving

state that a driver should have at least

grade 4/5 strength in the right lower

extremity and both upper extremities.

111

The physician should also be aware

that the amount of strength required for

safe driving may depend on the vehicle

driven by the patient. For example, a

patient who drives an older car that

does not have power steering or oper-

ates a large vehicle (e.g., a school bus,

which is not uncommon for retirees)

may require greater strength to safely

drive the vehicle.

Manual Test of Range of Motion

If the patient’s range of motion is not

within normal limits (i.e., if the patient

has a good range of motion with exces-

sive hesitation/pain or a very limited

range of motion), this signals the need

for intervention. Recently, the inability

to recognize an object that is presented

directly behind a patient (e.g., intact

cervical range of motion) was correlated

with increased risk of a motor vehicle

crash.

112

Scoring for range of motion is based on

simple dichotomous outcomes (normal

vs. impaired), and this is due to several

reasons: (1) Physicians are not usually

trained in use of goniometers nor have

the devices in the ofce setting; (2)

range of motion requirements vary with

automobile design, and thus it is dif-

cult to specify exact requirements;

(3) as discussed in the visual elds

section, the impact of limited range of

motion on driving safety also depends

on other functions; and (4) as with all

the other tests in the ADReS battery,

a patient’s poor performance should be

a stimulus for optimization of func-

111. Marottoli, R. A., & Drickamer, M. A. (1993).

Psychomotor mobility and the elderly driver.

Clin Geriatr Med. 9(2):403–411.

112. Ball, K. K., Roenker, D. L., Wadley, V. G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting? J Am

Geriatr Soc. 54:77–84.

tion, rather than for immediate driving

restrictions.

If the patient’s performance on this

test is not within normal limits, the

physician should be certain to elicit

the reason: Do these movements cause

muscle or joint pain? Does the patient

complain of tight muscles or stiff joints?

Do these movements cause a loss of

balance? Patients with a history of falls

have been noted to be at increased risk

of motor vehicle crashes.

113

Knowing

the answers to these questions will help

in the management of the patient’s

physical limitations.

If the patient’s performance war-

rants interventions, the physician

should:

• Encourage the patient to drive a

vehicle with power steering and

automatic transmission, if he/she

does not already do so.

• Recommend that the patient

maintain or commence a consistent

regimen of physical activity, including

cardiovascular exercise, strengthening

exercises, and stretching. (Successful

Aging Tips, in Appendix B, suggests

some exercises.)

• Refer the patient to a physical

therapist or occupational therapist

as needed for training and exercises

to improve strength and/or range of

motion.

• Provide effective pain control if the

patient’s range of motion and mobil-

ity are limited by pain. This may

include prescribing analgesics or med-

ications that treat the underlying dis-

order (e.g., a urate-lowering drug for

gout), or changing when the patient

takes pain medications so that relief is

achieved prior to driving. Please note

that many analgesics (including nar-

cotics and skeletal muscle relaxants)

have the potential to impair driving

ability, and may be more deleteri-

ous to driving performance than the

instigating pain. These medications

113. Margolis, K. L., Kerani, R. P., McGovern, P., et

al. (2002). Risk factors for motor vehicle crashes

in older women. J Gerontol Series A-Bio Sci Med

Sci. 57:M186–191.

should be avoided, if possible, or

prescribed in the lowest effective dose

possible. Patients should be advised to

refrain from driving when rst taking

these medications until they know

whether they are tolerated.

• Refer the patient to a specialist for

management of any joint disease,

podiatry issues, or neuromuscular

problems. Post-stroke patients with

residual decits that interfere with

the patient’s handling of car controls

should also be referred.

• Recommend an on-road assessment,

performed by a DRS, to assess the

patient’s performance in the actual

driving task. A comprehensive on-

road assessment is particularly useful

for assessing the impact of physical

fatigue on the patient’s driving skills.

• The DRS may prescribe adaptive de-

vices as needed (e.g., a spinner knob

on the steering wheel to compensate

for poor hand grip or an extended

gear shift lever to compensate for

reduced reach), and train the patient

in their use.

What do you do next?

After administering ADReS, you can

follow one of three courses of action.

(See also the Physician’s Plan for Older

Drivers’ Safety, Figure 1, Chapter 1.)

If the patient performs well on all three

sections of the ADReS battery, you may

advise him/her that there are no medical

contraindication to safe driving and no

need for further work-up or treatment.

Counsel the patient on health mainte-

nance by providing the Successful Aging

Tips and Tips for Safe Driving handouts,

and periodically follow-up on the

patient’s driving safety. However, if

there is evidence of a new onset of

impaired driving behaviors (e.g., a

decline from baseline) as described by

the patient and/or family, further

evaluation may be warranted despite

a normal score.

If the patient performs poorly on any

section of ADReS, but the causes of

poor performance are medically correct-

able, pursue medical treatment until the

38 Chapter 4—Physician Interventions

patient’s function has improved to the

fullest extent possible. The patient may

need to be counseled to limit driving as

treatment proceeds. Assess the patient’s

level of improvement with repeat

administration of ADReS. If the patient

now performs well on all three sections

of the ADReS battery, counsel him/her

on health maintenance as above.

If the patient’s poor performance on the

ADReS battery cannot be medically

corrected, or if the patient’s function

shows no further potential for improve-

ment with medical interventions, refer

him/her to a DRS.

The ADReS battery is useful as an

in-ofce assessment, but it does not

evaluate the patient’s performance in

the actual driving task, and the results

even if abnormal are not sufcient to

recommend driving cessation. For this,

an on-road assessment performed by

a DRS is needed. The DRS can more

specically determine the patient’s

level of driving safety and correct his/

her functional impairments, if possible,

through adaptive techniques or devices.

The role of the DRS is discussed in the

next chapter.

CHAPTER 5

The Driver

Rehabilitation Specialist

41Chapter 5—The Driver Rehabilitation Specialist

tion Specialists (ADED)

115

fullling education and experience

qualications

116

and passing a certica-

tion examination.

117

Certied driver

rehabilitation specialists (CDRSs)

renew their certication every three

years by fullling a minimum amount

of contact hours. While many DRSs

either hold certication or are in the

process of obtaining the necessary

education and experience to sit for

the examination, certication is not

required to practice driver rehabilita-

tion nor for ADED membership.

115. The acronym ADED was retained when the

association changed its name from the Associa-

tion of Driver Educators for the Disabled to its

current name.

116. Candidates must fulll one of the following

requirements: A. An undergraduate degree or

higher in a health-related area of study with

one year full time experience in degree area

of study and an additional one year full time

experience in the eld of Driver Rehabilitation;

B. Four year undergraduate degree or higher

with a major or minor in Trafc Safety and/or a

Driver and Trafc Safety Endorsement with one

year full time experience in Trafc Safety and

an additional two years of full time experience

in the eld of Driver Rehabilitation; C. Two

year degree in health-related area of study with

one year experience in degree area of study and

an additional three years full time experience

in the eld of Driver Rehabilitation; D. Five

years of full time work experience in the eld

of Driver Rehabilitation. Association of Driver

Rehabilitation Specialists: Driver Rehabilitation

Specialist Certication Exam fact sheet (www.

driver-ed.org/public/articles/index.cfm?Cat=10).

117. Examination content includes (1) program

administration, (2) the pre-driving assessment,

(3) the in-vehicle assessment, (4) the on-road

evaluation, (5) interpretation of assessment

results, and (6) planning and implementation

of recommendations. Association of Driver

Rehabilitation Specialists: Driver Rehabilitation

Specialist Certication Exam fact sheet

(www.driver-ed.org/public/articles/index.cfm?Cat=10).

Despite your medical interventions,

your patients will sometimes continue

to demonstrate functional impairments

that may impair their driving perfor-

mance. In these cases, a DRS is an

excellent resource. A DRS can perform

a more in-depth functional assessment

and evaluate performance with an ac-

tual driving task. Based on the patient’s

performance, the DRS can recommend

that he/she continue driving with or

without further restrictions or interven-

tions, recommend adaptive techniques

and devices to overcome functional

decits, or recommend that the

patient cease driving and offer

mobility counseling.

This chapter provides you with

information you should have when

you refer your patient to a DRS.

What is a driver rehabilitation

specialist?

A DRS is one who “plans, develops,

coordinates and implements driving ser-

vices for individuals with disabilities.”

114

DRSs are often occupational therapists

who undergo additional training in

driver rehabilitation. Aside from occu-

pational therapy, DRSs also come from

backgrounds such as physical therapy,

kinesiotherapy, psychology, and driver

education.

Many DRSs receive certication from

the Association for Driver Rehabilita-

114. Association of Driver Rehabilitation Specialists:

Driver Rehabilitation Specialist Certication

Exam fact sheet (www.driver-d.org/public/articles/

index.cfm?Cat=10).

After scoring Mr. Phillips’ (introduced

in previous chapters) performance

on the ADReS battery, you discuss

the results with him. You assure him

that he scored well on the cognitive

tests, but that his performance on

the visual and motor tasks indicates

a need for further evaluation and

treatment.

You recommend that Mr. Phillips

make an appointment with his oph-

thalmologist, whom he has not seen

for over a year. You also recommend

that he begin exercising regularly

by walking for 10-minute intervals,

three times a day, and stretching

gently afterwards. His son, who is

present at the clinic visit, offers to

exercise with him several times a

week. You schedule Mr. Phillips to

return to your clinic in one month.

When Mr. Phillips arrives for his

follow-up appointment, he is wear-

ing new glasses. His vision with the

new glasses is 20/40 OU. You retest

his motor skills, and he is now able

to complete the Rapid Pace Walk

in 8.0 seconds. His lower extremity

strength has improved to 4+/5, but

his range of motion on nger curl

and neck rotation remain restricted.

With Mr. Phillips’ agreement, you

refer him to a driver rehabilitation

specialist (DRS) for an evaluation

and adaptive equipment, if necessary.

CHAPTER 5

The Driver

Rehabilitation Specialist

42 Chapter 5—The Driver Rehabilitation Specialist

assessment if they meet the minimum

state standards for health and vision,

and the client holds a valid driver’s

license or permit. The on-road assess-

ment is performed in a driver rehabilita-

tion vehicle equipped with dual brakes,

a rear-view mirror and eye-check mirror

for the DRS, and any necessary adaptive

equipment.

Please note that clients who perform

poorly on the clinical assessment may

still undergo on-road assessment. In

these cases, the DRS may recommend

on-road assessment for one of two

reasons: (1) clients who perform poorly

on individual components of the clini-

cal assessment may still demonstrate

safe driving due to over-learning the

driving task; and (2) clients and family

members may need concrete evidence

of unsafe driving, which can only be

documented through observation of

behind-the-wheel performance.

Who can driver rehabilitation

specialists help?

Driver assessment and rehabilitation

are appropriate for a broad spectrum of

visual, physical, and/or cognitive dis-

abilities. DRSs work with clients who

have dementia, stroke, arthritis, low

vision, learning disabilities, limb ampu-

tations, neuromuscular disorders, spinal

cord injuries, mental health problems,

cardiovascular diseases, and other causes

of functional decits.

Vehicle modication can be as straight-

forward as providing extended gear shift

levers, padded steering wheels, or extra/

larger mirrors to patients with arthritis,

and training the client in their use.

It can also be as complex as working

with a client with dementia and his/her

caregivers to determine the individual’s

driving needs, plan driving routes for

the client (e.g., avoiding left hand turns

or busy intersections), supervise practice

drives, and provide close and extended

follow-up.

and the potential for improvement

with retraining is poor. In these

cases, alternative transportation op-

tions are reviewed with the client.

¤ Re-evaluation. This option is

indicated if a client’s function is

expected to improve, or if a client

demonstrates adequate skills to

drive at present but has a progres-

sive disorder that may cause future

decline.

Passenger Vehicle Evaluation

• Assessment of vehicle, vehicle

modications, and equipment needed

for the client’s safe transport as a

passenger.

• Consideration of the needs of the

patient’s family (for example, certain

lifts or tie-down systems may be

recommended due to an assisting

family member’s physical limitations).

Treatment and Intervention

• Adaptive driving instruction or driver

retraining, with or without vehicle

modications.

• Coordination of vehicle modications:

¤ Vehicle consultation: The DRS

serves as a consultant to clients

who are purchasing a new vehicle

to ensure that the vehicle will ac-

commodate the necessary adaptive

equipment.

¤ Vehicle modication recommenda-

tions: The DRS provides written

recommendations for all vehicle/

equipment needs to the client,

third party payer, and vehicle/

equipment dealer.

¤ Vehicle inspection: The DRS is

involved with the client and adap-

tive equipment dealer in a nal

tting to ensure optimal function-

ing of the recommended vehicle/

equipment.

An initial driver evaluation can last

one to four hours, depending on the

client’s presenting disabilities and

driving needs. Following the clinical

assessment, clients undergo an on-road

What do driver rehabilitation

specialists do?

A DRS evaluates the client’s driving

skills, recommends rehabilitation as

needed, and can suggest vehicle and/or

route modications (e.g., such as avoid-

ing left hand turns) to enable the per-

son to resume or continue driving safely.

Although driver rehabilitation programs

vary, most typically include the follow-

ing elements in their evaluation:

Driver Evaluation

• Clinical assessment, including review

of driving history, driving needs, and

license status; review of medical his-

tory and medications; visual/percep-

tual assessment; assessment of range

of motion, motor strength, coordina-

tion, sensation, and reaction time;

and cognitive assessment.

• Functional (on-road) assessment, in-

cluding assessment of vehicle ingress/

egress, mobility aid management (e.g.,

ability to transport a wheelchair or

scooter), vehicle preparation, vehicle

control, adherence to trafc rules and

regulations, environmental awareness

and interpretation, and consistent use

of compensatory strategies for visual,

cognitive, physical, and behavioral

impairments.

• Communication of assessment results

and recommendations to the client:

¤ Return to driving, with or without

adaptive driving equipment.

¤ Limit driving with restrictions

placed on either the geographic

areas or conditions in which the

client drives.

¤ Attend a remedial driving course to

establish/maintain defensive driv-

ing skills.

¤ Receive adaptive driving instruc-

tion or driver retraining using a

vehicle matched to the client’s

individual needs.

¤ Stop driving. This is advised when

a client does not demonstrate the

necessary skills to resume driving,

43Chapter 5—The Driver Rehabilitation Specialist

• How many years of experience does

the DRS (or program) have? In many

cases, experience may be a more

important indicator of quality than

certication alone—there are many

well-qualied DRSs who are not

certied.

• Does the DRS provide both the

clinical assessment and on-road as-

sessment? A DRS who provides both

components of the evaluation (or a

program whose specialists perform

both components as a team) is ideal.

Referral to two separate specialists

or centers is inconvenient for the

physician and the patient, and often

presents a greater insurance reim-

bursement challenge. In addition,

some programs utilize a driving simu-

lator program, which has strengths of

reliability, but weaknesses of validity,

lack of standardization, paucity of

evidence that correlates it with other

important outcomes, and possibly

sickness induced by the simulator.

• Does the DRS provide rehabilitation

and training? A good DRS (or pro-

gram) should be experienced in both

assessment and rehabilitation, and

should be able to prescribe adaptive

devices or vehicle modications and

train the patient in their use.

• How much can the patient expect to

pay out-of-pocket for assessment, re-

habilitation and adaptive equipment?

• Who will receive a report of the

assessment outcome? In most cases,

reports are sent to the patient and to

the physician and/or referring agency

(e.g., workers compensation or ofce

of retirement services) Some DRSs

also send reports to family members,

at the request of the family and with

the client’s consent. Whether or not

the DRS reports to the State DMV

is highly variable: In States with

mandatory reporting laws, the DRS

and/or physician may send a report; if

reporting is not legally required, some

DRSs will still send a report in the

interest of public safety. The policy of

the DRS should be discussed with all

parties prior to the evaluation.

• If the patient receives recommenda-

tions to cease driving, does the DRS

procedures (e.g., patient pays up-front

and is reimbursed when insurance pay-

ments are received, or payment is col-

lected directly from insurance provider).

Where can I ﬁnd a driver

rehabilitation specialist?

Driver rehabilitation programs and

DRSs are still fairly rare, but in private

practice they are often afliated with

hospitals, rehabilitation centers, driving

schools, and State departments of mo-

tor vehicles. DRS services may also be

found through area agencies on aging,

universities, and area departments of

education. Before referring patients to

driving schools for driver assessment

and rehabilitation, physicians are urged

to determine that the staff has training

and experience in driver rehabilitation.

A background in driver education

alone may be insufcient for appropriate

assessment of medically impaired drivers

and correct interpretation of

the assessment.

To locate a DRS in your area, you

may wish to start by calling the occupa-

tional therapy departments in your

local hospitals or rehabilitation centers.

The ADED’s online directory is another

good source of information. The direc-

tory, which can be found by clicking the

Directory button at www.driver-ed.org or

www.ADED.net, lists all 553 ADED

members (as of December 2006),

including 251 certied DRSs. You can

search the directory by State, county,

type of facility, program services offered,

and professional background of the

DRS, as well as by name of the DRS

or name of the driver rehabilitation

program. Please note that not all ADED

members provide direct assessment

and rehabilitation services; some are

involved solely in vehicle modication,

as indicated in their “program services”

eld. Many local chapters of the

Alzheimer’s Association (www.alz.org)

also provide lists of area driving

evaluation programs.

When selecting a DRS or driver

rehabilitation program, the patient

and family may want to ask:

What is the cost of driver

assessment and rehabilitation?

While the cost of driver assessment and

rehabilitation varies between programs

and according to the extent of services

provided, the range is typically $300

to $400+ (as of this printing) for a

full assessment and $100 an hour for

rehabilitation. If adaptive equipment

is required, the cost is approximately

$70 to $100 for a spinner knob, $400 to

$500 for a left foot accelerator, $700 to

$900 for hand controls, and thousands

of dollars for reduced-effort steering sys-

tems, wheelchair lifts, and raised roofs

and dropped oors on vans.

Two programs that may pay for driver

assessments, driver rehabilitation, and

vehicle modications are each State’s

workers compensation and vocational

rehabilitation programs. However,

not all drivers—and often many older

drivers—will not qualify for either

program, and insurance coverage from

Medicare, Medicaid, and private insur-

ance companies is variable. To date,

these expenses are usually out of pocket.

In general, Medicare does not reimburse

for driving services, and private insur-

ance companies—basing their coverage

on Medicare’s covered services—tend

to follow suit. However, some driver

rehabilitation programs have success-

fully pursued insurance reimbursement

from Medicare and other providers.

(Note that while Medicare may provide

partial or full reimbursement for driver

assessment and rehabilitation, it does

not cover the cost of adaptive equip-

ment.) At present, the American

Occupational Therapy Association

(AOTA) is actively lobbying for consis-

tent Medicare coverage of occupational

therapy-performed driver assessment

and rehabilitation, with the assertions

that these services fall under the scope

of occupational therapy practice and

that driving is considered an instrumen-

tal activity of daily living.

Because rates and extent of insurance

reimbursement vary among driver

rehabilitation programs, patients should

be encouraged to inquire about program

rates, insurance coverage, and payment

44 Chapter 5—The Driver Rehabilitation Specialist

Remind your patient to schedule a

follow-up appointment with you after

he/she undergoes evaluation. If your

patient is safe to drive (with or without

restrictions, adaptive devices, and/or

rehabilitation), reinforce any recom-

mendations made by the DRS. When

applicable, family and caregivers should

be informed of these recommendations.

Also remember to counsel your patient

on the Successful Aging Tips and Safe

Driving Tips handouts, and encourage

him/her to start planning alternative

forms of transportation in case they

ever become necessary. If your patient

is not safe to drive, then you will

need to counsel him/her on driving

cessation. This is discussed in the

following chapter.

Special mention is made of other reha-

bilitation specialists who may be helpful

for impairments that are not uncommon

in older adults. For instance, physical

therapists may be able to improve muscle

weakness, range of motion or physi-

cal frailty. Visual rehabilitation may be

available in some specialized centers.

Neurophthalmologists or optometrists

may provide vision training, especially

for patients with neurological insults that

affect convergence, alignment, nystagmus,

eye apraxia, and/or visual neglect from

stroke, head injury, brain tumors,

and trauma.

What if driver assessment is

not an option?

Unfortunately, driver assessment and

rehabilitation may not always be feasible

options for your patients. In some areas,

DRSs simply are not available. Even if

a DRS is available, your patient may

refuse further assessment, or may

be unable to afford it.

• If driver assessment through a driver

rehabilitation specialist is not an

option, you have several choices:

• Some occupational therapists are

“generalists” and still may be able to

perform off-road tests and/or mobility

counseling. Referral to these types

of health professionals may actually

be a more common option in your

community.

send you to someone who can assist us with

your driving abilities. Consider this a kind

of ‘driving check-up,’ to be sure you are t

to drive.

“This person, who’s called a driver

rehabilitation specialist, will ask you some

questions about your medical history and

test your vision, strength, range of motion,

and thinking skills—similar to what we did

the last time you were here. He/she will

also take you out on the road and watch

your driving, and might recommend some

accessories or modications for your car,

such as extra mirrors, and show you how

to use them.

“The cost of these assessments ranges any-

where from $300 to $400, and there may

be additional costs for accessories or reha-

bilitation training. However, it is possible

insurance may pay for part of the assess-

ment and training. I know this sounds like

a lot of money, but I think this is important

for your safety. If you were to ever get into

a serious car crash, your medical bills or

the costs for someone you injured could end

up costing you more money. We should try

to prevent that from happening.”

Most programs will require a written

physician prescription. When writing

the driving evaluation prescription, try

to list a specic cause for assessment

and rehabilitation. Assessment that is

ordered the patient is “an older adult,”

“debilitated,” or “frail” does not provide

adequate guidance to the DRS and can

complicate insurance reimbursement.

On the other hand, “OT driver evalu-

ation for hand weakness such as poor

nger exion or limited neck rotation

secondary to arthritis,” “DRS evaluation

for hemianopia secondary to stroke,”

and “DRS evaluation for cognitive

impairments secondary to Alzheimer’s

disease” provide more guidance for

the DRS and are more likely to be

reimbursed by insurance. In addition,

most DRS programs will send the

physician a referral form that includes

space for a list of current diagnoses

and medications.

provide any counseling or aid in iden-

tifying alternative forms of transpor-

tation? Please note that DRS counsel-

ing does not preclude the need for

physician follow-up. Many times, the

patient may be too distressed at the

time of DRS counseling to absorb

information. Mobility counseling is

crucial for reinforcement of this in-

formation, and it demonstrates to the

patient the physician’s involvement

and support.

CarFit is an educational program created

by the American Society on Aging and

developed in collaboration with AAA

(American Automobile Association),

AARP, and the American Occupational

Therapy Association. CarFit offers older

adults the opportunity to check out how

well their personal vehicles “t” them.

An evaluation, typically performed by

an occupational therapist or a trained

volunteer, employs a checklist for correct

positioning of the seat, use of mirrors,

and so forth. Information and materials

for community-specic resources and ac-

tivities that could make drivers personal

vehicles t better, enhance their safety as

drivers, or increase their mobility in the

community are available. More informa-

tion on referring your patients to this

service can be found at www.car-t.org.

Making the referral

Prior to making the referral, let your pa-

tient know why he/she is being referred,

what the assessment and rehabilitation

will accomplish, what these will consist

of, and how much he/she can expect to

pay out-of-pocket for these services.

For example, you could tell

Mr. Phillips:

“Mr. Phillips, I’m pleased that you can see

better with your new glasses, and that your

physical tness has improved with your

walking. I’d like you to keep up the good

work. However, I’m still concerned about

your hands and your neck. I’m concerned

about your poor grip on the steering wheel,

and I’m worried that you can’t see around

you well enough to drive safely. I’d like to

45Chapter 5—The Driver Rehabilitation Specialist

• If there are changes in driving behav-

ior that you feel are likely to improve

your patient’s driving safety (e.g.,

avoiding driving at night, rush hour,

adverse weather conditions, etc.),

make these recommendations to your

patient and follow up for compliance.

• Private driving schools and driving

education programs may be available

in your area; however, they may not

have expertise in assessing older

adults with medical impairments.

• If you are urgently concerned about

your patient’s driving safety, you may

wish to refer your patient to your

state DMV for a driving assessment.

Depending on your state’s reporting

laws, you may be legally responsible

for reporting “unsafe” drivers to the

DMV. (A detailed discussion of the

physician’s legal and ethical respon-

sibilities can be found in Chapter 7;

a reference list of reporting laws is in

Chapter 8.) The patient should be

• Driving educational specialists are

often based at high schools or afli-

ated with programs for novice drivers.

Yet, some of these specialists have

developed experience in assessing

and counseling medically impaired

drivers and may be a resource in your

community.

• Advise your patient to continue,

restrict, or cease driving based on

the medical history, the results of

ADReS, and your clinical judgment.

As always, document your recommen-

dation in the patient’s chart. Some

physicians have the patient sign a

document for the le acknowledging

the doctor’s recommendation to

cease driving.

• You might consider the evaluation

of another health professional

such as a geriatrician, neurologist,

psychiatrist, or neuropsychologist

for a patient who has a chronic

disease such as Alzheimer’s.

referred with his/her knowledge, and

this should be documented in the

chart. Many States will require the

physician to ll out forms that require

medical information and vision test-

ing results, and provide an opinion

on whether the driver should undergo

visual and/or on-the-road testing.

• If there are no medical contraindica-

tions to continued driving, remember

to counsel your patient on Successful

Aging Tips and Safe Driving Tips and

encourage him/her to start planning

alternative forms of transportation.

46 Chapter 5—The Driver Rehabilitation Specialist

CHAPTER 6

Counseling the Patient

Who is no Longer Safe

to Drive

For various reasons, physicians may be

reluctant to discuss driving cessation

with their patients. Physicians may fear

delivering bad news or be concerned

that the patient will lose mobility and

all its benets. Physicians may avoid

discussions of driving altogether because

they believe that a patient will not

heed their advice or become angry. The

physician may also be concerned about

losing a patient to another practice.

These concerns are all valid. However,

physicians have an ethical responsi-

bility to protect their patients’ safety

through assessment of driving-related

functions, exploration of medical and

rehabilitation options to improve their

patients’ driving safety, and—when all

other options have been exhausted—

recommendations for driving restriction

or driving cessation. Physicians are

inuential in a patient’s decision to stop

driving; in fact, advice from a doctor is

the most frequently cited reason that a

patient stops driving.

118

In this chapter, we discuss the key

points to address when counseling a

patient to stop driving and provide

strategies for managing challenging

cases. When counseling a patient to

stop driving, the following steps may

be useful:

118. Persson, D. (1993). The elderly driver: deciding

when to stop. Gerontologist. 33:88–91.

and the senior citizen shuttle in his

community will be adequate for his

transportation needs, and he plans

to give his car to his granddaughter.

Your next patient is Mrs. Allen an

82-year-old woman who is ac-

companied by her daughter. The

daughter reports that her mother,

who lives alone, has become increas-

ing forgetful, repeats herself within

minutes, and has difculty dressing

herself, performing personal hygiene

tasks, and completing household

chores. She is particularly concerned

about her mother’s daily trips to

the grocery store two miles away.

Mrs. Allen has become lost while

on these trips and—according to the

store manager—has handled money

incorrectly. Dents and scratches

have appeared on the car without

explanation. Mrs. Allen’s daughter

has asked her mother to stop driving

and tried to take the car keys, but

Mrs. Allen responds with anger and

resistance each time. The daughter

would like to know how to manage

her mother’s long-term safety and

health, and would especially like to

know how to address the driving

issue. What do you tell her?

For most of us, driving is a symbol of

independence and a source of self-es-

teem. When an individual retires from

driving, he/she not only loses a form of

transportation, but all the emotional

and social benets derived from driving.

Mr. Phillips returns for follow-up

after undergoing driver assessment.

From the driver rehabilitation spe-

cialist (DRS) report, you know that

the DRS recommends that Mr. Phil-

lips resume driving after his car has

been tted with wide-angle rear-view

mirrors. At the visit, Mr. Phillips

states that he is driving more com-

fortably with this adaptive device.

You counsel him on the Tips for Safe

Driving and Successful Aging Tips,

advise him to continue walking, and

encourage him to start planning

alternate transportation options. His

daughter is recruited to assist with

these discussions and interventions.

You continue to provide care for Mr.

Phillips’ chronic conditions and fol-

low up on his driving safety. Three

years later, Mr. Phillips’ has a right

middle cerebral artery stroke and

decits of left-sided weakness and

hemispatial inattention. His health

has declined to the extent that you

believe it is no longer safe for him

to drive. You also feel that due to

the xed nature of his decits (more

than six months since the event)

driver rehabilitation is unlikely to

improve his driving safety. Mr. Phil-

lips has decreased his driving over

the years, and you now tell him that

it is time to stop driving completely.

Mr. Phillips replies, “We’ve talked

about this before, and I gured it

was coming sooner or later.” He feels

that rides from family and friends

CHAPTER 6

Counseling the Patient

Who is no Longer Safe

to Drive

50 Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

long explanations. Rather, you should

focus on making certain your patient

understands your recommendation and

understands that this recommenda-

tion was made for his/her safety. If the

patient is competent but will allow the

presence of a spouse or family member,

having this person present may be help-

ful when communicating this sensitive

information. All discussions should be

documented in the chart.

Discuss transportation

options.

Once you have recommended that

your patient stop driving, you need to

explore possible transportation alterna-

tives. Unfortunately, driving cessation

has been associated with a decrease

in social integration.

119

Discuss with

your patient the fact that there may be

alternative ways to reach destinations.

Encourage your patient to take control

of his/her future by creating a transpor-

tation plan. (Please note: If your patient

does not have the cognitive capabili-

ties for these tasks, see the section on

patients who lack decision-making

capacity later in this chapter.)

Give your patient resources to explore

options (see Appendix B handout

sheets). By providing this information,

you empower your patient to formu-

late a personal plan for transportation.

Special mention is made of The Hart-

ford insurance company’s educational

brochures “We Need to Talk” and “At

the Crossroads.” These guides provide

excellent worksheets for dening perti-

nent out-of-home activities, initiating

discussions between patients and their

families, and assisting the patient and

the family member on deciding how

specic trips will be accomplished.

120

This process will help your patient pre-

serve a sense of self-determination and

119. Mezuk, B., & Rebok, G. W. (2008). Social

integration and social support among older

adults following driving cessation. J Gerontol

Series B Psychol Sci Social Sci. 63:S298-303.

120. The Hartford. (2007). Alzheimer’s, Dementia

& Driving. Hartford, CT. www.thehartford.com/

alzheimers/brochure.html. Accessed October 24,

2007.

Explain to your patient

why it is important to

stop driving.

If your patient has undergone the

ADReS battery (see chapters 3 and 4)

or assessment by a driver rehabilitation

specialist, explain the results of the

assessment in simple language. Clearly

explain what the results tell you about

his/her level of function, and then

explain why this function is important

for driving. State the potential risks of

driving, and end with the recommen-

dation that your patient stop driving.

This might be a good time to discuss the

patient’s thoughts or feelings, especially

if he/she did cause a crash. If the patient

should not drive, you might discuss is-

sues related to injury, public safety, and/

or liability. This discussion should be

put in writing and if the patient lacks

decision-making capacity, involve a

family member or caregiver.

For example, you could say to

Mr. Phillips:

“Mr. Phillips, the results of your eye exam

show that your vision isn’t as good as it

used to be. Good vision is important for

driving, because you need to be able to

see the road, other cars, pedestrians, and

trafc signs. With your impaired vision

due to underlying eye disease and now a

stroke, I’m concerned that you’ll get into a

car crash. Since your vision cannot be cor-

rected to a level safe for driving, for your

own safety and the safety of others, it’s

time for you to retire from driving. In addi-

tion, there are legal requirements for vision

and you do not meet those any longer. “

Your patient may become upset or angry

at your recommendation to stop driv-

ing. Acknowledge your patient’s feelings

and be empathetic to any emotional

responses. While you should be sensi-

tive to the practical and emotional

implications of driving cessation, it

is also necessary to be rm with your

recommendation. At this time, it is

best to avoid engaging in disputes or

Figure 1

Transportation alternatives

• Walking

• Train/subway

• Bus

• Taxi

• Friends/family

• Paratransit

• Community transportation services

• Hospital shuttles

• Medi-car

• Delivery services

• Volunteer drivers (church, synagogue,

community centers)

• Private for-proﬁt elderly care services

51Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

independence. While older adult non-

drivers usually prefer rides from friends

and family, they are often uncomfort-

able with the accompanying feelings

of dependency.

121

Using alternative

transportation options such as buses,

trains, cabs, or even walking, offers pa-

tients independence from having to rely

on others. However, these may not be

a reasonable alternative for those with

physical frailty and/or dementia.

To begin a discussion on driving alter-

natives, ask if your patient has made

plans to stop driving or how he/she cur-

rently nds rides when driving is not an

option. Offer alternative transportation

methods for your patient to use (Figure

6.1). Explore any barriers your patient

foresees to these methods (i.e., nancial

constraints, limited service and destina-

tions, and required physical skills for

accessibility).

Help your patient identify his/her

most feasible transportation options, as

there often are necessary cognitive and

physical skills required to access certain

transportation alternatives. Stress the

importance of planning ahead for social

activities—which contribute to quality

of life. Your patients can contact their

Area Agency on Aging and/or Alzheim-

er’s Association for information on local

resources such as taxis, public trans-

portation services, and senior-specic

transportation services. To nd contact

information for your local area, call the

nationwide Eldercare Locator at

800-677-1116. This might be a good

time to refer to a social worker or a

gerontological care manager who may

be aware of alternate modes of transpor-

tation and/or can deal with the patient’s

feelings of social isolation or depression.

The Federal Government has rec-

ognized the limited transportation

alternatives that are currently available

(especially in rural areas) for an aging

country with an increasing number of

older adults who will no longer be able

121. Coughlin, J. (2001). Transportation and the

Older Persons: Perceptions and Preferences.

AARP Public Policy Institute Issue Paper.

Figure 6.2

Encourage family/caregiver

assistance

• Encourage family to promote the

health and safety of their loved one

by endorsing your recommendation

and assisting in securing needed

transportation.

• Include them in the mobility

counseling process.

• Provide resources to caregivers.

• Give copies of the How to Assist the

Older Driver resource sheet (see

Appendix B).

• Refer caregivers to the National

Family Caregivers Association (NCFA)

at 800-896-3650 or www.nfcacares.

org to ﬁnd resources and tips on

caring for loved ones.

• Look for signs of caregiver burnout.

• Keep the communication door open

to the family.

• In the case of cognitive impairment

where it is believed the patient does

not have decision-making capacity

(e.g., lack of insight), communication

with a family member to reinforce

recommendations is imperative.

• Recognize that if the caregiver has

depended on the patient for trans-

portation, the situation may require

more time, counseling, and support

to meet the needs of the family.

to operate an automobile. To that end,

legislation has been enacted to sup-

port funding of novel programs to assist

seniors with transportation to needed

destinations. To nd more information

on transportation options, please go

to www.unitedweride.com.

Encourage your patient to involve fam-

ily members in creating a transportation

plan. Obtain your patient’s permission

when involving family or caregivers,

and encourage them to offer rides and

formulate a weekly schedule for running

errands. They can also help arrange for

delivery of prescriptions, newspapers,

groceries and other services (See Figure

6.2 for more tips). However, do not

ignore your patient while including the

caregiver in the discussion.

Reinforce driving cessation.

The message to cease driving is essen-

tial to ensure your patient’s safety, yet

also presents a signicant demand on

your patient to change his/her current

behavior. Therefore, you will need to

ensure that your patient understands

the reasons (legal, health and safety)

why you have recommended driving

discontinuation. Your patient may be-

come argumentative or emotional dur-

ing the ofce visit. He/she may not fully

comprehend your recommendations and

may not remember all the information

you provide. To help re-enforce your

message:

• Ask your patient if he/she has any

questions regarding the assessment

and your recommendation. Reassure

your patient that you are available

should he/she have questions or need

further assistance.

• Ask your patient to reiterate to you,

why he/she must not drive. Stress this

recommendation is for personal safety

and the safety of others on the road.

• Your patient may benet from the

visual reinforcement of a prescrip-

tion with the words “Do Not Drive.”

Ensure that your patient understands

why he/she is receiving this prescrip-

tion, so as to avoid feelings of anxiety

or anger. See Figure 3 for further re-

able to plan for and schedule transpor-

tation to and from necessary appoint-

ments. Ensure that your patient has

secured reliable and sufcient transpor-

tation resources to meet his/her needs.

Consider referral to a social worker or

gerontological care manager.

As an example of a follow-up conversa-

tion with Mr. Phillips in your ofce, you

could state the following;

Physician: Here is a prescription for your

medicines, you’ll need to rell this at your

pharmacy after our appointment … now

how did you get here to the ofce today?

Mr. Phillips: Oh, my son dropped

me off.

Physician: I see, has he been driving

you lately?

Mr. Phillips: Yes, ever since I stopped

driving, he and his wife have been taking

me where I need to go. He is going to pick

me up in 15 minutes.

Physician: How has that been working

for you?

Mr. Phillips: This has worked quite well.

Physician: Will he be able to take you to

the pharmacy?

Mr. Phillips: Yes, that will not be a

problem.

Physician: It’s wonderful that you have

found them to be a reliable source for rides.

What do you do when one of them is

unable to drive you where you need to go?

Be alert to signs of depression, neglect,

and social isolation (see Figures 6.4

122

and 6.5 for details). Older adult who

stop driving are at increased risk for

122. APA. (2000). Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition, Text Revi-

sion. Washington, DC: American Psychiatric

Association.

enforcement tips.

• Send your patient a follow-up letter

(see Figure 6.6). Place a copy of this

letter in the patient’s chart as docu-

mentation and another visual tool for

re-enforcement. The letter should be

written in simple language to ensure

your patient understands your recom-

mendation. You can use the sample

letter in Figure 6.6 as a template.

• Discuss State reporting requirements

with your patient (see Chapter 7 and

Chapter 8 for more details). In the

case of mandatory reporting laws,

inform your patient that you are

required by law to inform your local

DMV of medical conditions that

could affect a patient’s safe operation

of a vehicle. Let your patient know

the DMV will follow up, and what to

expect as part of this evaluation (i.e.,

review of driving record, required

road test). In States with voluntary

laws, a referral to the DMV could still

be appropriate and patients may need

to hear they will be reported if they

drive against medical advice.

• Help facilitate family members’ assis-

tance in encouraging driving cessa-

tion, and if necessary, encourage your

patient to self-report his/her impair-

ment to the DMV. It may be helpful

to enlist other trusted allies, such as

clergy, friends, or the family attorney.

• Ask your patient to return to you in

one month for a follow-up assess-

ment. (See next section for details of

this visit.)

Follow-up with your patient.

At your patient’s follow-up appoint-

ment, you will want to assess:

• Your patient’s ability to comply with

the stop driving recommendation.

• Transportation resources your patient

has identied and has or has not uti-

lized, looking especially at viability.

• Signs of isolation or depression.

Start the assessment by asking the

patient how he/she got to the appoint-

ment that day. This will help you de-

termine whether your patient has been

Figure 6.3

Tips to reinforce driving cessation

Tip 1: Give the patient a prescription

on which you have written “Do Not

Drive, For Your Safety and the Safety

of Others.” This acts as a reminder for

your patient and also emphasizes the

strength of your message.

Tip 2: Remind your patient this recom-

mendation is for his/her safety and for

the safety of other road users.

Tip 3: Ask the patient how he/she

might feel if they were to get in a crash

and injure themselves or someone else.

Tip 4: Use economic arguments. Point

out rising gas and oil prices, expense

of car maintenance (tires, tune-ups,

insurance), registration/license fees,

ﬁnancing expenses and depreciation

of car value. Web sites are available

to demonstrate the ﬁnancial burden of

owning and operating a car, and it may

be useful to perform this exercise with

the older adult.

Also, some physicians

will state that the patient’s life savings

may be at stake if they drive against

medical advice and injure someone.

Tip 5: Have a plan in place that involves

family member support for alternative

transportation.

1. The Real Cost of Car Ownership Calculator.

(2007). Bikes at Work Inc. www.bikesatwork.

com/carfree/cost-of-car-ownership.html.

Accessed December 13, 2007.

Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

Physician: Mr. Adams, when do you

think it’s an appropriate time for a person

to stop driving?

Mr. Adams: I suppose when they

drive unsafely or are a threat to others

on the road.

Physician: That is an excellent

observation; and I would agree with you.

Mr. Adams: Well, a friend of mine

doesn’t drive very well. He drives all over

the road and runs red lights. I won’t get in

the car with him anymore because I worry

about what may happen.

Physician: That can be a scary situation

for your friend and others on the road as

well. It’s great that you are aware of the

potential danger and that you know how to

ensure your own safety. I am wondering,

is there someone whom you trust, and who

would tell you when they thought it was

unsafe for you to continue driving?

Many older drivers are able to iden-

tify peers whose driving they consider

unsafe, yet may not have the insight

to recognize their own unsafe driving

habits. Ask your patients if they have

friends with whom they are afraid to

drive and why. It’s important to have

your patients begin to think about what

they can expect when their driving abil-

ities begin to decline. Let your patients

know they are not alone and that many

people make the decision to restrict

or cease driving when safety becomes

a concern. Encourage your patients to

obtain a second opinion if they feel ad-

ditional consultation is necessary.

• Have your patient identify support

systems. Ask your patient to list fam-

ily members, church groups, neigh-

bors, etc. who are able and willing to

help with transportation decisions.

This will help your patient become

aware of a supportive network and

feel more at ease when searching for

alternative transportation.

Situation #1:

The resistant patient.

If your patient is belligerent or refuses to

stop driving, it is important for you to

understand why. Knowing this will help

you address your patient’s concerns.

Listen to your patient. Use supportive

statements when addressing your pa-

tient’s concerns. Let your patient know

you are there as an advocate for his/her

health and safety.

Physician: Mr. Adams, I understand you

drove yourself to the appointment today.

This worries me. At our last visit, I recom-

mended that you retire from driving. I am

wondering why you chose to drive yourself

here today?

Mr. Adams: Well, doctor, I don’t under-

stand it. I’ve never gotten into an accident.

My driving is ne and frankly, I don’t think

you have any right to tell me not to drive.

Physician: It sounds like you are frus-

trated and I can’t imagine how difcult it

must be for you to adjust to a life without

driving. It’s not an easy choice to make;

however, it’s the best choice for your health

and safety, and as your physician, that is

my primary concern. I want to help make

this easier for you. Let’s talk about some

of your concerns regarding retiring from

driving.

Remember driving cessation can have

severe emotional and practical implica-

tions for your patients, and they may

have a difcult time adjusting.

• Have the patient dene when a

person would be unt to drive. This

will better help your patient recognize

impairment in his/her own driving

capabilities and will help you assess

your patient’s judgment and insight.

In addition, it might open up discus-

sion where you can each reach some

common ground.

decreasing out-of-home activities.

123

Driving cessation has also been as-

sociated with an increase in depres-

sive symptoms in the elderly

124

125

addition to an increased risk of nursing

home placement.

126

Because depres-

sive symptoms have also been linked to

physical decline and mortality in the

elderly,

127

it is important to continue

to monitor your patient for any signs of

decompensation. Ask your patient how

he/she is managing without driving.

Educate family members and caregivers

on signs of depression and inquire about

any concerns they may have.

Continue to assess and treat your

patient’s functional or cognitive impair-

ments. If they improve to the extent

that the patient is safe to drive again,

notify the patient and give him/her the

resource sheet on Tips for Safe Driving

(see Appendix B).

Situations that require

additional counseling.

It may be necessary to provide addi-

tional counseling to encourage driv-

ing retirement or to help your patient

cope with this loss. Below, we provide

potential situations (e.g., new patient

scenarios) that may arise with patients

who have difculty coping or adhering

to the recommendation to stop driving.

123. Marottoli, R. A., de Leon, C. F. M., Glass, T. A.,

et al. (2000). Consequences of driving cessation:

decreased out-of-home activity levels. J Gerontol

B Psychol Sci Soc Sci. 55:S334–340.

124. Marrottoli, R. A., Mendes de Leon, C., Glass, T.

A., Williams, C. S., Cooney, L. M., Berkman, L.

F., et al. (1997). Driving cessation and increased

depressive symptoms: prospective evidence

from the New Haven EPESE. J Am Geriatr Soc.

45:202–210.

125. Fonda S. J., Wallace R. B., Herzog A. R. (2001).

Changes in driving patterns and worsening

depressive symptoms among older adults.

J Gerontol. 56(6):S343–351.

126. Freeman E. E., Gange S. J., Munoz B., Wet

S. K. (2006). Driving status and risk of entry

into long-term care in older adults. Am J Public

Health. 96:1254–1259.

127. Berkman L. F., Berkamn C. S., Kasl S., et al.

(1986). Depressive symptoms in relation to

physical health and functioning in the elderly.

Am J Epidemiol. 124:372–388.

Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

Situation #2: Your patient presents

with symptoms of depression.

This results from a combination of

factors such as diminished health,

social isolation, or feelings of loss.

If you suspect your patient may be

depressed (see Figure 6.4

128

), conduct a

full assessment to determine the most

appropriate treatment. Talk with your

patient and appropriate family members

about symptoms of depression and avail-

able treatment options. Consider refer-

ring your patient to individual therapy

or group therapy, and social/recreational

activities. Also consider treatment with

medications if appropriate, or referral to

a mental health professional. Normalize

this experience for your patient—

acknowledge they have suffered a loss—

and recognize this may be an especially

difcult time for them.

Situation #3: Your patient lacks

decision-making

capacity.

When your patient presents with sig-

nicant cognitive impairment, or lacks

insight or decision-making capacity

as in certain cases of dementia, it is

imperative that you employ the help of

the appointed guardian, caregiver, or

surrogate decision-maker to encourage

your patient to stop driving. Let family

and caregivers know they play a crucial

role in helping the patient nd alterna-

tives to driving. Inform the family that

you will be available to support and

assist in any way you can. In rare in-

stances, it may be necessary to appoint

a legal guardian for the patient. In turn,

the guardian may forfeit the patient’s

car and license on behalf of the safety of

the patient. These actions should only

be used as a last resort. From a practical

standpoint, hiding, donating, disman-

tling, or selling the car may also be

useful in these difcult situations.

128. APA. (2000). Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition,

Text Revision. Washington, DC: American

Psychiatric Association.

• Help your patient view the positives

of this decision—an opportunity to

assert control over a limitation. Of-

ten, discussion of relinquishing driv-

ing privileges tends to focus on the

negative aspects of driving cessation;

i.e., “losing independence” or “giving

up freedom.” Help your patients view

this as a step in health promotion

and safety for themselves and others.

Use phrases such as “it’s time to retire

from driving” and point out that he/

she may still request rides from family

and utilize community services, and

will have lower costs and responsibil-

ity for maintaining an automobile.

• Refer patient to social worker. Your

patient may need additional help in

securing resources and transitioning

to a life without driving. Social work-

ers can provide supportive counseling

to patients and families, assess your

patient’s psychosocial needs, assist in

locating and coordinating commu-

nity services and transportation, and

enable your patient to maintain inde-

pendence and safety, while preserving

quality of life. The National Associa-

tion of Social Workers Register of

Clinical Social Workers is a valuable

resource for nding social workers

in your area who have met national

veried professional standards for

education, experience and supervi-

sion. Order information or access the

on-line Register at www.socialwork-

ers.org (see Appendix B for more

details)Another resource for social

workers may be your local hospital

and a referral source may be the Area

Agency on Aging or the Alzheimer’s

Association.

Figure 6.4

Questions to assess for major

depression (adapted from the DSM-

IV-TR)

• Has your mood been down lately

on a consistent basis?

• Have you lost interest or pleasure in

all or most activities?

• Have you noticed any changes in

appetite or weight?

• Have you noticed any changes in

sleeping habits or in concentration?

• Have you noticed feelings of

worthlessness or recurrent

thoughts of death?

Figure 6.5

Signs of neglect or self-neglect

The patient has:

• An injury that has not been properly

treated

• Symptoms of dehydration and/or

malnourishment

• Weight loss

• Soiled clothing

• Recurrent falls with or without injuries

• Evidence of inadequate or inappropri-

ate administration of medications

• Spoiled or outdated food in the

refrigerator

• Loss of income from difﬁculty with

ﬁnances

1. 146 American Psychiatric Association (APA)

2000. Diagnostic and Statistical Manual IV-R.

(Fourth Edition-Text Revision). Washington:

American Psychiatric Association.

Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

Situation #4: Your patient shows signs

of self-neglect or neglect.

Your patient may be unable to secure

resources for him/herself and may be

isolated, lacking sufcient support

from family, friends or an appointed

caregiver. If your patient does not have

the capacity to care for him/herself, or

family and caregivers lack the ability

to adequately care for your patient, be

alert for signs of neglect or self-neglect

(see Figure 6.5). If you suspect neglect

or self-neglect, involve adult protective

services (APS). Neglect is the failure of

a caregiver to fulll his/her caregiving

responsibilities, whether due to will-

ful neglect or an inability as a result of

disability, stress, ignorance, lack of ma-

turity, or lack of resources. Self-neglect

is the failure to provide for one’s own

essential needs. APS will investigate

for neglect, self-neglect or abuse of the

elderly person. APS can secure services

such as case planning, monitoring, and

evaluation; and can arrange for medical,

social, economic, legal, housing, law

enforcement and other emergency or

supportive services. To obtain contact

information for your State ofce, call

the Eldercare Locator at 800-677-1116.

Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

Figure 6.6

July 1, 2009

Clayton Phillips

123 Lincoln Lane

Sunnydale, XX 55555

Dear Mr. Phillips:

I am writing to follow-up on your clinic visit on June 20, 2009. As you recall, we talked about your safety when

you drive a car. I tested your vision (eyes), strength, movement, and thinking skills, and asked you about your

health problems and medicines. I recommended that you stop driving due to your slowed reaction time, poor vi-

sion and muscle weakness.

I know that driving is important to you, and I know that it is hard to give up driving, but your safety is more

important than driving. To help you get around, you can ask for rides from your son and your friends. You can

also use the special bus in your neighborhood. The hand out How to Assist the Older Driver (enclosed) has some

other ideas that we talked about. As we discussed, I am also sending a copy of these materials to your son and you

two can discuss this plan together.

I want to make sure you can still visit your friends, and go other places without a car. It is important for you to

maintain your connection with the community. Please see me again in one month—we will talk about how this

plan is working for you.

For a mandatory reporting State considering adding:

As we discussed, the State of _____ requires me to submit the names of potentially unsafe drivers. Because I am

required by law to do this, I have given your name to the ____ Department of Motor Vehicles (DMV). The DMV

will send you a letter in a few weeks to discuss your driver’s license.

For a voluntary reporting State consider adding:

It is very important that you do not drive since you are putting yourself and the public at risk. If you continue to

drive, I will need to report you to the Department of Motor Vehicles for an evaluation and possible revocation of

your license.

Please call my ofce if you have any questions. I look forward to seeing you next month.

Sincerely,

Your Physician

Enc: How to Assist the Older Drive

cc: Your son

Note the sample letter in Figure 6.6 has been written at a 5th grade reading level, as measured by the S.M.O.G. Readability Formula

Chapter 6—Counseling the Patient Who is no Longer Safe to Drive

CHAPTER 7

Ethical and Legal

Responsibilities of the

Physician

light duties of the physician that are

relevant to the issue of driving.

These include:

“ Duty to Protect”

The Patient

Protecting the patient’s physical and

mental health is considered the physician’s

primary responsibility. This includes not

only treatment and prevention of ill-

ness, but also caring about the patient’s

safety. With regard to driving, physi-

cians should advise and counsel their

patients about medical conditions and

possible medication side effects that

may impair one’s ability to drive safely.

Certain states have enacted mandatory

reporting requirements, which place the

physician in danger of both civil and

criminal liability for failure to report.

131

Wording in the Pennsylvania law has

led the Pennsylvania DMV to state that

physicians who do not report “could be

held responsible as a proximate cause of

an accident resulting in death, injury or

property loss caused by your patient; the

Pennsylvania statute further states that

131. OR. REV. STAT.§ 807.710 (2001)

Driving is a difcult topic to address,

particularly when there is the risk of

damaging the patient-physician rela-

tionship, violating patient condentiality,

and potentially losing patients. To

complicate matters, many physicians are

uncertain of their legal responsibility,

if any, to report unsafe drivers to their

state DMV.

129,130

As a result, physicians

are often faced with a dilemma: should

they report the unsafe driver to the

State DMV at the expense of breaching

condentiality and potentially damaging

the patient-physician relationship, or

should they forego reporting and risk

being liable for any potential patient or

third-party injuries for failing to report?

Furthermore, should they engage the

family in taking the responsibility for

driving restriction or cessation?

The Physician’s Ethical Duties

Current legal and ethical debates high-

129. Kelly, R., Warke, T., & Steele, I. (1999). Medical

restrictions to driving: the awareness of patients

and doctors. Postgrad Med J. 75:537–539.

130. Miller, D., Morley, J. (1993). Attitudes of

physicians toward elderly drivers and driving

policy. J Am Geriatr Soc. 40:722–724.

Upon further evaluation, you

diagnose Mrs. Allen (see Chapter

6) with Alzheimer’s disease. It is

readily apparent that her condition

has progressed to the extent that she

is no longer safe to drive and that

rehabilitation is not likely to improve

her driving safety. You tell Mrs.

Allen that she must stop driving

for the sake of her safety and the

safety of others on the road. You

also explain that the State physician

reporting law requires you to notify

the Department of Motor Vehicles

(DMV) of your diagnosis. Initially,

Mrs. Allen does not comprehend,

but when you specically tell her

that she can no longer drive herself

to the grocery store every day, she

becomes agitated and abusive,

screaming, “I hate you!” and “I’m

going to sue you!” Her daughter

understands your decision to report

Mrs. Allen to the DMV, but is now

concerned that she will encounter

legal problems if her mother attempts

to drive without a license. She asks

if it is absolutely necessary for you to

report her mother. What do you say?

This chapter is intended to provide a general overview of a

physician’s ethical and legal responsibilities as related to

reporting unsafe drivers to their State’s DMV. While some

sections of this chapter address issues that are inherently legal,

the chapter is not intended to provide legal advice. The views,

discussion, conclusions and legal analysis are those of the

authors and do not represent the opinions, policies or ofcial

positions of NHTSA. This chapter conveys the current

environment at the time of publication and compiles general

knowledge to assist physicians in understanding the reporting

process. Laws, regulations and policies vary not only by State

but also by local jurisdiction, and are subject to change. There-

fore, it is important for physicians to seek out legal advice

from a licensed attorney in their States on specic issues or

questions that may arise with an individual patient. The

cases cited in this chapter are provided as examples of the

range of opinions in attempting to fairly dene the scope of

the physician’s responsibility to report impaired drivers. The

cases additionally demonstrate society’s efforts to provide safe

environments for its citizens.

For your reference, we have compiled a State-by-State list

of reporting laws, licensing requirements, license renewal

information, and DMV contact information in Chapter 8.

Please note that information may have changed since the

publication of this guide. You are encouraged to contact

your State DMV for the most up-to-date information.

CHAPTER 7

Ethical and Legal

Responsibilities of

the Physician

60 Chapter 7—Ethical and Legal Responsibilities of the Physician

Portability and Accountability Act of

1996, or HIPAA.

139

Patient condenti-

ality is dened as the physician’s ethical

obligation to keep information about

the patient and his/her care unavailable

to those—including the patient’s family,

the patient’s attorney, and the government

—who do not have the authorization to

receive or review this information.

140,141

Patient condentiality is crucial within

the physician-patient relationship

because it encourages the free exchange

of information, allowing the patient to

describe symptoms for diagnosis and

treatment.

142

Without belief in the

patient condentiality of their care,

individuals may be less likely to seek

treatment, disclose information for

effective treatment, or trust the health

care professional.

143

The need for patient condentiality

cannot be considered absolute; a

patient is entitled to freely disclose his

or her symptoms and condition to his

or her physician in condence except

where the public interest or the private

interest of the patient so demands, and

thus a patient possesses a limited right

to patient condentiality in extra-

judicial disclosures subject to exceptions

prompted by the supervening interest of

society.

144

Thus, patient condentiality

does not necessarily protect the physi-

139. Health Insurance Portability and Accountability

Act of 1996 (HIPAA), Public Law 104-191.

45 C.F.R.§ 164.512(a)—Uses and Disclosures

Required by Law (2000). Federal Register / Vol.

65, No. 250 / Thursday, December 28, 2000 /

Rules and Regulations; page 82811. Available

at www.hhs.gov/ocr/privacy/hipaa/administrative/

privacyrule/prdecember2000all8parts.pdf

140. Justice J. Patient condentiality and pharmacy

practice. Consult Pharmacist. 1997:12(11).

Available at: www.ascp.com/public/pubs/tcp/1997/

nov/patient.html.

141. Tasman A, Kay J, Lieberman JA, Fletcher J

(eds). Psychiatry, 1st ed. Philadelphia: W.B.

Saunders Company; 1997: p. 1808.

142. Retchin SM, Anapolle J. An overview of the

older driver. Clin Geriatr Med. 1993;9(2):279-

296.

143. Ferguson v. City of Charleston, 532 US 67

(deliberating in a South Carolina court case

the benets and risks of physician disclosing

condential patient information when that

condential information may protect patients

and society from possible harm).

144. Tasman A, Kay J, Lieberman JA, & Fletcher

J (eds). (1997). Psychiatry, 1st ed. P. 1808.

Philadelphia: W. B. Saunders Company.

states, physicians have been found

liable for third-party injuries because

they failed to advise their patients

about medication side effects,

136

medical

conditions,

137

and medical devices

138

that may impair driving performance

thus causing harm to those other than

the patient.

Maintaining patient

conﬁdentiality

Patient condentiality is the right of an

individual to have personal, identi-

able medical information kept private;

these protections are enumerated in the

federal statute, the Health Insurance

136. Gooden v. Tips, 651 SW 2d; 364. Kaiser v.

Suburban Transportation System, 65 Wn. 2d

461, 398 P.2d 14 (stating in this Washington

state case, that a physician could be held liable

due to the fact that a patient took medication

completely unaware that it would have any

adverse effect on him because the physician

failed to warn his patient, whom he knew to

be a bus driver, of the dangerous side effects of

drowsiness or lassitude that may be caused by

taking this particular medication).

137. Caldwell v. Hassan, 260 Kan. 769 (nding in a

Kansas court case that that the doctor had no

duty to protect bicyclists - a third party- from

his patient’s actions because the patient who

had a sleep disorder was aware of the problem

and admitted to knowing that she should have

stopped driving).

Duvall v. Goldin, 362 NW 2d 275 (nding

in a Michigan court case that the physician

was liable to third persons injured as it was

foreseeable that a doctor’s failure to diagnose or

properly treat an epileptic condition could have

created a risk of harm to a third party and that

as a result of the patient’s medical condition,

caused an automobile accident involving the

third persons).

Myers v. Quesenberry, 144 Cal App 3d 888,

(nding in a California court case that if a

physician knows or should know a patient’s

condition will impair the patient’s mental

faculties and motor coordination, a comparable

warning is appropriate).

Schuster v. Alternberg, 424 NW 2d 159 (nding

in a Wisconsin court case that if it was

ultimately proven that it could have been

foreseeable to a psychiatrist, exercising due care,

that by failing to warn a third person or failing

to take action to institute detention or commit-

ment proceedings someone would be harmed,

negligence could be established).

138. Joy v. Eastern Maine Medical Center, 529 A2d

1364 (nding in a Maine court case that when

the doctor knew, or reasonably should have

known that his patient’s ability to drive has been

affected by treatment that the doctor provided,

he had a duty to the driving public as well as to

the patient to warn his patient of that fact).

providers who do not comply with

their legal requirement to report may

be convicted of a summary criminal

offense”.

132

Some cases illustrate that a

physician’s failure to advise the patient

about such medical conditions and

medication side effects can be considered

negligent behavior.

133

The Public

In addition to caring for their patients’

health, physicians may, in certain

circumstances and jurisdictions, have

some responsibility for protecting the

safety of the public.

134,135

In certain

132. Title 75 PA. CODE § 1518(b) The Vehicle

Code (stating physicians are immune from

any civil or criminal liability if they do report

patients 15 years of age or older who have been

diagnosed as having a condition that could

impair his/her ability to safely operate a motor

vehicle; but, if the physician does not report

could, then, possibly be held responsible as a

proximate cause of an accident resulting in

death, injury, or property loss caused by the

physician’s patient. Also, physicians who do

not comply with their legal requirement to

report may be convicted of a summary criminal

offense). Available at www.dmv.state.pa.us/

pdotforms/fact_sheets/fs-pub7212.pdf

133. Gooden v. Tips, 651 SW 2d 364 (stating in a

Texas court case that physicians have a duty

to warn patients that medications may impair

driving but that physicians do not have a duty

to control a patient’s behavior).

Wilschinsky v. Medina, 108 NM 511 (stating in

a New Mexico court case the physician owed

a duty of care to an individual harmed by the

physician’s patient, that the patient’s doctor’s

duty specically extended to persons the patient

injured by driving a car from the doctor’s ofce

after being injected with drugs that were known

to affect judgment and driving ability; the

medical standards for administering drugs had to

dene the physician’s duties of care).

134. Tarasoff v. Regents of University of California, 13

Cal. 3d 177. It should be noted that the Tarasoff

ruling per se, upon which the principles of

‘Duty to Warn’ and ‘Duty to Protect’ are based,

originally applied only in the state of California

and now applies only in certain jurisdictions.

The U.S. Supreme Court has not heard a case

involving these principles. Many states have

adopted statutes to help clarify steps that are

considered reasonable when a physician is pre-

sented with someone making a threat of harm to

a third party. Tasman A, Kay J, Lieberman JA,

Fletcher J (eds). Psychiatry, 1st ed. Philadelphia:

W.B. Saunders Company; 1997: p. 1815

135. Brisbine, supra, 2002 PA Super 138, *; 799 A.2d

89 (dening factors applied in a Pennsylvania

court case in determining the existence of a

duty: (1) the relationship between the parties;

(2) the social utility of the actor’s conduct; (3)

the nature of the risk imposed and foreseeability

of the harm incurred; (4) the consequences of

imposing a duty upon the actor; (5) the overall

public interest in the proposed solution).

61Chapter 7—Ethical and Legal Responsibilities of the Physician

own state and/or have poor insight into

their own driving abilities,

153

or simply

cannot face voluntarily giving up their

freedom to drive. Although the au-

thors of this guide are not aware of any

supporting studies, there are concerns

about “doctor shopping,” failure to

disclose pertinent information in order

to secure more favorable opinions, or

approaching a new clinician who is un-

aware of the pertinent medical diagno-

ses. Physicians may be unaware of what

functional battery or tests to perform

to determine tness-to-drive.

154

Inter-

rater reliability has been reported to be

low when different physicians lled out

the same type of medical report on the

same patient.

155, 156

However, physicians

will continue to play an integral role

in these types of evaluations and will

require education in this area.

157

Thus, a

comprehensive approach such as iden-

tifying medical conditions or red ags,

and using the ADReS battery should

assist physicians in addressing some of

the concerns.

Physicians Concerns about Reporting

A study of 523 Canadian physicians’

attitudes on medical tness to drive

found that most physicians would

report unt drivers, but at the same

time believed this reporting could

adversely affect the condentiality

expectations within the patient-

physician relationship.

158

Physicians

153. Kelly RM., Warke T, & Steele J. (1999).

Medical restriction to driving: the awareness

of patients and doctors. Postgrad Med J,

75:537-539.

154. Ibid.

155. Steir TS, Kitai E, Wiener A, & Kahan E.

(2003). Are medical reports on tness to drive

trustworthy? Postgrad Med J. 79:52-54.

156. Di Stefano M & Macdonald W. (2003).

Assessment of older drivers: relationships among

on-road errors, medical conditions and test

outcome. J Safety Res. 34:415-429.

157. Kakaiya R, Tisovec R, & Fulkerson P. (2000).

Evaluation of tness to drive: the physician’s

role in assessing elderly or demented patients.

Postgrad Med J. 107:229-236.

158. Shawn C, Marshall MD, & Gilbert N. (1999).

Saskatchewan physicians’ attitudes and knowl-

edge regarding assessment of medical tness

to drive. Canadian Medical Association Journal.

160(12):1701-1704. Molnar & Eby; Medical

Fitness to Drive & A Voluntary Reporting

Law: The AAA Foundation for Trafc Safety,

pg 30 (2008).

et al. on medically impaired drivers

who are referred for tness-to-drive

evaluations found that very few older

adults retain their license (<3%) when

referred by any source.

150

Notably, very

few (<30%) of referrals came from phy-

sicians- most reports were submitted

by police ofcers- indicating a need

to educate health professionals in this

area. The mean age of the study group

was 80 and had an elevated crash risk

prior to license referral when compared

to controls. The majority of the referrals

were due to an underlying cognitive

impairment such as dementia (45%),

although visual impairment was present

30% of the time. Of the 4,100 reported

individuals, 144, (3.5%) retained a

driver’s license after the process.

Missouri has a voluntary reporting law

and further study is required to deter-

mine the benets between mandatory

reporting States and those that allow

voluntary reporting.

151

Differences in referral rates, laws, and

procedures probably account for varia-

tions among states. The information

from the various states suggests that

more research is needed on the sources

of referral, barriers for reporting and the

medical conditions of these drivers to

determine whether referral is useful or

whether other common conditions are

underreported.

Limitations of Reports: Most states

require that physicians ll out their

state’s forms when assessing tness to

drive. Physicians may experience prob-

lems or barriers to providing the state

with accurate information. Taylor and

colleagues found that patients, in fact,

may not inform their doctor of relevant

medical history that could pertain to

driving.

152

Older drivers may have a

poor understanding of the laws in their

150. Meuser T, Carr DB, & Ulfarsson GF. Motor-Ve-

hicle Crash History and Licensing Outcomes for

Older Drivers Reported as Medically Impaired

in Missouri. Accident Analysis and Prevention.

Accepted November 2008 (in press).

151. Ibid.

152. Taylor J, Chadwick DW, & Johnson T. (1995).

Accident experience and notication rates

in people with recent seizures, epilepsy or

undiagnosed episodes of loss of consciousness.

Q J Med. 88:733-740.

cian in the impaired driver situation.

145

Reporting Facts and Trends

Medically Impaired Driver Reports

National Highway Trafc Safety

Administration (NHTSA) provides

some information on state reporting for

medically impaired drivers.

146

Data from

Oregon in 1993 suggested that close

to 5,300 reports were submitted each

year. About 55% were for drivers over

age 65 years, and surprisingly one-third

of reports were self-referral. Health

care providers accounted for 37% of

all reports. The two leading reasons for

referral were epilepsy (19%) and stroke

(15%). Few people had their license

suspended. In 1995 Florida reported

that 11.7% of referred drivers had their

license suspended.

147

Pennsylvania requires health profes-

sionals to report any medical condition

that can impair the ability to control

or safely operate a motor vehicle.

148

In 2008, Pennsylvania received over

27,000 reports, and 22% of these

individuals have impairments serious

enough to merit recall of their driv-

ing privilege. An additional 21% of

reports result in restrictions placed on

the individual’s driving privilege. Half

of the recalls were attributed to seizure

disorders, while 16% were attributable

to other neurological disease.

149

A recent Missouri report by Meuser,

145. Ferguson v. City of Charleston, 532 US 67.

146. National Highway Trafc Safety Administra-

tion. Family and Friends Concerned about

an Older Driver. Available at www.nhtsa.dot.

gov/people/injury/olddrive/FamilynFriends/state.

htm. (Accessed 11/12/07). Also see, Molnar &

Eby; Medical Fitness to Drive & A Voluntary

Reporting Law: The AAA Foundation for

Trafc Safety (2008).

147. National Highway Trafc Safety Administra-

tion. Family and Friends Concerned about an

Older Driver. www.nhtsa.dot.gov/people/injury/

olddrive/FamilynFriends/state.htm. Accessed

11/12/07.

148. Title 75 PA. CODE § 1518(b) The Vehicle

Code.

149. PENNSYLVANIA DEPARTMENT OF

TRANSPORTATION; PHYSICIAN REPORT-

ING FACT SHEET; March 2008. Available

at www.dmv.state.pa.us/pdotforms/fact_sheets/

fs-pub7212.pdf (Accessed September 23, 2009)

report patients to the DMV, physicians

should have patient authorization in

order to disclose medical information.

In these states, physicians who disclose

medical information without patient

authorization may be liable for breach

of condentiality. Nevertheless, this

should not dissuade physicians from

reporting when it is necessary and justi-

ed to protect the patient and/or public.

The AMA recognizes that the safety of

older drivers is a growing public health

concern that is best addressed through

multi-sector efforts to optimize vehicle

design, the driving environment, and

the individual’s driving capabilities.

166

Please refer to chapter 1 in this guide to

review AMA Ethical Opinion E-2.24

“Impaired Drivers and Their Physicians.”

Putting it all together

How can you fulll these competing

legal and ethical duties? In this section,

we provide recommendations for

achieving this balance.

Counsel your patient and if indicated,

include the family.

Patients should be advised of medical

conditions, procedures and medications

that may affect driving performance.

(A reference table of medical conditions

and medications that may affect driving

performance, with recommendations for

each, can be found in Chapter 9.) If you

can get the patient’s permission, involve

the family in the counseling process

whenever it seems appropriate. If the

patient does not have decision-making

capacity (e.g., due to Alzheimer’s

disease), this information should be

given to a cognitively intact surrogate

decision-maker.

Recommend driving cessation

as needed.

As discussed in the previous chapters,

you should recommend that a patient

cease driving if you believe that he/

166. AMA policy H-15.954 Older Driver Safety;

(CSA Rep. 6, A-03).

mittee on Uniform Trafc Laws and

Ordinances (NCUTLO) reporting of a

“Model Driving Impairment Law” has

suggested that physician immunity from

civil liability should be an important

component of any law.

163,164

Physicians

have concerns about breach of con-

dentiality; however, several exceptions

to maintaining condentiality exist. For

example, information may be released

if the patient gives his/her consent,

or may be released without patient

authorization in order to comply with

reporting statutes (such as child abuse

reporting statutes) and court orders.

The Health Insurance Portability and

Accountability Act (HIPAA) has a

regulation that allows for reporting

information that includes a patient’s

protected health information when it is

in the public interest.

165

In some cases,

the act of reporting itself may help

protect the physician from damages

sought by third parties.

Adhering to State Reporting Laws

Because each state has its own reporting

laws, we have provided a state-by-state

reference list in the following chapter.

Please note that information may

have changed since the publication

of this guide. You should contact your

State DMV for the most up-to-date

information.

Please note that in states where there

are no laws authorizing physicians to

163. Reporting of Driver Impairment Model Law;

The National Committee on Uniform Trafc

Laws and Ordinances, at www.ncutlo.org/

impairment.htm Accessed Sept 24th, 2009.

164. Lococo K, Staplin L. (2004) In-Depth Study

to Identify Best Practices for Licensing Drivers

with Medical and Functional Impairments and

Barriers to their Implementation. #DTNH22-

02-P-05111; National Highway Trafc Safety

Administration; 2004.

165. HIPAA (45-CFR-164.512) allows for reporting

to the state when the situation is signicant

enough to put public safety at risk. Source:

http://answers.hhs.gov/cgi-bin/hhs.cfg

Also see 45 C.F.R. Part 160, Subpart B, for

specic requirements related to preemption

of state law, “Permitted uses and disclosures 5.

Public interest and benet activities” Available

at www.hhs.gov/ocr/privacy/hipaa/understanding/

summary/index.html

have raised concerns about mandatory

reporting, stating it can violate privacy,

compromise the ability to counsel

patients, and negatively impact the

doctor-patient relationship.

159

Some

physicians have suggested that man-

datory reporting has the potential to

discourage patients from seeking

health care.

160

Six states have mandatory reporting

requirements: California, Delaware,

Nevada, New Jersey, Oregon, and

Pennsylvania. In California, physicians

are required to report specic conditions

such as seizure disorders or Alzheimer’s

disease, among other conditions. Cable

et al. found that physicians practicing

in mandatory reporting States are more

likely to report impaired drivers to the

licensing agency.

161

Thus, physicians

may choose not to report in certain situ-

ations unless they are required by law to

do so. We are not aware of any studies

that examine the efcacy of mandatory

or voluntary reporting laws, or any that

have drawn comparisons between States

with differing approaches. But, physi-

cians are required to follow the law of

their particular state as it now stands.

We urge you to become familiar with

your state’s laws.

Immunity and Condentiality: Of the 43

states with voluntary reporting laws,

18 currently do not protect reporting

health professionals from liability for

civil damages.

162

The National Com-

159. Molnar & Eby; Medical Fitness to Drive & A

Voluntary Reporting Law: The AAA Founda-

tion for Trafc Safety, pg 30 (2008).

160. Kelly R, Warke T, Steele I. Medical restric-

tions to driving: the awareness of patients and

doctors. Postgrad Med J. 1999;75:537-539. Karen

West et al., The Mandatory Reporting of Adult

Victims of Violence: Perspectives from the

Field, 90 Ky. L.J. 1071 (2001-2002).

161. Cable G, Reisner M, Gerges S, & Thirumava-

lavan V. Knowledge, attitudes, and practices of

geriatricians regarding patients with dementia

who are potentially dangerous automobile

drivers: a national survey. J Am Geriatr Soc.

48(1):100-102. (2000).

162. Lococo K. (2003). Summary of Medical

Advisory Board Practices in the United States.

Task Report Prepared Under NHTSA Contract

No. DTNH22-02-P-05111. Available at

www.aamva.org/KnowledgeCenter/Driver/At-Risk/

ProgramPracticesRecommendationsAndModelLaws

.htm

Chapter 7—Ethical and Legal Responsibilities of the Physician

your patient may be potentially at risk

for unsafe driving.

• Any counseling specic to driving

(e.g., documenting that the patient

is aware of the warning signs of

hypoglycemia and its effects on

driving performance).

• Formal assessment of your patient’s

driving-related functions (e.g.,

documenting that the patient has

undergone the ADReS battery and

including the ADReS scoring sheet

in the chart).

• Any medical interventions and

referrals you have made to improve

the patient’s function and any repeat

testing to measure improvement.

• A copy of the DRS report, if the

patient has undergone driver

assessment and/or rehabilitation.

• Your recommendation on whether

the patient should continue driving

or cease driving. If you recommend

that the patient cease driving, include

a summary of your interventions (e.g.,

“sent letter to patient to reinforce

recommendation,” “discussed trans-

portation options and gave copy of

‘Patient Resource Sheet’,” “contacted

family members with patient’s permis-

sion,” and “reported patient to DMV

with patient’s knowledge”). Include

copies of any written correspondence

in the chart or electronic record.

• Follow-up for degree of success in

using alternate transportation options

and any signs of social isolation and

depression. Document any further

interventions, including referral to a

social worker, geriatric care manager,

or mental health professional.

Additional legal and ethical

concerns

What should you do if you nd yourself

in a particularly challenging situation?

In this section, we offer recommenda-

tions for several potential situations:

Situation 1: My patient threatens to sue

me if I report him/her to the DMV.

A patient’s threat to sue should by no

means deter you from complying with

information condential. Even in

States that offer anonymous reporting

or reporter condentiality, it is a good

idea to be open with your patients.

You may wish to remind the patient

that ultimately the physician does not

determine driver licensing. This is the

responsibility of the State. Thus, the

State has the nal decision on deter-

mining whether the patient should still

be allowed to drive.

When submitting your report, provide

only the information necessary or

required to establish that your patient

may be unsafe. Consider giving your

patient a copy of his/her report. By

providing your patients with as much

information as possible, you can involve

them in the process and give them a

greater sense of control.

Before contacting your patient’s family

members and caregivers, request the

patient’s permission to speak with these

parties and document this in the chart.

If your patient maintains decisional

capacity and denies permission for you

to speak with these parties, you must

respect the patient’s wishes.

Document diligently.

Through documentation, you provide

evidence of your efforts to assess and

maintain your patient’s safety. In the

event of a patient or third-party crash

injury, good documentation may protect

you against a judgment from a lawsuit.

To protect yourself legally, you should

document your efforts, conversations,

recommendations, and any referrals for

further testing in the patient’s chart.

167

In other words, you should document

all the steps of Physician Plan for Older

Drivers’ Safety (PPODS) (see page 6)

that you have performed, including:

• Any direct observations of your

patient’s functional status, red ags

as described in PPODS, or driving

history that lead you to believe that

167. Carr DB. The older adult driver. Am Fam

Physician. 2000;61(1):141-148.

she may be an unsafe driver and that

his/her driving cannot be made safe

by any available medical treatment,

adaptive device, or adaptive technique.

As always, base your clinical judgment

on the patient’s driving abilities rather

than the patient’s age. This recom-

mendation should be documented in

the chart and there should be a system

in the ofce setting to check on future

compliance with recommendations.

Know and comply with your State’s

reporting laws.

You must know and comply with your

State’s reporting laws (see Chapter 8).

If you fail to follow these laws, you may

be liable for patient and third-party

injuries.

If your State has a mandatory medi-

cal reporting law, report the required

medical condition(s) using the DMV’s

ofcial form. If your State has a volun-

tary physician reporting law, report the

information using the DMV’s ofcial

form and any other reporting guidelines.

If the DMV’s guidelines do not indi-

cate what patient information must be

reported, provide only the minimum

information necessary to show that your

patient may be an unsafe driver.

Reduce the impact of breaching

patient conﬁdentiality

In adhering to the State’s reporting laws,

it may be necessary for the physician to

breach their patient’s condentiality.

However, you can do several things

to reduce the impact of this on the

patient-physician relationship.

Providing Notice to the DMV

Before reporting to the DMV, tell

your patient what you are about to do.

Explain that it is your ethical, and in

some cases legal, responsibility to refer

him/her to the State DMV, and describe

what kind of follow-up can be expected

from the DMV. Assure your patient

that out of respect for his/her privacy,

you will disclose only the minimum

information required and hold all other

Chapter 7—Ethical and Legal Responsibilities of the Physician

• Discuss the nancial and emotional

burden a car collision would cause

them, their family, and all others

involved.

• If your patient is cognitively impaired

and lacks insight into this problem,

the issue must be discussed with the

individual who holds decision-making

authority for the patient and with any

other caregivers. These parties should

understand their responsibility to

prevent the patient from driving.

• If your patient continues to drive and

your state has a physician reporting

law, adhere to the law by reporting

your patient as an unsafe driver (even

if you have already done so previ-

ously, resulting in the revocation of

your patient’s license). If your state

does not have a physician reporting

law, base your decision to report as in

Situation 2 (see above). The DMV,

as the agency that grants and revokes

the drivers license, will follow-up as it

deems appropriate.

Situation 4: My patient threatens to

ﬁnd a new doctor if I report him/her to

the DMV.

This situation, while unfortunate,

should not prevent you from adhering

to your state’s reporting laws. As a

physician, it is your responsibility to

care for your patients’ health and safety,

regardless of such threats.

Several strategies may help you diffuse

this situation:

• Reiterate the process and information

used to support your recommendation

that the patient stop driving.

• Reiterate your concern for the safety

of your patient, his/her passengers,

and those sharing the road.

• Remind your patient that you try to

provide the best possible care for

his/her health and safety. State that

driving safety is as much a part of

patient care as encouraging patients

to wear a seat belt, keep a smoke

detector in the house, oss their

teeth, and have regular physical

check-ups.

stop driving despite your best efforts,

then you must consider which is more

likely to cause the greatest amount of

harm: breaching the patient’s conden-

tiality versus allowing the patient to

poten-tially injure himself/herself and

third parties in a motor vehicle crash.

According to AMA Policy E-2.24 (see

Chapter 1), “in situations where clear

evidence of substantial driving impair-

ment implies a strong threat to patient

and public safety, and where the physi-

cian’s advice to discontinue driving

privileges is ignored, it is desirable and

ethical to notify the Department of

Motor Vehicles.”

Situation 3: My patient has had his/

her license suspended by the DMV for

unsafe driving, but I am aware that he/

she continues to drive.

This patient is clearly violating the law,

and several questions are raised: Is the

physician responsible for upholding the

law at the expense of breaching patient

condentiality? Since the license

has been revoked by the DMV, is the

driving safety of the patient now the

responsibility of the DMV, the physi-

cian, or both?

There are several steps you can take in

this situation:

• Ask your patient why he/she continues

to drive. Address the specic causes

brought up by your patient (see the

previous chapter for recommendations).

With your patient’s permission, the

family should be involved in nding

solutions such as alternative methods

of transportation.

• Ask your patient if he/she understands

that he/she is breaking the law.

Reiterate your concerns about the

patient’s safety, and ask how he/she

would feel about causing a crash and

potentially being injured or injuring

someone else. Discuss the nancial

and legal consequences of being

involved in a crash without a license

or auto insurance. Many clinicians

will remind the patient and/or family

that the patient could have nancial

liability for any injuries caused by

driving.

your state’s reporting laws. If a patient

threatens to sue, there are several steps

you can take to protect yourself in the

event of a lawsuit:

• Know if your state has passed legisla-

tion specically protecting health

care professionals against liability

for reporting unsafe drivers in good

faith.

168

(This information can be

found in the following chapter.)

• Even if your state has not passed

such legislation, physicians generally

run little risk of liability for follow-

ing mandatory reporting statutes in

good faith. Consult your attorney

or malpractice insurance carrier to

determine your degree of risk.

• Make certain you have clearly docu-

mented your reasons for believing

that the patient is an unsafe driver.

Be aware that physician-patient privilege

does not prevent you from reporting your

patient to the state DMV. Physician-

patient privilege, which is dened as the

patient’s right to prevent disclosure of

any communication between the physi-

cian and patient by the physician, does

not apply in cases of required reporting.

Remind the patient that ultimately the

physician does not determine licensing.

This is the responsibility of the state.

Thus, the state has the nal decision on

determining whether the patient should

still be allowed to drive.

Situation 2: Should I report an unsafe

driver even if my state does not have

any reporting laws?

In this situation, the physician’s rst

priority is to ensure that the unsafe

driver does not drive. If this can be ac-

complished without having the patient’s

license revoked, then there may be no

need to report the patient to the DMV.

Before reporting your patient, you may

address the risk of liability for breaching

patient condentiality by following the

steps listed under Situation 1.

However, if your patient refuses to

168. Tasman A, Kay J, Lieberman JA, Fletcher J

(eds). Psychiatry, 1st edition. Philadelphia: W.B.

Saunders Company; 1997; p. 1809.

Chapter 7—Ethical and Legal Responsibilities of the Physician

65Chapter 7—Ethical and Legal Responsibilities of the Physician

Before consulting the reference list in Chapter 8, it will be helpful to familiarize

yourself with the terms and concepts provided in the Glossary of Terms.

Glossary of Terms

Anonymity and Legal Protection: Several States offer anonymous reporting

and/or immunity for reporting in good faith. More than half of all the States will

maintain the condentiality of the reporter, unless otherwise required by a court

order.

169

Driver Rehabilitation Programs: These programs, run by driver rehabilitation

specialists (DRS), help identify at-risk drivers and improve driver safety through

adaptive devices and compensatory techniques. Clients typically receive a clini-

cal evaluation, driving evaluation, and—if necessary—vehicle modications and

training. (Driver assessment and rehabilitation are discussed in greater detail in

Chapter 5.)

Duty to Protect: In certain jurisdictions state physicians have a legal duty to

warn the public of danger their patients may cause, especially in the case of

identiable third parties.

170

With respect to driving, mandatory reporting laws

and physician reporting laws provide physicians with guidance on their duty

to protect.

Good Faith: Honest and respectful in all professional interactions

171

Immunity for reporting: Many States exempt physicians from liability for civil

damages brought by the patient if the physician reported the patient to the

DMV beforehand.

Mandatory Medical Reporting Laws: In some States, physicians are required to

report patients who have specic medical conditions (e.g., epilepsy, dementia)

to their State DMV. These States provide specic guidelines and forms that can

be obtained through the DMV.

Medical Advisory Boards: Medical Advisory Boards (MAB) generally consist of

local physicians who work in conjunction with the DMV to determine whether

mental or physical conditions may impair an individual’s ability to drive. Some

MABs specify mitigation that would permit continued licensure. MABs vary

among States in size, role, and level of involvement.

Physician Reporting Laws: Some states require physicians to report “unsafe”

drivers to the State DMV, with varying guidelines for dening “unsafe.” The

physician may need to provide: (a) the patient’s diagnosis; and (b) any evidence

of a functional impairment that can affect driving (e.g., results of neurological

testing) to prove that the patient is an unsafe driver.

172

169. Sterns HL, Sterns R, Aizenberg R, & Anapole R. (2001, August). Family and Friends Concerned

About an Older Driver. NHTSA Report No. DOT HS 809 307. “State Reporting Practices.” Wash-

ington, DC: National Highway Trafc Safety Administration.

170. Tarasoff v. Regents of University of California, 13 Cal. 3d 177.

171. The American Medical Association Principles of Medical Ethics; Preamble, generally I-IX. Adopted

June 1957; revised June 1980; revised June 2001. Code of Medical Ethics of the American Medical

Association: Council on Ethical and Judicial Affairs; 2008-2009 Edition. American Medical Associa-

tion, 2008.

172. Messinger-Rapport B & Rader E. (2000). High risk on the highway: how to identify and treat the

impaired older driver. Geriatrics. 55(10)32-45.

• Encourage your patient to seek a

second opinion. A DRS may evaluate

the patient if this has not already

been done, or the patient may consult

another physician.

• If your state DMV follows up on

physician reports with driver retesting,

inform the patient that just as it is

your responsibility to report him/

her to the DMV, it is the patient’s

responsibility to prove his/her driving

safety to the DMV. Emphasize that

the DMV makes the nal decision,

and that only the DMV can legally

take away the license. Remind your

patient that you have done every-

thing medically possible to help him/

her pass the driver test.

• As always, maintain professional

behavior by remaining unemotional

and not expressing hostility toward

your patient even if he/she ultimately

makes the decision to seek a new

physician.

66 Chapter 7—Ethical and Legal Responsibilities of the Physician

Glossary of Terms (continued)

Physician Liability: Previous cases have illustrated situations in which the

physician was held liable for civil damages caused by his/her patient’s car

collision when there was a clear failure to report an at-risk driver to the DMV

prior to the incident.

173

Renewal Procedures: License renewal procedures vary by State. Some States

have age-based renewal procedures; that is, at a given age, the State may reduce

the time interval between license renewal; restrict the ability to obtain license

renewal by mail; require specic vision, trafc law and sign knowledge; and/or

require on-road testing. Very few States require a physician’s report for license

renewal.

174

Restricted Drivers License: Some States offer the restricted license as an

alternative to revoking a driver’s license. Typical restrictions include prohibiting

night driving, limiting driving to a certain distance from home, requiring adap-

tive devices, and shortening the renewal interval. To our knowledge, the efcacy

of these types of restrictions has not been tested.

Third (3rd) Party: The generic legal term for any individual who does not

have a direct connection with the physician or legal transaction, but who

might be affected by it, e.g., anyone injured other than the patient.

173. Capen K. (1994). New court ruling on tness-to-drive issues will likely carry “considerable weight”

across country. Can Med Assoc J. 151(5):667.

174. Tripodis VL. (1997). Licensing policies for older drivers: balancing public safety with individual

mobility. Boston Coll Law Rev. 38 B.C.L. Rev 1051.

CHAPTER 8

State Licensing and

Reporting Laws

effects of license renewal timing, and

tests of visual acuity, knowledge and

road examinations on older driver fa-

talities. The researchers concluded that

tests of visual acuity were associated

with a lower fatal crash risk for older

drivers.

179

Another study investigated

the effect of renewal testing by compar-

ing the crash rates of older adults in

Indiana and Illinois (which at the time

required vision, knowledge, and road

testing at age 75) with similar controls

in states that do not have age-based

testing (e.g., Ohio and Michigan). In

states that had age-based testing, there

was a 7 percent reduction in involve-

ment in injurious crashes, but an

increase in at-fault single-vehicle crash

rates.

180

The authors concluded that

routine road testing was not warranted.

An examination of the effects of shorter

licensure renewal periods for older

adults along with an analysis of the

crashes before and after discontinuation

of road tests for those under 75 in Illinois

was performed. Comparing changes in

1989 from before to after new policies

were enacted, no effects were observed

on crashes, fatal crashes, crash rates, or

licensure rates of older drivers. Although

there are no data to support an im-

provement in public safety when

road testing the general older adult

population during license renewal,

mandatory road testing requirements

along with vision testing have been

179. Levy, D. T. (1995). The relationship of age

and state license renewal policies to driving

licensure rates. Accid Anal Prev. 27(4):461–467.

180. Lange, J. E., & McKnight, A. J. (1996). Age-

based road test policy evaluation. Transport Res

Rec. 1550:81–87.

one year (Illinois at age 87) to ve years

(Arizona, Colorado, South Carolina).

Surprisingly, one state actually has a

decelerating renewal for older drivers,

with no renewal required after age 65

(Tennessee). Over time, there has been

a trend toward lengthening the period

of license renewal. Seventeen states

have special renewal provisions for older

drivers, including in-person renewal,

vision tests, written tests, road tests, a

medical certication of tness, or some

combination of these. Thus, a minority

of states have requirements for more-

frequent testing for adults over 65.

176

A variety of options can apply due to

the special renewal provisions of older

drivers. These include license renewal,

revocation or suspension, restriction,

or shortening of the renewal cycle.

A recent review indicates that in some

jurisdictions in Australia age-based

assessment has not been associated with

safety benets.

177

Some of the literature

supports vision testing during license

renewal for older adults. One investiga-

tor compared occupant motor vehicle

fatalities for those over age 60 in states

with and without a vision-related reli-

censing laws and concluded there would

be a 12.2-percent reduction in fatalities

over the period of study if the majority

of states without such laws were to adopt

one.

178

Another study examined the

176. Morrisey, M. A., & Grabowski, D. C. (2005).

State motor vehicle laws and older drivers.

Health Econ. 14(4):407–419.

177. Fildes, B. N., Charlton, J., Pronk, N., et al.

(2008). An Australian model license reas-

sessment procedure for identifying potentially

unsafe drivers. Trafc Inj Prev. 9:350–359.

178. Shipp, M. D. (1998). Potential human eco-

nomic cost-savings attributable to vision testing

policies for driver license renewal 1989–1991.

Optom Vis Sci. 75:103–118.

Each state has its own licensing and

license renewal criteria for drivers of

private motor vehicles. In addition,

certain states require physicians to

report unsafe drivers or drivers with

specic medical conditions to the

driver licensing agency.

This chapter contains licensing agency

contact information, license renewal

criteria, reporting procedures and medi-

cal advisory board information, listed

by state. These materials are intended

to guide physicians in understanding

their legal responsibilities and managing

the driving safety of their patients. The

information in this chapter should not

be construed as legal advice nor used to

resolve legal problems. If legal advice

is required, please consult an attorney

who is licensed to practice in your state.

Please note that information may have

changed since the publication of this guide.

You should contact your State DMV for

the most up-to-date information.

License renewal practices

among states

Practices vary among states for license

renewal based on age. A recent review

summarized some of these nuances, and

are reviewed in this paragraph.

175

Many

states require renewal every four to ve

years, and one state requires no renew-

als until age 65 (Arizona). Fourteen

states require some type of accelerated

renewal for older drivers, ranging from

age 60 to 80, with the length of the

accelerated renewal cycle ranging from

175. Molnar, L. J., & Eby, D. W. (2005). A brief look

at driver license renewal policies in the United

States. Public Policy and Aging Report. National

Academy on an Aging Society. 15;1, 13–17.

CHAPTER 8

State Licensing and

Reporting Laws

70 Chapter 8—State Licensing and Reporting Laws

safety benets for mandatory assessment

programs.

185

Similarly, a comparison of

Swedish and Finnish licensing practices

did not demonstrate an advantage for

age-related license renewal require-

ments. Finland requires regular medi-

cal evaluations starting at age 70 for

license renewals, whereas Sweden has

no age-related requirements. The Finn-

ish program not only did not have a

reduction in crash rates but was actually

associated with higher pedestrian fatal-

ity rates.

186

Speciﬁc state information

Information on each specic state was

obtained from each state’s driver licens-

ing agency and reects the most current

information at the time of publication.

Please note that this information is

subject to change. Contact your specic

states statutes for up-to-date changes

in the laws or requirements. This is

especially important when it comes to

creating a clinic policy or deciding on

an individualized approach to reporting.

Legal counsel is recommended to advise

your decision-making in this area.

When information was not available

from an individual state’s driver licensing

agency, the following references were

used and remain as useful resources for

clinicians. The Insurance Institute for

Highway Safety and Insurance Informa-

tion Institute sites are usually updated

at frequent intervals and the Web site

will indicate the latest version.

185. Langford, J., Fitzharris, M., Newstead, S., & Ko-

ppel, S. (2004). Some consequences of different

older driver licensing procedures in Australia.

Accid Anal Prev. 36: 993–1001.

186. Hakamies-Blomqvist, L., Johansson, K., &Lun-

dberg, C. (1996). Medical screening of older

drivers as a trafc safety measure: a comparative

Finnish-Swedish evaluation study. J Am Geriatr

Soc. 446:650–653.

noted to decrease license renewal

rates.

181

A recent U.S. study raises further doubt

about the efcacy of intensive screen-

ing during the license renewal process.

Vision tests were not found to reduce

crash risk, while an in-person renewal

requirement reduced fatalities for driv-

ers 85 and older by 16.3 percent.

182

This

may result from license renewal staff

requesting that older adults be evaluat-

ed, with subsequent revocation of their

license or some older drivers deciding

to give up their licenses rather than go

through the renewal process.

These testing procedures and regulations

do impose signicant costs on states,

and at times inconvenience and costs

to individual drivers. If licenses are

revoked, older adults face the problems

of restricted mobility and loss of out-of-

home activities, which may decrease

social connectedness. In addition, the

impact on family members and caregiv-

ers, such as time away from work, is

not insignicant. This burden must

be carefully weighed against the actual

“added value” or benets of improved

public safety.

183

International experience

In Australia, different states have

various requirements for older adults,

ranging from no license renewal

requirements, to vision, road, and/or

requirement for a medical evaluation

from a physician.

184

One study found

similar crash rates across populations

based on the number of licenses issued,

indicating there were no demonstrable

181. Levy, D. T., Werrick, J. S., Howard, K. A. (1995).

Relationship between driver’s license renewal

policies and fatal crashes involving drivers 70

years and older. JAMA. 274:1026–1030.

182. Grabowski, D. C., Campbell, C. M., Morrisey,

M. A. (2004). Elderly licensure laws and motor

vehicle fatalities. JAMA. 291:2840–2846.

183. Miller, T.R., & Levey, D.T. (2000). Cost-out-

come analysis in injury prevention and control:

eighty-four recent estimates for the United

States. Med Care. 2000;28(6):562–582.

184. Fildes, B., Pronk, N., Langford, J., Hull, M.,

Frith, W., & Anderson, R. (2000). Model

license re-assessment procedure for older and

disabled drivers (Report # AP-176/00).

Canberra, Australia: Ausroads.

Name of State & DMV

contact information

Alabama Department of Public Safety

PO Box 1471

Montgomery, AL 36102-1471

www.dps.state.al.us

334-242-4239

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/60 in best eye with or without

corrective lenses. Class D only.

Yes-for daylight driving only for

2 years then will be reviewed.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

110° both eyes-Class D only

Keystone View

Color vision requirement Must be able to distinguish between amber, red, and green. New and professional drivers only

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In-person

Yes

Age-based renewal procedures No special requirements for age.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physician reporting is encouraged.

Immunity Yes

Legal protection Yes

DMV follow-up Driver notiﬁed in writing of referral. For diabetes, seizures, and convulsions, etc., a form is sent to be

completed by patient’s doctor.

Other reporting Will accept information from courts, police, other DMVs, family members, and anyone who completes

and signs the appropriate forms.

Anonymity Yes, unless the subjects request a copy of their medical records by completing the necessary forms,

having them notarized, and paying the proper fee for copying these records.

Medical Advisory Board

Role of the MAB The MAB was created to assist the Director for Public Safety concerning the medical aspects of driver

license. The MAB consists of at least 18 members, with the chair elected on an annual basis. They as-

sist the Medical Unit.

Medical Review contact

information

The Medical Unit may be reached at 334-242-4239.

Alabama

Alaska

Name of State & DMV

contact information

Alaska Department of Motor Vehicles

3300 B Fairbanks Street

Anchorage, AK 99503

www.state.ak.us/dmv/

907-269-5551

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/100 needs report from eye

specialist—license request deter-

mined by discretion

Only under certain conditions spe-

ciﬁcally recommended by physician

in regards to lighting conditions,

number of miles to and from speciﬁc

locations. Need letter stating “with

the bioptic telescopes this patient

can safely operate a motor vehicle

without endangering the public under

the following conditions:”

Visual ﬁelds Minimum ﬁeld requirement .........................................................None

Color vision Is there a color vision requirement? .............................................No

Road test Type of road test ........................................................................N/A

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Mail in every other cycle

Yes, at in-person renewal

Age-based renewal procedures No renewal by mail for drivers 69+, and to drivers whose prior renewal was by mail.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting A licensee should self-report medical conditions that cause loss of consciousness to the DMV.

Immunity No

Legal protection N/A

DMV follow-up All medical information submitted to DMV is reviewed by the Department of Public Safety personnel.

Other reporting Requires retest/re-exam upon receipt of documented problem by law enforcement, other DMVs, and

family members.

Anonymity N/A

Medical Advisory Board

Role of the MAB Alaska does not have a Medical Advisory Board

Medical Review contact

information

Referrals for reexamination can be sent to:

Department of Administration, Juneau Driver Licensing | Po Box 110221 | Juneau, Alaska 99811

907-465-4361 | fax 907-465-5509

Arizona

Name of State & DMV

contact information

Arizona Motor Vehicle Department

Medical Review Program

Mail Drop 818Z

PO Box 2100

Phoenix, AZ 85001-2100

www.dot.state.az.us/MVD/mvd.htm

623-925-5795 phone

623-925-9323 fax

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/60 in best eye restricted to

daytime only

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

70°, 35° Nasal

Keystone view

Color vision Is there a color vision requirement? .............................................Commercial Drivers Licenses only

Road test Depends on physician recommendation and provided information

Restricted licenses Yes, daylight only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

12 years

N/A

Yes

If recommended

Age-based renewal procedures At age 65, reduction of cycle to 5 years. No renewal by mail after age 70

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes

Immunity Yes

Legal protection Reporting immunity is granted

DMV follow-up Follows physician recommendation

Other reporting Will accept information from courts, police, other DMVs, family members and other resources.

Anonymity Yes

Medical Advisory Board

Role of the MAB Reports are reviewed by the Medical Review Program staff to determine of a license requires

a re-examination of driving skills/written testing, or medical/psychological evaluation.

Medical Review contact

information

Mail Drop 818Z

Medical Review Program

PO Box 2100

Phoenix, AZ 85001

623-925-5795

Fax 623-925 9323

Name of State & DMV

contact information

Arkansas Driver Control

Hearing Ofﬁcer, Rm 1070

1910 West 7th

Little Rock, AR 72203

www.state.ar.us/dfa/odd/motor_vehicle.html

501-682-1631

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50

20/40

20/40 in best eye for unrestricted;

20/60 restricted

Yes, under certain circumstances.

20/50 through telescope, 20/50

through carrier/must still have

minimal ﬁeld of vision 105°

Visual ﬁelds Minimum ﬁeld requirement .........................................................Both eyes 105°

Color vision Is there a color vision requirement? .............................................OPTEC Screening Machine

Road test Type of road test ........................................................................Standardized

Restricted licenses Yes, daylight driving only at physicians’ recommendation—

however must meet minimal visual requirements

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person, and by mail only

if out of state

Yes

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting We do encourage unsafe driver’s to be reported to our ofﬁce.

Immunity No

Legal protection No

DMV follow-up Medical information is reviewed by the director of Driver Control. An appointment is scheduled within 2

weeks of receipt. At that time, a medical form is given to the licensee for completion by a physician. If

the medical exam is favorable, the road test is given.

Other reporting Will accept information from courts, police, other DMVs, and family members.

Anonymity N/A

Medical Advisory Board

Role of the MAB Arkansas has no Medical Advisory Board.

Medical Review contact

information

Unsafe drivers may be referred to Driver Control at the contact above.

Arkansas

Name of State & DMV

contact information

Licensing Requiring/Renewal

California Department of Motor Vehicles

2415 First Avenue, Mail station C152

Sacramento, CA 95818-2698

www.dmv.ca.gov/

916-657-6550

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

One eye 20/70 if other is 20/40. This

is a screening standard, if failure then

referral to vision specialist, possible

road test. Not an absolute standard.

20/40. Also a screening standard

20/40 (with road test given unless

stable, long-standing condition

Better than 20/200, best corrected, in

at least one eye. Cannot use bioptic

telescope to meet standard.

Yes, daylight driving only.

Visual ﬁelds Minimum ﬁeld requirement .........................................................75 degrees for a person wearing a

bioptic telescopic lens. No minimum

ﬁeld exists for any other drivers

Color vision requirement No

Type of road test The Driving Performance Evaluation (DPE) is administered for original licensing and for some experi-

enced impaired drivers (e.g., drivers with vision problems). For other experienced drivers (e.g., drivers

with cognitive deﬁcits), the Supplemental Driving Performance Evaluation (SDPE) is administered.

Restricted licenses Yes, varied restrictions—most commonly to corrective lenses.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

In person or, if qualify, mail renewal

for no more than 2 license terms in

sequence.

Yes, at in person, not mail, renewal

At in-person renewal, unless driver

has had 2 and would be eligible for a

3rd sequential mail renewal, if there

were such. These drivers don’t take a

written test.

Not generally, unless evidence of

highly likely impairment for driving.

Age-based renewal procedures No mail renewal at 70+

Reporting Procedures

Mandatory medical reporting Yes, physicians are required to report all patients diagnosed with ‘disorders characterized by lapses of

consciousness’. Law speciﬁes that this deﬁnition includes Alzheimer’s ‘and those related disorders that

are severe enough to be likely to impair a person’s ability to operate a motor vehicle.’

Physician reporting laws Physicians are not required to report unsafe drivers. However, they are authorized to report, given their

good faith judgment that it’s in the public interest.

Immunity Yes, if condition is required to be reported. (A physician who has failed to report such a patient may be

held liable for damages.) A physician has immunity from reporting a condition, even if it not required, if

in good faith, the physician believes it will serve the public interest.

Legal protection See above

California

California (continued)

DMV follow-up The medical information obtained from physician is reviewed by DMV hearing ofﬁcers within Driver

Safety Branch. Driver will be reexamined; at conclusion of process DMV may take no action, impose

restrictions, limit license term, order periodic reexaminations, suspend or revoke the driver’s license.

Other reporting Basically anyone—DMV will accept information from driver him or herself, courts, police, other DMVs,

family members and other resources.

Anonymity If so requested, name will not be divulged (unless court order mandates disclosure)

Medical Advisory Board

Role of the MAB Gathers specialists for panels on special driving related topics (e.g., vision). Panels make policy recom-

mendations to DMV for dealing with groups of drivers having a particular type of impairment. No recom-

mendations are made regarding individuals as such.

Medical Review contact information MAB no longer meets as a group. For further information contact:

Post Licensing Policy

California Dept. of Motor Vehicles

2415 First Ave., Mail Station C163

Sacramento, CA 95818-2698

916-657-5691

Name of State & DMV

contact information

Colorado Division of Motor Vehicles

Driver’s License Administration

1881 Pierce Street, Room 136

Lakewood, CO 80214

www.colorado.gov/revenue/dmv

303-205-5646

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40*

20/40

No absolute minimum acuity. Will

license any individual that physician/

optometrist feels is not a danger.

Yes, however we are going to revisit

the issue in the near future.

Visual ﬁelds Minimum ﬁeld requirement ......................................................... Yes, we now test for minimum

horizontal ﬁelds.

Color vision requirement No

Restricted licenses Yes: based on the results of the vision screening test and/or doctor’s recommendations.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

If eligible, mail in every other cycle

Yes, unless mail-in renewal

Only if point accumulation results in

suspension

No, unless condition has developed

since last renewal that warrants road

test.

Age-based renewal procedures All licenses are valid for 5 years. However, license holders 61 and older cannot renew by mail.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Drivers should self-report medical conditions that may cause a lapse of consciousness, seizures, etc.

Physicians are encouraged but not required to report patients who have a medical condition that may

affect their ability to safely operate a motor vehicle.

Immunity Yes—no civil or criminal action may be brought against a physician or optometrist, licensed to practice

in Colorado, for providing a written medical or optometric opinion.

Legal protection No

DMV follow-up Driver notiﬁed in writing of referral. Driver undergoes re-examination. One circumstance for retest:

incident report from law enforcement. Medical clearance may be required from a physician.

Restrictions may be added to license.

Other reporting Will accept information from courts, police, other DMVs and family members.

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB Colorado does not currently retain a medical advisory board.

Medical Review contact information Questions about medical review can be referred to 303-205-5788

* Unless the driver is blind in one eye, testing each eye is not typically conducted.

Colorado

Name of State & DMV

contact information

Connecticut DMV Medical Review Division

60 State Street

Wethersﬁeld, CT 06161-2510

http://dmvct.org/

860-263-5223

Fax: 860-263-5774

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 better eye restricted; some

circumstances allow for license at

20/200 or better

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

100° monocular; 140° binocular

OPTEC 1000

Color vision Is there a color vision requirement? .............................................No (only for commercial drivers)

Road test A general on the road skills test with Motor Vehicle instructor or licensing agent. Test for “graduated

license’ conducted by off-site staff who makes and appt. with applicant at residence and conducts test

in State-owned, dual control vehicle. Applicant with speciﬁc needs is trained/tested by a Handicapped

Driver Training Unit certiﬁed driving instructor.

Restricted licenses Graduated license considerations include applicant’s health problem/condition, accident record and

driving history. Restrictions include: daylight only, corrective lenses, no highway driving, automatic

transmission only, required external mirrors, special controls or equipment, use of hearing aid.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

6 years

In-person at DMV full-service branch,

mobile units scheduled locations,

satellite ofﬁces, license renewal

centers, authorized AAA ofﬁces.

Yes, at age 65.

Only for new applicants or for

applicants whose license has

expired for two or more years.

Age-based renewal procedures Yes, age 65+ may renew for 2 years; age 65+ may renew by mail upon written application showing

hardship which shall include but not limited to proximity of operator’s residence to DMV renewal facility.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Sec 14-46 states that “physicians may report to the DMV, in writing the name, age, and address of any

person diagnosed by him to have any chronic health problem which in the physicians judgment will

signiﬁcantly affect the person’s ability to safely operate a motor vehicle.”

Immunity No civil action my be brought against the commissioner, the department or any of its employees, the

board or any if its members or any physician for providing any reports, records, examinations, opinions

or recommendations. Any person acting in good faith, shall be immune from liability.

Legal protection Only the laws regarding immunity apply.

DMV follow-up Driver notiﬁed in writing of referral to MAB. If MAB requires additional information for review in order to

make a recommendation, driver is requested to ﬁle the additional medical information requested; entire

ﬁle is referred back to MAB and driver is notiﬁed of such referral.

Connecticut

Connecticut (continued)

Other reporting State regulations, require “reliable information’ to be on ﬁle for DMV to initiate a medical review case.

This includes a written, signed report from person in medical/law enforcement profession., or a third

party report on the DMV afﬁdavit which requires signing in the presence of a notary public.

Anonymity All information on ﬁle in a medical review case is classiﬁed as “conﬁdential” but is subject to release to

the person at their representative, upon written authorization from the person to release the data.

Medical Advisory Board

Role of the MAB MAB must be comprised of 8 specialties: general medicine or surgery, internal medicine, cardiovascular,

medicine, neurology, or neurological surgery, ophthalmology, orthopedics, psychiatry or optometrist.

Advise commissioner on health standards relating to safe operation of motor vehicles; recommend

procedures and guidelines for licensing individuals with impaired health; assist in developing

medically acceptable standardized report forms; recommend training course for motor vehicle

examiners on medical aspects of operator licensure; undertake any programs/activities commissioner

may request relating to medical aspects of motor vehicle operator licensure; make recommendations

and offer advice on individual health problem cases referred and establish guidelines for dealing with

such individual cases.

Medical Review contact

information

Department of Motor Vehicles

Medical Review Division

60 State Street

Wethersﬁeld, CT 06161-2510

Name of State & DMV

contact information

Delaware Department of Safety

Division of Motor Vehicles

Medical Records

PO Box 698

Dover, DE 19903

www.dmv.de.gov

302-744-2507

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50 restricted license, beyond

20/50 driving privileges denied

Yes, on a case by case basis:

daytime only

Visual ﬁelds Minimum ﬁeld requirement .........................................................None

Color vision Is there a color vision requirement? .............................................None

Restricted licenses Yes, daytime only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

In person

Yes, must pass vision screening

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting Yes. Failure to do so is punishable by a ﬁne of $5 to $50. Physicians should report patients subject to

“losses of consciousness due to disease of the central nervous system.”

Physician/medical reporting Yes

Immunity Yes

Legal protection Unknown

DMV follow-up Driver notiﬁed in writing of referral; license suspended and further examination necessary.

Other reporting DMV will accept information from courts, other DMVs, police, and family members.

Anonymity Yes. DMV protects the identity of the reporter.

Medical Advisory Board

Role of the MAB If the DMV receives conﬂicting or questionable medical reports, they are sent to the MAB for a determi-

nation as to whether or not a person is medically safe to operate a motor vehicle.

Medical Review contact information Medical Records Section - Driver Improvement Unit

PO Box 698

Dover, DE 19903-0698

Phone: 302-744-2507

Fax: 302-739-5667

Delaware

Name of State & DMV

contact information

District of Columbia Department of Motor Vehicles

Medical Review Ofﬁce

301 C Street NW., Room 1033

Washington, DC 20001

http://dmv.washingtondc.gov/

202-727-6244

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70

20/40

20/40 acuity; 20/70 in better eye

requires 140 E visual ﬁeld for

restricted license.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

130° both eyes (may be approved by

director at 110°)

Confrontation or perimetry (Binocular)

Color vision requirement New drivers

Type of road test Road test is required for new drivers. Senior citizens may be required to take the read test on an

observational basis. Also, some physical disabilities may require re-testing.

Restricted licenses Yes: acuity not less than 20/70 and daytime, if ﬁeld of vision is 140°

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

IDC drivers with clean driver record

and no medical requirements can

now renew driver licenses on-line

Yes

Yes, however drivers are allowed a

6 months grace period

Age-based renewal procedures At age 70, the licensee must have the physician complete the certiﬁcation on the drivers license

application form.

Reporting Procedures

Physician/medical reporting If patient has a medical condition that may impair your ability to safely operate a motor vehicle, even

temporarily, you must provide a Medical and/or Eye Report* from your physician. Some of these condi-

tions include: Alzheimer’s disease: Requires a Medical Report* and the completion of the knowledge

and road skills tests; Seizure Disorder/Loss of Consciousness: Requires a Medical Report* DC regulation

states you must be seizure-free for at least twelvemonths prior to obtaining a driver’s license. If you are

currently licensed and experience a seizure or loss of consciousness, you must report the incident to

DMV within 30 days. Unless your physician indicates the seizure was due to a change in medication,

or strictly nocturnal, DMV will suspend your driving privilege for twelve months from the date of the

last episode; Insulin-dependent Diabetes: Requires a Medical and Eye Report; Vision impairment (i.e.,

glaucoma, cataracts, eye disease, and monocular vision): Requires an Eye Report*

Immunity No

Legal protection No

District of Columbia

District of Columbia (continued)

DMV follow-up DMV will use the medical information provided by your physician to determine if a driver’s license may

be issued or issued with restrictions. We may also issue a driver’s license for a shorter duration based

on your physician’s information. Also, if your doctor recommends follow-up Medical and/or Eye Reports,*

we will track this information to ensure compliance. If we do not receive the follow-up reports within the

timeframe speciﬁed by your physician, your license will be subject to suspension.

Other reporting A Medical Report* is also required when a law enforcement ofﬁcer suspects a driver may have a medi-

cal condition that led to a trafﬁc citation or accident. If DMV receives a detailed, written statement from

a family member, law enforcement ofﬁcer, or physician related to the unsafe driving of a resident, we

will also require the resident to complete a Medical Report.* Driving tests may also be required in any of

these situations, depending on the circumstances.

Anonymity Yes, reporters are allowed to remain anonymous

Medical Advisory Board

Role of the MAB DC-DMV does not currently have a Medical Advisory Board.

Medical Review contact information Referrals can be made to the contact above.

* Available at www.dmv.washingtondc.gov/info/forms/medical_eye_pdf.shtm

Name of State & DMV

contact information

Florida Division of Drivers License

Medical Review

Neil Kirkman Building, Room A227-MS 86

Tallahassee, FL 32399-0500

www.hsmv.state.ﬂ.us/ddl/dlfaq_new.html

850-488-8982 phone

850-921-6147 fax

Licensing Requirements

Visual acuity Each eye without correction ........................................................

Both eyes without correction .......................................................

Each eye with correction.............................................................

Both eyes with correction ...........................................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40: 20/50 or worse referred to eye

specialist for possible improvement

20/40: 20/50 or worse referred to eye

specialist for possible improvement

20/70, other eye better than 20/200

20/70, unless one eye 20/200

20/40

20/70

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

130° horizontal

None, Goldman by eye specialist if

indicated

Color vision requirement No

Type of road test Standard Road Test

Restricted licenses Yes: Corrective lenses, outside rearview mirror, business &/or employment purposes only, daylight

driving, automatic transmission, power steering, directional signals, grim on steering wheel, hearing

aid, seat cushion, hand control or pedal ext, left foot accelerator, probation interlock device, medical

alert bracelet, educational purposes, graduated license restrictions, other restrictions.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4–6 years, depending on driving

history

In-person, every 3

cycle

At in-person renewal only

Depending on driving history and/or

DL supervisor requires on the basis

of observation of physical or mental

impairments

Only if DL supervisor requires on the

basis of observation of physical or

mental impairments

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting “Any physician, person or agency having knowledge of a licensed driver or applicant’s mental or physi-

cal disability to drive may report the person to the Department of Highway Safety and Motor Vehicles.”

Forms are available on DHSMV Web site, as well as at local driver license ofﬁces. Physicians are

“authorized” by law and encouraged to report—DDL Medical Section provides other forms as situation

requires.

Immunity The law provides that no report shall be used as evidence in any civil or criminal trial or in any court

proceeding.

Legal protection Florida law “authorizes” the physician to report unsafe drivers.

DMV follow-up Investigation: Sanction actions if needed, Driver notiﬁed in writing.

Other reporting Law authorizes any person, physician or agency.

Anonymity Yes

Florida

Florida (continued)

Medical Advisory Board

Role of the MAB To advise the Department on medical criteria and vision standards and to make recommendations on

mental and physical qualiﬁcations of individual drivers.

Medical Review contact information MAB Chairperson

DHSMV/DDL/Driver Improvement Medical Section

2900 Apalachee Parkway

Tallahassee, FL 32399-0570

Telephone: 850-488-8982

Fax 850-921-6147

Name of State & DMV

contact information

Georgia Department of Public Safety

Attn: Medical Unit

PO Box 1456

Atlanta, GA 30371

www.dds.ga.gov/drivers/index.aspx

678-413-8500 or 678-413-8600

Outside Atlanta metro

866-754-3687

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/60

20/60 in either eye with or without

corrective lenses.

Yes, permitted for best acuity as low

as 20/200, with restrictions. 20/60

through telescope; 20/60 through

carrier

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

140° each eye; 140° both eyes

Juno Vision machine

Color vision requirement None

Type of road test N/A

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person

Yes

Not required for renewals

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting Yes. Physicians should report patients with a diagnosed “conditions hazardous to driving”

Physician/medical reporting Yes, physicians may report a person who has a handicap which would render the individual incapable

of safely operating a motor vehicle

Immunity No

Legal protection No

DMV follow-up Medical evaluation and retest

Other reporting Will take information from anyone with knowledge that the driver may be medically or mentally unsafe.

Anonymity No

Medical Advisory Board

Role of the MAB The Medical Advisory Board advises agency personnel on individual medical reports and

assists the agency in the decision making process.

Medical Review contact information Department of Motor Vehicle Safety

C/O Medical Unit

PO Box 80447

Conyers, GA, 30013

Georgia

Name of State & DMV

contact information

Honolulu Division of Motor Vehicles & Licensing

Drivers License Branch

1199 Dillingham Boulevard, Bay A-101

Honolulu, HI 96817

www.co.honolulu.hi.us/mvl.index.htm

808-532-7730

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 for better eye

Not allowed to meet visual ﬁeld

requirements, however permitted to

use while driving

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

70° one eye

Eye testing machine or eye specialist

certiﬁcation

Color vision Is there a color vision requirement? .............................................No

Road test N/A

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

2, 4 or 6 years

In person, or by mail

Yes

Only if necessary

Age-based renewal procedures After age 72, must renew every 2 years. Age 15 to 17 every 4 years, age 18 to 71 every 6 years

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity No

Legal protection No

DMV follow-up Driver notiﬁed in writing of referral.

Other reporting Will accept information from courts, police, other DMVs, and family members.

Anonymity N/A

Medical Advisory Board

Role of the MAB Action based on recommendation of majority.

Medical Review contact

information

General Information: Department of Transportation 808-692-7656

Case Speciﬁc, County of Issue:

Honolulu 808-532-7730

Hawaii: 808-961-2222

Kauai: 808-241-6550

Maui: 808-270-7363

Hawaii

Name of State & DMV

contact information

Idaho Transportation Department

Division of Motor Vehicles, Driver Services

PO Box 7129

Boise, ID 83707

http://itd.idaho.gov/dmv/online_services.htm

208-334-8735

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 in better eye for unrestricted

license; 20/50-20/60 requires annual

testing; 20/70 denied license

Yes, if acuity is 20/40 through lens,

20/60 through carrier

Visual ﬁelds Minimum ﬁeld requirement .........................................................None

Color vision requirement None

Type of road test Annual road test may be required to coincide with vision or medical re-testing requirements

Restricted licenses Available

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

DL expires 5 days after age 18 and

age 21. 4-year renewal age 21 and

older. 8-year renewal for age 21 to 62.

Mail in every other cycle, if 4 year DL,

not CDL’s

Yes

Only if requested by examiner, law

Enforcement agency, family member

or DMV. An annual road test may be

required to coincide with vision or

medical re-testing requirements.

Age-based renewal procedures After age 69, no renewal by mail.

Reporting Procedures

Physician/medical reporting Yes (not speciﬁed)

Immunity None

Legal protection N/A

DMV follow-up License suspended upon referral.

Other reporting Will accept information from family members, other DMVs, and law enforcement ofﬁcers.

Anonymity Not anonymous or conﬁdential

Medical Advisory Board

Medical Desk Technician The medical information submitted is initially reviewed by employees within the Driver Support Division

who work speciﬁcally with medical cases.

Role of the MAB Idaho does not have an MAB.

Medical Review contact information MVR/Medical Unit Supervisor can be reached at 208-334-8716

Idaho

Name of State & DMV

contact information

Illinois Ofﬁce of the Secretary of State

Driver Services Department–Downstate

2701 S. Dirksen Parkway

Springﬁeld, IL 62723

Driver Services Department–Metro

17 N. State Street, Suite 1100

Chicago, IL 60602

www.sos.state.il.us/departments/drivers/drivers.html

217-785-0963

312-814-2975

Licensing Requirements

Visual acuity Each eye with/without correction ...................................

Both eyes with/without correction .................................

If one eye blind—other with/without correction ..............

Absolute visual acuity minimum ....................................

Are bioptic telescopes allowed? ....................................

20/40

20/40 in better eye unrestricted; 20/70 in

better eye daylight only restrictions,

Yes, may have 20/100 in better eye and 20/40

through bioptic telescope.

Visual ﬁelds Minimum ﬁeld requirement ............................................

Visual ﬁeld testing device ..............................................

105° one eye, 140° both eyes

Stereo optical testing machine

Color vision Is there a color vision requirement? ................................ No

Road test Type of road test ...........................................................On-road driving test

Restricted licenses Yes: daytime, two outside mirrors

License Renewal Procedures

Standard Length of license validation...........................................

Renewal options and conditions ....................................

Vision testing required at time of renewal? ....................

Written test required? ...................................................

Road test required? ......................................................

4 years

Mail in every other cycle for drivers with clean

records and no medical report

At in-person renewal only

Every 8 years unless clean driving record

Only for applicants age 75+

Age-based renewal procedures Age 81–86 every 2 years, at age 87 reduce renewal to 1 year. Age 75+ no renewal by mail, vision test

required, and on-road driving test required.

Reporting Procedures

Mandatory medical reporting Are physicians required/encouraged to report “unsafe”

drivers?

Are physicians required to report patients with certain

medical conditions?

Physicians are encouraged to inform patients

of their responsibility to notify the Secretary

of State of any medical conditions that may

cause a loss of consciousness or affect safe

operation of a motor vehicle within 10 days of

becoming aware of the condition.

Physician/medical reporting Are physicians exempt from liability for civil damages

caused by the patient if they report the patient to the

DMV beforehand?

Yes

Immunity Does the State offer the physician legal protection for

breaking the patient’s conﬁdentiality?

N/A. Illinois is not a mandatory reporting State.

Legal protection How does the DMV follow up? Driver notiﬁed in writing of referral. Driver

required to submit a favorable medical report.

Determination of further action based on

various scenarios.

Illinois

DMV follow-up Aside from physicians, who else can report? Will accept information from courts, foreign

State DMVs, law enforcement, member of

the IL Medical Advisory Board, NDR, PDPS,

SOS management employee, FMCSA, driver

rehabilitation specialist, or self-admission.

Other reporting Does the DMV protect the identity of the reporter? Yes

Anonymity Does the DMV protect the identity of the reporter? Yes

Medical Advisory Board

Role of the MAB Review the medical report and make a determination as to the status of the driving privileges of the

driver. Decision of the MAB implemented by the Secretary of State.

Medical Review contact

information

Supervisor, Medical Review Unit

Ofﬁce of the Secretary of State

Driver Services Department

2701 South Dirksen Parkway

Springﬁeld, IL 62723

217-785-3002

Name of State & DMV

contact information

Indiana Bureau of Motor Vehicles

Medical Section

Indiana Government Center North

100 N Senate Avenue. Room N402

Indianapolis, IN 46204

www.mybmv.IN.gov

317-233-6000

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40 minimum each eye without

restrictions. 20/50 each eye with

correction = glasses/contacts restric-

tion required unless vision referral

presented with approval from Medical

Advisory Board specifying that cor-

rective lenses will not improve acuity.

Indiana tests each eye individually

One eye 20/40 other eye 20/50

through blind without correction =

outside rearview mirrors restriction.

One eye 20/40 other eye 20/50

through blind with correction =

glasses/contacts, outside rearview

mirrors restriction.

One eye 20/50 other eye 20/70

through blind with correction =

glasses/contacts, outside rearview

mirrors and daylight driving only

restrictions.

The absolute minimum visual acuity

obtained by a customer service rep-

resentative in order to issue a license

is 20/70 in each eye with correction

= glasses/contacts, outside rearview

mirrors and daylight driving only

restrictions for licensing. The BMV will

license an individual with less acuity

upon the recommendation of the

Medical Advisory Board.

Yes, for acuity as low as 20/200

if 20/40 can be achieved with

telescope = restrictions apply

Visual ﬁelds Minimum ﬁeld requirement .........................................................N/A for standard license renewal,

70° one eye, 120° both eyes

(when required)

Color vision Is there a color vision requirement? .............................................N/A for standard renewal

Road test Type of road test ........................................................................Standardized road tests are

administered by State examiners

Special/courtesy drives tests

(extended) are administered

by a State senior examiner

Restricted licenses A variety of restrictions are available—most common restriction is for corrective lenses

Indiana

* Testing (visual, written or skills) to obtain a 4-year commercial driver license is more stringent per Federal guidelines than for renewal

of a standard operator license as stated here.

Indiana (continued)

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

Standard length of license validation

Operator License

June 7th 2007–Dec. 31st 2007:

5 years

Jan. 1st 2008–Dec. 31st 2008:

4 years

Jan. 1st 2009: 6 years

In person

Yes (acuity)

Yes, if new to State, if 6 or more

points appear on the driving record,

if expired more than 2 years or

recommended by the Medical

Advisory Board.

Yes, if new from out of country, if out

of State license is expired more than

1 year, if Indiana license is expired

more than 3 years or in the event the

bureau receives evidence of driving

impairment

Age-based renewal procedures Licenses issued to individuals under the age of 18 expire at midnight on the individuals’ 21st birthday.

Age 75–84, renewal cycle is reduced to 3 years

Age 84 +, renewal cycle is reduced to 2 years.

Reporting Procedures

Mandatory medical reporting None

Physician/medical reporting Drivers should self-report medical conditions that may cause lapse of consciousness, seizure, etc.

Physicians are encouraged but not required to report to the bureau a patient who may have a medical

condition that would adversely affect their ability to operate a motor vehicle safely.

Immunity A physician licensed to practice medicine under IC 25-22.5, an optometrist licensed to practice

optometry under IC 25-24, or an advanced practice nurse licensed under IC 25-23 who has personally

examined the patient not more than thirty (30) days before making a report concerning the patient’s

ﬁtness to operate a motor vehicle is not civilly or criminally liable for a report made in good faith to the:

(1) bureau;

(2) commission; or

(3) driver licensing medical advisory board;

concerning the ﬁtness of a patient of the physician, optometrist, or advanced practice nurse to operate

a motor vehicle in a manner that does not jeopardize the safety of individuals or property.

Legal protection Applicable immunity law only.

DMV follow-up Written notiﬁcation.

Other reporting Will accept information from courts, law enforcement, family members and other reliable sources

Anonymity The BMV protects the identity of the reporter, unless information is required by a court of law

Medical Advisory Board

Role of the MAB MAB advises the Bureau of Motor Vehicles on medical issues regarding individual drivers. Actions are

based on the recommendation of the majority and/or specialist.

Medical Review contact information Referrals can be faxed to 317-233-3138. Questions should be directed to 317-232-0901

Name of State & DMV

contact information

Iowa Department of Motor Vehicles

IA DOT, Park Fair Mall

100 Euclid Avenue, PO Box 9204

Des Moines, IA 50306-9204

www.dot.state.ia.us/mvd/

515-237-3201

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50 daylight driving only, 20/70

in better eye restricted license for

daylight only up to 35 mph; 20/100

recommendation from vision special-

ist, if worse—recommendation from

MAB; absolute minimum 20/200

Visual ﬁelds Minimum ﬁeld requirement .........................................................140° both eyes. With outside mirrors

70°T + 45° N one eye, 115° both

eyes. If less than 95° both eyes and

60°T+35°N one eye need MAB

recommendation

Color vision Is there a color vision requirement? .............................................No

Road test Type of road test ........................................................................Non-ﬁxed Course, general trafﬁc

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

2 or 4 years

In-person, extensions available if out

of State for 6 months.

Yes, If physical or mental condition

present

Age-based renewal procedures At age 70, renewal every 2 years.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting A physician may report to the department of motor vehicles “the identity of a person who has been di-

agnosed as having a physical or mental condition which would render the person physically or mentally

incompetent to operate a motor vehicle in a safe manner.

Immunity Yes

Legal protection Yes—321.186 A physician or optometrist making a report shall be immune from any liability, civil or

criminal, which might otherwise be incurred or imposed as a result of the report

DMV follow-up Driver notiﬁed in writing of referral. License suspended upon referral.

Other reporting Will accept information from courts, other DMVs, police and family members.

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB To review medical/vision reports as requested and advise of their recommendation to a person’s capa-

bility to drive safely.

Medical Review contact

information

Iowa Department of Transportation Des Moines, IA 50306-9204

Ofﬁce of Driver Services Phone 800-532-1121

PO Box 9204

Iowa

Name of State & DMV

contact information

Kansas Division of Motor Vehicles, Driver Control

Docking State Ofﬁce Building

915 SW Harrison Street 1st Floor

Topeka, Kansas 66625

www.ksrevenue.org/dmvdrlic.htm

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 better eye unrestricted, 20/60

better eye with doctor report, worse

than 20/60 must demonstrate ability

to operate a vehicle and safe driving

record for 3 years.

Yes, with eye doctor’s report.

Visual ﬁelds Minimum ﬁeld requirement ......................................................... Worse than 110° with both eyes and

55° monocular

Color vision requirement None

Type of road test Non-ﬁxed course

Restricted licenses Up to 4 restrictions can be added, at doctors/examiners discretion. These can include: corrective

lenses, daylight only, no interstate driving, outside business area, within city limits, mileage restriction

in increments of 5 mi. up to 30, outside mirror, mechanical aid, automatic transmission, prosthetic aid,

licensed driver in front seat.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

6 years

In person

Yes

Yes, by examiner challenge or for visual

acuity, or at medical doctor request.

Age-based renewal procedures At age 65, renewal every 4 years. There is no age-based road test.

Reporting Procedures

Mandatory medical reporting No, statutes specify that physicians may not be required to volunteer information to the division or to the

medical advisory board concerning the mental or physical condition of any patient

Physician/medical reporting N/A

Immunity Yes, people reporting in good faith are statutorily immunized from civil actions for damages caused by

such reporting.

Legal protection Patient has to sign a form to show it is ok for M.D. or O.D. to release information to DMV.

DMV follow-up Driver is notiﬁed in writing of referral.

Other reporting Will accept information from courts, other DMVs, police and family members, concerned citizens.

Letters must be signed.

Anonymity Yes. Letters of concern are conﬁdential.

Medical Advisory Board

Role of the MAB To help Director of Vehicles and Driver Review interpret conﬂicting information or action based on

recommendation of specialists. Determine eligibility of hardest or borderline cases.

Medical Review contact information Kansas Driver Review, Medical Advisory Board

915 SW Harrison Room 162 | Topeka, KS 66626

785-296-3601

Kansas

Name of State & DMV

contact information

Kentucky Division of Driver Licensing

200 Mero Street

Frankfort, KY 40622

www.kytc.state.ky.us/drlic

502-564-0280

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/60

20/60 with corrective lenses

Yes, with distance acuity of 20/60

or better using a bioptic telescopic

device. KRS 186.578(1)c.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Binocular horizontal ﬁeld of vision of

at least 35 degrees to the left and

right side of ﬁxation and a binocular

vertical ﬁeld of vision of at least 25

degrees above and below ﬁxation.

N/A

Color vision Is there a color vision requirement? .............................................No

Road test Medical Advisory Board may recommend further examination or investigative testing.

Restricted licenses Available

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity Yes

Legal protection None

DMV follow-up Driver notiﬁed in writing of referral to medical advisory board.

Other reporting Will accept information from courts, other DMVs, family members and police.

Anonymity None

Medical Advisory Board

Role of the MAB The medical advisory board identiﬁes drivers with physical or mental impairments that impede their

ability to safely operate a motor vehicle.

Medical Review contact

information

Questions regarding medical review can be directed to 502-564-0280 ext. 2174.

FAQs for medical review can be found at http://transportation.ky.gov/DrLic/mrb/MRB.htm

Kentucky

Name of State & DMV

contact information

Louisiana Ofﬁce of Motor Vehicles

Drivers License Suspension Unit

PO Box 64886

Baton Rouge, LA 70896

www.expresslane.org

225-925-3929

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 in better eye unrestricted,

20/50-20/70 better eye with restric-

tions, 20/70-20/100 better eye with

possible restricted license. Less than

20/100 for better eye refer to MAB

Visual ﬁelds Minimum ﬁeld requirement .........................................................No

Color vision Is there a color vision requirement? .............................................No

Restricted licenses Yes, daytime only, weather restrictions, radius limitation, no interstate driving

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person or mail in every other cycle,

Internet, interactive voice response,

unless license expired 6 months or

more.

Yes

Yes, if expired one year or more

Yes, if expired 2 years or more

Age-based renewal procedures No renewal by mail for drivers over the age of 70

Reporting Procedures

Mandatory medical reporting No, there is no statutory provision requiring physicians to report patients

Physician/medical reporting N/A

Immunity Yes, a physician who provides such information has statutory immunity from civil or criminal liability

for damages arising out of an accident.

Legal protection Louisiana has statutory protection for good faith reporting of unsafe drivers.

DMV follow-up Driver is notiﬁed in writing of referral.

Other reporting DMV employee or agent in performance of duties, law enforcement ofﬁcer, health care provider,

or family member

Anonymity An order from a court of competent jurisdiction required before identity of reporter can be released.

Medical Advisory Board

Role of the MAB The medical advisory board identiﬁes drivers with physical or mental impairments that impede their

ability to safely operate a motor vehicle.

Medical Review contact

information

Questions regarding medical review can be directed to 502-564-0280 ext. 2174.

FAQs for medical review can be found at http://transportation.ky.gov/DrLic/mrb/MRB.htm

Louisiana

Name of State & DMV

contact information

Maine Bureau of Motor Vehicles

Attn: Medical Unit

29 State House Station

Augusta, ME 04333-0029

www.state.me.us/sos/bmv

209-624-9000

Licensing Requirements

Visual acuity Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 with restrictions

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

110° both eyes-Class D only

Keystone View

Color vision requirement None

Type of road test Assesses general driving skills

Restricted licenses Yes: daytime only, radius from home, special equipment

License Renewal Procedures

Standard Length of license validation.........................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

6 years

At age 40, 52, 65 and every 4 years

thereafter

Age-based renewal procedures At age 65, renew every 4 years.

Reporting Procedures

Mandatory medical reporting Yes

Physician/medical reporting Yes

Immunity Yes

Legal protection Yes

DMV follow-up Requires a medical evaluation form to be completed by a physician at periodic intervals

Other reporting Will accept information from courts, other DMVs, police, family members and other resources

Anonymity Yes, but identity may be revealed at an administrative hearing if requested.

Medical Advisory Board

Role of the MAB The Medical Advisory Board reviews the medical information submitted whenever a person contests a

Division action. Reports received or made by the Board are conﬁdential and may not be disclosed unless

the individual gives written permission

Medical Review contact information The Medical Review Coordinator can be reached at 207-624-9101

Maine

Name of State & DMV

contact information

Maryland Motor Vehicle Administration

6601 Ritchie Highway, NE

Glen Burnie, MD 21062

www.marylandmva.com

301-729-4550 or

800-950-1682

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

If one eye blind—other with correction ........................................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 in better eye for restricted;

20/70-20/100 requires special

permission from MAB.

Yes: daytime only, outside mirrors

20/70 through telescope. 20/100

through carrier lens.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Continuous ﬁeld of vision at least

140E in each eye unrestricted; 70°

(+/- 35°)/110°

Stereo Optical Optec 1000

vision screener

Color vision requirement Only for commercial drivers

Type of road test N/A

Restricted licenses Yes: daytime only, outside mirrors for low vision drivers

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 year

In-person

Yes (binocular, acuity, peripheral)

Age-based renewal procedures Are there any age-based license renewal procedures?

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Maryland law provides for the discretionary reporting to the Motor Vehicle Administration of people who

have “disorders characterized by lapses of consciousness”

Immunity Yes, a civil or criminal action may not be brought against any person who makes a report to the Medical

Advisory Board and who does not violate any conﬁdential or privileged relationship conferred by law.

Legal protection Action may not be brought against any person who makes a report to the Medical Advisory Board and

does not violate any conﬁdential or privileged relationship conferred by law.

DMV follow-up Driver is notiﬁed in writing of referral. License is suspended and further examination is required.

Other reporting Will accept information from court, other DMVs, police, family members and other resources.

Anonymity Yes, if requested

Medical Advisory Board

Role of the MAB The MAB advises the Motor Vehicle Administration regarding medical review for ﬁtness to drive through

its Division of Driver Wellness and Safety.

Medical Review contact information Manager, Driver Wellness & Safety Division, Maryland Motor Vehicle Administration

6601 Ritchie Highway, NE | Glen Burnie, MD 21062

410-424-3644; Fax: 410-768-7627

Maryland

Name of State & DMV

contact information

Massachusetts Medical Affairs

PO Box 199100

Boston, MA 02119

www.state.ma.us/rmv/index.htm

617-351-9222

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

N/A

20/40 better eye unrestricted; 20/50-

2070 in better eye results in daylight

only restriction.

Yes. As long as 1) The peripheral

vision is at least 120; 2) Vision is

corrected to 20/40 through the biop-

tic and 20/100 through the carrier

lens. Also, must have at least 20/100

in the other eye. The bioptic must

meet certain requirements: it must

be monocular, ﬁxed focus, no greater

than 3X magniﬁcation, and must be

an “integral part of the lens”

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

120°

Optec 1000 Vision Testing Machine

Color vision requirement Yes—distinguish red, green and amber

Type of road test N/A

Restricted licenses Yes: daytime only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 Years

In person, or via Internet.

Yes

No; however DMV reviews on

case-by-case basis and if indicated

will administer test.

No; however DMV reviews on

case-by-case basis and if indicated

will administer test.

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No, MA is a self-reporting State, meaning it is the responsibility of the driver to report to the RMV any

medical condition that may impair driving ability.

Physician/medical reporting Yes, physicians are encouraged to report unﬁt drivers to the RMV.

Immunity No, the law does not provide any protection from liability, nor does it promise conﬁdentiality due to

“Public Records” law which states simply that a driver is entitled to any information upon receipt of

written approval.

Legal protection No, see “Immunity”

Massachusettes

Massachusettes (continued)

DMV follow-up If report comes from family or member of public it must be in writing and signed. If report is accepted,

then driver contacted by mail and asked to obtain medical clearance to certify that he/she is safe to

drive. If DMV does not receive a response within 30 days a second request is mailed. If still no re-

sponse, a license revoked.

If report is from law enforcement or physician, it is considered “immediate threat.” Driver is contacted

by mail and requested to voluntarily surrender license or submit medical clearance within 10 days.

If no response, license revoked.

Other reporting Will accept information from court, other DMVs, police, family members and other resources.

Anonymity No, see “Immunity”

Medical Advisory Board

Role of the MAB The purpose is to provide guidance to the Registry when a medical issue has been raised regarding the

ability of applicants for learner’s permits and licenses to operate a motor vehicle and for those whose

privileges to operate a motor vehicle has been (or should be) restricted, suspended or revoked. One of

our goals in consulting with the MAB on matters requiring medical expertise is to bring consistency to

these decision making processes.

Medical Review contact

information

Registry of Motor Vehicles

Director of Medical Affairs

PO Box 55889

Boston, MA 02205-5889

Attn: Director of Medical Affairs

Fax: 617-351-9223

100

Name of State & DMV

contact information

Michigan Department of State

Driver Assessment and Appeal Unit

PO Box 30196

Lansing, MI 48909-7696

www.michigan.gov/sos

517-335-7051 phone

517-335-2189 fax

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 to and including 20/50

20/50

Minimum of 20/70 in better eye

with no progressive abnormalities

of the eye, daylight only restriction;

Minimum of 20/60 in better eye if

progressive abnormalities or disease

of the eye, daylight only restriction.

Yes, will require a road test for all

ﬁrst-time users.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

110°-140° both eyes; less than 110°

to/including 90° additional condi-

tions and requirements; less than 90

degrees, no driving allowed.

Optic 1000 DMV Vision Tester

Color vision requirement No

Type of road test Standardized course and requirements with various locations throughout the State

Restricted licenses Yes. Restrictions are based on review of medical input and reexamination testing. Examples include

radius driving, daylight only driving, no expressway driving.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

Mail in every other cycle, if free of

convictions

Yes

No. A written test is not required

at the time of renewal. It may be

required at driver assessment re-

examinations and to obtain an

original license.

Yes, if license expired more than

4 years.

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are encouraged to report unsafe drivers to the Department of State for evaluation.

Immunity No

Legal protection No

DMV follow-up The driver is notiﬁed in writing of the request for evaluation. The Department may require the driver to

submit updated medical information and to appear for reexamination and testing. The testing includes a

vision screening, written exam, and on-road driving evaluation.

Other reporting The Department accepts requests for driver evaluation from family, police, public ofﬁcials and any other

concerned persons who have knowledge of a driver’s inability to drive safely or health concerns that

may affect his/her driving ability.

Michigan

101

Michigan (continued)

Anonymity The Department of State cannot accept anonymous requests for driver evaluation. The requestor must

include his/her name, address, daytime phone number and signature. The Department would protect

the identity of the author of the request for driver evaluation to the extent allowed by law.

Medical Advisory Board

Role of the MAB Current medical reviews are based on recommendation of specialist. The Department of State is in the

process of reestablishing a Medical Advisory Board. The Department intends for the MAB to review

current Department medical review processes and establish updated guidelines for the medical review

of Michigan drivers.

Medical Review contact

information

Driver Assessment and Appeal Division can be reached at 517-335-7051.

102

Name of State & DMV

contact information

Minnesota Medical Unit

445 Minnesota Street, Suite 170

Town Square Building

St. Paul, MN 55101-5170

www.dps.state.mn.us/dvs/index.html

651-296-2021

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 in better eye with speed

limitations, 20/80 referred to a

driver evaluation unit; 20/100 denied

license

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

105° unrestricted

Yes, at renewal

Color vision requirement No

Type of road test 20/80, special test with driver exam supervisor

Restricted licenses Yes: daytime, area restriction, speed, no freeway

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person

Yes

Only if driver license expired more

than 1 year

If driver license is expired more than

5 years

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physician reporting is encouraged

Immunity Yes

Legal protection Not addressed in driver licensing laws

DMV follow-up Driver is notiﬁed in writing of referral. License is suspended upon referral and further examination is

conducted.

Other reporting Will accept information from court, other DMVs, police, family members and other resources.

Anonymity Yes, unless court subpoenas record

Medical Advisory Board

Role of the MAB Action is based on recommendation of majority.

Medical Review contact

information

Minnesota Department of Public Safety

Medical Unit

445 Minnesota Street, Suite 170

St. Paul, MN 55101-5170

651-296-2021

Minnesota

103

Name of State & DMV

contact information

Mississippi Driver Improvement

PO Box 958

Jackson, MS 39205

www.dps.state.ms.us

601-987-1231

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 daytime

Yes, 20/70 with telescope

Visual ﬁelds Minimum ﬁeld requirement ......................................................... 140° unrestricted; one eye T 70°; N

35° with 2 outside mirrors

Color vision requirement No

Type of road test

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person

No (an exception can be made if

examiner feels testing is warranted)

Age-based renewal procedures Those 71 and older are not allowed to do on-line renewal.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting

Immunity No

Legal protection

DMV follow-up Patient is called into DMV ofﬁce for road and vision test when they receive a report from any source.

Other reporting Will accept information from court, other DMVs, police and family members.

Anonymity Yes, granted for all reporters.

Medical Advisory Board

Role of the MAB In situations where the DMV is unsure, cases are reviewed by an external medical panel convened by

the State medical board.

Medical Review contact

information

The medical board can be reached at 601-853-6733

Questions about referrals to the DMV should go to 601-987-1231

Mississippi

104

Name of State & DMV

contact information

Missouri Drivers License Bureau

Attn: Medical Review

PO Box 200

Jefferson City, MO 65105

http://dor.mo.gov/mvdl/drivers/

573-751-2730

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50

20/160 for restricted

Not for meeting vision requirements

but can be used for skills tests and

while driving

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

55° or better in both eyes; 85° in one

eye with restrictions

Objective/Quantitative

Color vision requirement No

Restricted licenses Yes. As long as they meet the vision requirements, we have restrictions for equipment, speed,

radius, (location of driving) time of day and/or length of time driving. Virtually any restriction a doctor

or examiner recommends.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

6 years

In person, or renewal by mail if out

of State.

Yes

Only if license is expired for more

than 6 months (184 days) or if an

individual is cited and after the review

process a written test could be

required.

See written test requirement above.

Age-based renewal procedures At age 70, reduction in renewal cycle to 3 years. Also, any school bus driver 70 or older must renew

their School Bus Permit annually. Below 70, renewal is every 3 years.

Reporting Procedures

Mandatory medical reporting Not mandatory but encouraged for any condition that could impair or limit a person’s driving ability.

A form is available (form 1528, Physician’s Statement) but not required. Forms are available at the

Department of Revenue, P.O. Box 200 Jefferson City, Mo 65105-0200. Attention Medical Review.

Physician/medical reporting Medical professionals will not be prevented from making a report because of their physician-patient

relationships 302.291.

Immunity Yes, an individual is immune from civil liability when they have made a report in good faith.

Legal protection See Physician Reporting Laws above.

DMV follow-up Depending on the information received, we may ask for additional information, add restrictions, require a

written exam, skills test, vision exam, physical exam or deny the privilege.

Other reporting Will accept information from court, DMV clerks, peace ofﬁcers, social workers and family members

within three degrees of consanguinity.

Anonymity Yes

Missouri

105

Missouri (continued)

Medical Advisory Board

Role of the MAB The Medical Advisory Board evaluates each case on an individual basis. The medical information

is reviewed by staff personnel of the Driver’s License Bureau. The MAB relies on the person’s

physician’s opinion on whether the applicant or licensee can drive safely. Action is based on

recommendation of majority.

Medical Review contact information Attention Medical Review

Department of Revenue

P.O. Box 200

Jefferson City, Mo 65105-0200

573-751-2730

Fax: 573-522-8174

http://dor.mo.gov/mvdl/drivers/faq/doctor.htm

106

Name of State & DMV

contact information

Montana Motor Vehicles Division

Medical Unit

PO Box 201430

Helena, MT 59620-1430

www.doj.mt.gov/driving/default.asp

406-444-4536

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 in better eye with restrictions

on daylight and speed; 20/100 in

better eye, with possible restricted

license.

Yes, 20/100 through carrier lens

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Only for commercial drivers

Optic 1000

Color vision requirement Commercial only

Type of road test Figure-8, 3 left and 3 right turns, 2 stop signs, through intersection and parallel parking.

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

8 years; if renewing by mail a 4 year

license is issued—next renewal

requires a personal appearance by

the applicant. Commercial licenses

are now only good for 5 years.

Yes

Discretion of examiner if safe

operation of the motor vehicle is in

question.

Same as written requirement

Age-based renewal procedures For ages 68 to 74, renewal cycle reduced to 1–6 years. At age 75, renewal cycle is reduced to 4 years.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are encouraged to report

Immunity Yes, There is a statute giving the physician immunity from liability for reporting in good faith any patient

whom the physician diagnoses as having a condition that will signiﬁcantly impair the patient’s ability to

safely operate a motor vehicle. No action may be brought against a physician for not making such a report.

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity State is required to tell person who reported them, if asked.

Medical Advisory Board

Role of the MAB Montana does not have a Medical Advisory Board

Medical Review contact information Supervisor

Records and Control Bureau

303 North Roberts

Helena, Montana 59620

Montana

107

Name of State & DMV

contact information

Nebraska Department of Motor Vehicles

Driver License Examining Division

PO Box 94726

Lincoln, NE 68509

www.dmv.state.ne.us

402-471-3861

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70, the other eye not blind;

17 restrictions are used, depending

on vision in each eye

Yes, 20/70 minimum through

telescope

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Less than 100° denied, 140° both eyes

Vision Machine

Color vision requirement Commercial only

Type of road test On the road test that includes requirements such as emergency stop, right turns, left turns, etc.

Restricted licenses Yes, Nebraska offers restricted licenses.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Must apply in person before a driver

license employee. Individuals who re-

side out-of-state during their renewal

time may renew via mail.

Yes

Only if license is expired over 1 year

or license is suspended, revoked or

cancelled.

Only if license is expired over 1 year

or license is suspended, revoked or

cancelled.

Age-based renewal procedures No. Nebraska does not have age-based renewal regulations.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes, encouraged but not required.

Immunity No

Legal protection No

DMV Follow-up Drivers are notiﬁed by certiﬁed mail that they must appear for retesting. Drivers are also required to bring

in a vision and medical statement that has been completed by their physicians within the last 90 days.

Other reporting Will accept information from law enforcement and other concerned parties.

Anonymity Yes, unless the driver appeals the denial or cancellation of their license to District Court.

Nebraska

108

Nebraska (continued)

Medical Advisory Board

Role of the MAB To provide advice to the Department concerning the physical a mental ability of an applicant or holder of

an operator’s license to operate a motor vehicle.

Medical Review contact information Driver’s License Administrator

Nebraska Department of Motor Vehicles

P.O. Box 94789,

301 Centennial Mall South

Lincoln, NE 68509

109

Name of State & DMV

contact information

Nevada Department of Motor Vehicles

Management Services and Programs Division

555 Write Way

Carson City, NV 89711

www.dmvnv.com

775-684-4717

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50, other eye no worse than

20/60 daylight driving only.

Yes, 20/40 through telescope, 20/120

through carrier, 130 E visual ﬁeld.

Visual ﬁelds Minimum ﬁeld requirement ......................................................... Binocular 140° unrestricted

Binocular 110°-140° restricted

Color vision requirement None

Type of road test Yes, if the vision specialist’s report does not meet the 20/40 standard but within the minimum (restrict-

ed) acuity levels for licensing.

Restricted licenses Yes; daytime only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

Mail-in or Internet every other cycle.

Yes

Only if license classiﬁcation

has changed

Only if license classiﬁcation

has changed

Age-based renewal procedures Vision test and medical report required to renew by mail at age 70.

Reporting Procedures

Mandatory medical reporting Yes. Physicians are required to report patients diagnosed with epilepsy or any seizure disorder or lapse

of consciousness

Physician/medical reporting Yes

Immunity Yes

Legal protection Yes

DMV follow-up Letters and suspensions

Other reporting Court, other DMVs, police and family members.

Anonymity Yes

Medical Advisory Board

Role of the MAB Advisory role to DMV. Developing medical and health standards. Advisory role regarding medical reports

submitted to determine the mental or physical condition of the applicant. The department has the

authority to have a Medical Advisory Board due to Nevada Administrative Code 483.380. However, due

to the cost, Nevada has been unable to have such an advisory board in place.

Medical Review contact information Questions about medical review can be directed to 775-684-4717.

Nevada

110

Name of State & DMV

contact information

New Hampshire Department of Motor Vehicles

Directors Ofﬁce

10 Hazen Drive

Concord, NH 03305

www.state.nh.us/dmv

603-271-2371

Licensing Requirements

Visual acuity Vision in both eyes .....................................................................

Vision in one eye ........................................................................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/30

20/70, restricted to daytime only

Yes

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Snellen Eye chart or Stereo Optical

Viewer

Color vision requirement No

Type of road test Yes, on road practical

Restricted licenses Yes, daytime only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In-person

Yes

Age-based renewal procedures No special requirements for age.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are encouraged to report

Immunity N/A

Legal protection No, as reporting is not a requirement

DMV follow-up Full re-examination and in some cases an administrative hearing

Other reporting Will accept information from court, other DMVs, police, and family members.

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB None

Medical Review contact

information

Department of Safety

Division of Motor Vehicles

Driver Licensing

23 Hazen Drive

Concord NH 03305

603-271-2371

New Hampshire

111

Name of State & DMV

contact information

New Jersey Division of Motor Vehicles

Medical Division

PO Box 173

Trenton, NJ 08666

www.njmvc.gov

609-292-4035

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/50

Yes, 20/50 through telescope

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

N/A

Color vision requirement Yes—new drivers (not cause for denial)

Type of road test Standardized

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In-person digitized photos were

implemented in 2003.

Only if recommended.

If recommended by examiner

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting Yes. Only for cases of recurrent loss of consciousness

Physician/medical reporting Physicians are required to report patients who experience convulsive, seizures, recurrent periods of

unconsciousness, impairment or loss or loss of motor coordination.

Immunity Yes

Legal protection No

DMV follow-up A medical review is generated. Results of the medical review may result in suspension of license; the

driver may request an appeal.

Other reporting Will accept information from police, family, other agencies, courts, and other concerned persons. MVC

will not generate a letter based on an anonymous letter.

Anonymity No

Medical Advisory Board

Role of the MAB New Jersey has forms for each type of medical condition that may be cause for concern. Form is com-

pleted by driver’s physician. In problem cases, then passed on to the Medical Advisory Board. MAB is a

multidisciplinary group of physicians who then make licensing recommendations based on information.

Medical Review contact

information

New Jersey Division of Motor Vehicles

609-292-7500 ext. 5032

Medical Division

PO Box 173

Trenton, NJ 08666

New Jersey

112

Name of State & DMV

contact information

New Mexico Motor Vehicles Division

Driver Services, Attn: Medical

PO Box 1028

Santa Fe, NM 87504-1028

www.state.nm.us/

505-827-2296

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/80 better eye with restrictions

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

120°E, 30° in nasal ﬁeld of one eye

Normal Ophthalmic Procedures

Color vision requirement No

Type of road test

Restricted licenses Yes

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 or 8 years

Yes

May be required

Age-based renewal procedures Drivers may not apply for 8-year renewal, if they turn 75 during the last 4 years of the 8-year period.

Becomes 1-year renewal after age 75.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes

Immunity Yes

Legal protection No

DMV follow-up By notice, drivers are informed that their licenses will be cancelled in 30 days unless they provide a

medical report clearing them to drive. If they do not provide reports, their licenses are cancelled.

Other reporting Will accept information from court, other DMVs, police, and family members.

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB Periodic medical updates required by drivers with certain medical conditions including epilepsy,

diabetes, and certain heart conditions. The DMV learns of an individual’s condition through questions

asked on the application

Medical Review contact information New Mexico MVD Driver Services Bureau can be reached at 505-827-2296.

New Mexico

113

Name of State & DMV

contact information

New York Department of Motor Vehicles

Attn: Driver Improvement Bureau

6 Empire State Plaza

Albany, NY 12228

www.nydmv.state.ny.us

518-474-0841

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

For applicants with visual acuity less

than 20/40 but not less than 20/70,

can complete form MV-80L and

submit for licensing consideration.

Yes

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

20/40-20/70 best corrected requires

140 E horizontal visual ﬁelds; 20/80-

20/1000 best corrected requires

minimum 140 E horizontal visual ﬁeld

plus 20/40 through bioptic telescope

lens

Eye chart

Color vision requirement No

Type of road test Standard road test, includes basic maneuvers needed for everyday driving.

Restricted licenses Yes: daytime only, radius from home, annual vision update

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

8 years

Mail or in person

Yes

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity No

Legal protection N/A

DMV follow-up If a physician reports a condition that can affect the driving skills of a patient, the DMV can suspend the

driver license. The DMV suspends the driver license until a physician provides a certiﬁcation that the

condition has been treated or controlled and does not affect driving skills If the DMV receives a report

from a source who is not a physician the DMV decides each case separately.

Other reporting Will accept information from court, other DMVs, police, family members and other resources.

Letters must be signed.

Anonymity If a person in a professional or ofﬁcial position (i.e., physician), the DMV does disclose the name of the

person who sent the report however if the reporter does not fall under this category, under the Freedom

of Information Law, the identity is protected.

New York

114

New York (continued)

Medical Advisory Board

Role of the MAB The medical advisory board advises the commissioner on medical criteria and vision standards for the

licensing of drivers.

Medical Review contact information Referrals for reexamination must be made in writing to:

New York State

Department of Motor Vehicles

Medical Review Unit Room 220

6 Empire State Plaza

Albany, NY 12228-0220

Information about the forms and procedures can be found at

www.nydmv.state.ny.us/license.htm#drivermed

115

North Carolina

Name of State & DMV

contact information

North Carolina Division of Motor Vehicles

Driver License Medical Division

1100 New Bern Ave.

Raleigh, NC 27697

www.dmv.dot.state.nc.us

919-861-3809

Licensing Requirements

Visual acuity Each eye without correction ........................................................

Both eyes without correction .......................................................

Each eye with correction.............................................................

Both eyes with correction ...........................................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50

20/30 or better

20/100; 20/70 if one eye blind

No. However, there is a medical

appeal process if requested.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

60° in one eye (30° on each side

Keystone; Stereo Optic 1000

Color vision requirement No

Type of road test Standardized road test, certain tasks must be completed to pass.

Restricted licenses Yes: daytime, speed restrictions, no interstate driving.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

In person

Yes

Age-based renewal procedures 60+ are not required to parallel park on road test.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are encouraged to report unsafe drivers.

Immunity Yes, North Carolina statutes protect the physician who reports an unsafe driver.

Legal protection No

DMV follow-up Driver is notiﬁed in writing of referral.

Other reporting Will accept information from court, other DMVs, police, family members, and other resources, as long as

they are signed.

Anonymity No, however must request records in writing.

Medical Advisory Board

Role of the MAB Action is based on majority and/or opinion of specialist. Medical physicians review all medical

information that is submitted to the DMV. If more information is necessary, can issue a request.

Board decides what action should be taken. This action can be appealed.

Medical Review contact information Medical Review Unit

3112 Mail Service Center

Raleigh, NC 27697

Fax 919-733-9569

116

Name of State & DMV

contact information

North Dakota Department of Transportation

Drivers License and Trafﬁc Safety Division

Attn: Chief Examiner

608 East Boulevard Avenue

Bismarck, ND 58505

www.dot.nd.gov/

701-328-2601

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/80 better eye if 20/100 in other

eye

Yes: 20/130 in carrier, 20/40 in

telescope, full peripheral ﬁeld

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Both eyes 105°

OPTEC 1000 Vision Tester

Color vision requirement No

Type of road test N/A

Restricted licenses Yes: daytime, pending a sight-related road test, area and distance restriction

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

N/A

Yes

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No, physicians may report. Submit letter to the Drivers License and Trafﬁc Safety Division

Physician/medical reporting There is a law giving physicians permission to report to the ND Department of Transportation in writing,

the name, date of birth, and address of every patient over the age of 14 whom they have reasonable

cause to believe is incapable, due to physical or mental reason, of safely operating a motor vehicle

Immunity Yes, physicians who in good faith make a report or give an opinion or recommendation or participate in

any proceeding pursuant to this law, are immune from liability.

Legal protection ND Century Code addresses medical advice provided by physicians.

DMV follow-up Vision and/or medical reports

Other reporting Will accept information from court, other DMVs, police and family members.

Anonymity No

Medical Advisory Board

Role of the MAB Action based on recommendation of majority and/or specialist. MAB is used when drafting

Administrative rules.

Medical Review contact information Drivers License and Trafﬁc Safety Division staff can be reached at 701-328-2070

North Dakota

117

Name of State & DMV

contact information

Ohio Driver License Information Unit

Ohio Bureau of Motor Vehicles, Attn: Medical Unit

PO Box 16784

Columbus, OH 43216-6784

www.bmv.ohio.gov

614-752-7500

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Both eyes with/without correction when one eye is blind ...............

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/200 or better

20/40 or Better: Unrestricted Driving

20/50 – 20/70: Daylight Driving Only

Worse than 20/70: No Driving Privileges

Primary eye no worse than 20/200

Deﬁcient eye: Worse than 20/300

20/30 or Better: Unrestricted Driving

20/40 – 20/60: Daylight Driving Only

Worse than 20/60: No Driving Privileges

20/70 through telescope, 20/200

through carrier lens.

Yes: 20/70 through telescope,

20/200 through carrier lens.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Each eye must have 70° temporal

reading

Keystone Vision II

Color vision requirement Yes

Type of road test Standardized course

Restricted licenses Right or left outside mirror restrictions for persons who are unable to obtain the required minimum

Temporal ﬁeld requirement of 70 degrees in each eye but has a visual ﬁeld of 70∞ Temporal and 45∞

nasal readings (mirror required on the side that does not have 70 ∞ Temporal). Persons with certain

medical or physical conditions may be required to furnish periodic medical statements or take periodic

drivers license examinations.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In person or renewal by mail only if

out of State.

Yes

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No, however we will accept and take action on information submitted by a physician on an unsafe driver.

The doctor must agree to be our source of information and allow us to divulge this information to the driver.

Immunity No

Legal protection No

DMV follow-up Letter is sent requiring driver to submit a medical statement and/or take a driver license examination.

Driver is given 30 days to comply.

Other reporting Will accept information regarding unsafe drivers from courts, law enforcement agencies, hospitals,

rehabilitation facilities, family and friends. The person or facility making the report must agree to be our

source of information and allow us to divulge this information to the driver.

Anonymity Not conﬁdential

Ohio

118

Ohio (continued)

Medical Advisory Board

Role of the MAB No medical advisory board. Ohio has a medical consultant to contact for assistance with difﬁcult cases

or policy-making assistance.

Medical Review contact information Information on making referrals can be obtained through the contacts above.

119

Name of State & DMV

contact information

Oklahoma Driver Improvement Division Department

of Public Safety

Attn: Medical

PO Box 11415

Oklahoma City, OK 73136

www.dps.state.ok.us/dls/

405-425-2059

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/60

20/50

20/100 for better eye with

restrictions

Not permitted. Laws will not allow

for consideration of licensing or

restrictions.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Both eyes, 70° in the horizontal

meridian.

Yes

Color vision requirement No

Type of road test Non-ﬁxed course

Restricted licenses Yes, physician recommendations such as daylight driving only, speed limitations, or local driving only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

In-person

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes, any physician participating in good faith and without malicious intent in making a report of an

unsafe driver shall have immunity from civil liability that might otherwise be incurred.

Immunity Yes

Legal protection By statute the physician has full immunity.

DMV follow-up Driver is notiﬁed in writing of referral, required to appear for an interview at the Department. Requires a

current medical evaluation from qualiﬁed practitioner as determined a full review examination.

Other reporting Will accept information from any veriﬁable source with direct knowledge of the medical condition that

would render the driver unsafe.

Anonymity No

Medical Advisory Board

Role of the MAB Action is based on the recommendation of the majority and/or specialist.

Medical Review contact information Department of Public Safety

Executive Medical Secretary

PO Box 11415

Oklahoma City, OK 73136

Oklahoma

120

Name of State & DMV

contact information

Oregon Department of Motor Vehicles

Attn: Driver Programs Section, Medical Program Coordinator

1905 Lana Avenue NE

Salem, OR 97314

www.oregon.gov/ODOT/DMV/ATRISK/index.shtml

503-945-5000

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/70 better eye with restrictions

Bioptic-telescopic lenses are not

permitted to meet acuity standards;

however, may be used while driving.

Must pass vision test with carrier

lens only.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

110° in horizontal (one or both eyes

Both Keystone Driver Vision Screen-

ing System & OPTEC Vision Screening

Instruments are used.

Color vision requirement No

Type of road test Standardized course

Restricted licenses Yes. Daytime driving only for vision between 20/40 and 20/70

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

8 years

In person renewal. A “valid without

photograph” license may be issued if

the person is temporarily out of State

at the time of license renewal.

After age 50

Age-based renewal procedures After age 50, vision screening every 8 years.

Reporting Procedures

Mandatory medical reporting Oregon’s mandatory medical reporting system is not based solely on diagnosis or medical condition.

Physicians and health care providers meeting the deﬁnition of “primary care provider” are required to

report persons presenting functional and/or cognitive impairments that are severe and cannot be cor-

rected/controlled by surgery, medication, therapy or driving device or technique.

Physician/medical reporting ORS 807.710 addresses mandatory reporting by physicians and other health care providers.

Oregon also has a voluntary reporting system that can be utilized by physicians and other medical

providers. This reporting system is not required by law.

Immunity Under the mandatory reporting system, the law provides the primary care provider with immunity from

civil liability.

Legal protection By Oregon law, a report ﬁled under the mandatory reporting system is conﬁdential and may not be

admitted as evidence in any civil or criminal action.

Oregon

121

Oregon (continued)

DMV follow-up In most cases, drivers reported under the mandatory system have their driving privileges immediately

suspended. A driver may request the opportunity to demonstrate ability to safely operate a motor vehicle

via knowledge and drive tests. For cognitive impairments (and for speciﬁc functional impairments),

medical ﬁle and driving record is sent to the State Health Ofﬁce for determination of whether or not it is

safe at this point in time.

The majority of reports received under the voluntary reporting system will not result in an immediate

suspension action. Instead, these drivers will be given 30–60 days to pass DMV tests and/or submit

medical information before a suspension action is taken.

Other reporting Under the voluntary system, DMV will accept information from court, other DMVs, law enforcement,

physicians, family members and other sources.

Anonymity Under the mandatory system, only the medical information being reported is conﬁdential. Under the

voluntary system, DMV will make every attempt to hold the reporter’s name conﬁdential if requested.

Medical Advisory Board

Role of the MAB Oregon does not have a Medical Advisory Board. DMV’s Medical Determination Ofﬁcer reviews medical

cases and makes determination on an individual’s medical condition and ability to drive. Cases can be

referred to the Health Department for advice.

Medical Review contact information DMV-Driver Programs Section

503-945-5295

Attn: Medical Program Coordinator

1905 Lana Avenue NE

Salem, OR 97314

122

Name of State & DMV

contact information

Pennsylvania Department of Transportation

Attn: Medical Unit

PO Box 68682

Harrisburg, PA 17106

www.dmv.state.pa.us/centers/olderDriverCenter.shtml

717-787-9662

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 in better eye unrestricted, up

to 20/100 combined vision restricted

Not permitted to meet acuity stan-

dards; however, are permitted for

driving. Must pass vision test with

carrier lens only: 20/100.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

120° both eyes

PENNDOT does not regulate the kind

of testing devise used to measure this

Color vision requirement No

Type of road test Standardized road test, same as those used for the ﬁrst-time permit application drivers.

Restricted licenses Yes: daytime driving only, area restrictions, dual mirrors, class restriction—all vision related

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

Internet, mail, in-person

Age-based renewal procedures Drivers 65+ renew every 2 years instead of 4; all drivers 45+ requested to submit physical and vision

exam prior to renewing (random mailing of 1,650 per month)

Reporting Procedures

Mandatory medical reporting Any person qualiﬁed to make a medical diagnosis is required to report any patient they feel exhibits

unsafe driving behaviors.

Physician/medical reporting Required, “All physicians and other persons authorized to diagnose or treat disorders and disabilities

deﬁned by the Medical Advisory Board shall report to PENNDOT in writing the full name, DOB, and ad-

dress of every person 15 years of age and older, diagnosed as having any speciﬁed disorder or disability

within 10 days.”

Immunity Yes—see 1518 (f)—“No civil or criminal action may be brought against any person or agency for

providing the information required under this system.”

Legal protection Yes

DMV follow-up PENNDOT then sends out appropriate correspondence to drivers asking them to have necessary forms

completed and/or test performed.

Other reporting Will accept information from court, other DMVs, police, emergency personnel, and family members/

neighbors/caregivers, so long as reports are signed with a way to conﬁrm reporter facts.

Anonymity Yes

Pennsylvania

123

Pennsylvania (continued)

Medical Advisory Board

Role of the MAB The board advises PENNDOT and reviews regulations proposed by PENNDOT concerning physical and

mental criteria including vision standards relating to the licensing of drivers. It meets, typically, once

every 2 years or as needed.

Medical Review contact information Bureau of Driver Licensing

Driver Qualiﬁcations Section

PO Box 68682

Harrisburg, PA 17106-8682

717-787-9662

124

Name of State & DMV

contact information

Rhode Island Department of Motor Vehicles

Division of Motor Vehicles Services

286 Main Street

Pawtucket, RI 02860

www.dmv.state.ri.us/

401-588-3020

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 better eye.

Not mentioned in the regulations

Visual ﬁelds Minimum ﬁeld requirement .........................................................115° in horizontal meridian, for one

eye 40° nasally

Color vision requirement No

Type of road test

Restricted licenses No

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

If license has been expired three

years or more, it cannot be renewed

Yes

No, only if license has been expired 3

years or more

No, only if license has been expired 3

years or more

Age-based renewal procedures Age 75, renewal cycle reduced to 2 years.

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes, Any physician who diagnoses a physical or mental condition which in the physician’s judgment

will signiﬁcantly impair the person’s ability to safely operate a motor vehicle may voluntarily report the

person’s name and other information relevant to the condition to the Medical Advisory Board within the

Registry of Motor Vehicles.

Immunity Yes, Any physician reporting in good faith and exercising due care shall have immunity from any liability,

civil or criminal, that otherwise might result by reason of his actions pursuant to the section. No cause

of action may be brought against any physician for not making a report pursuant to this section.

Legal protection

DMV follow-up Driver is notiﬁed in writing of referral.

Other reporting Will accept information from court, other DMVs, police, and family members.

Anonymity

Medical Advisory Board

Role of the MAB Action is based on the recommendation of the majority.

Medical Review contact information Information related to medical review can be obtained by calling 401-588-3020

Rhode Island

125

Name of State & DMV

contact information

Department of Motor Vehicles

PO Box 1498

Blythewood, SC 29016

www.scdmvonline.org

803-896-5000

Licensing Requirements

Visual acuity Each eye without correction ........................................................

Both eyes without correction .......................................................

Each eye with correction.............................................................

Both eyes with correction ...........................................................

If one eye blind—other without correction ...................................

If one eye blind—other with correction ........................................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40—must have outside mirror

20/40 better eye unrestricted, 20/70

in better eye if worse eye is 20/200

or better; if not then 20/40.

Not permitted to meet acuity standard

(must meet acuity standard through

carrier lens); however, permitted to

use while driving.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Not speciﬁed.

Color vision requirement No

Type of road test Not speciﬁed.

Restricted licenses Yes: corrective lens, outside mirrors, daylight driving only

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Renewal by mail if no violations in

past 2 years, no suspension, revoca-

tions or cancellations.

Only if 5+ points on record

Only if there appears to be a need.

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity No

Legal protection N/A

DMV follow-up License is suspended upon referral and further examination is conducted.

Other reporting Will accept information from court, other DMVs, and police.

Anonymity N/A

Medical Advisory Board

Role of the MAB The Medical Advisory Board determines the mental of physical ﬁtness of license applicants through a

medical evaluation process, and makes recommendations to the department’s director or designee on

the handling of impaired drivers.

Medical Review contact information South Carolina Driver Improvement Ofﬁce

PO Box 1498

Columbia, SC 29216

803-896-9925

South Carolina

126

Name of State & DMV

contact information

South Dakota Driver Licensing

118 West Capitol Avenue

Pierre, SD 57501

www.state.sd.us/dps/dl

800-952-3696 or

605-773-6883

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

N/A

20/40

20/60 both eyes with/without

correction

Yes (skill test required)

Visual ﬁelds Minimum ﬁeld requirement .........................................................No

Color vision requirement No

Type of road test Standardized course

Restricted licenses Yes: daylight only, outside rearview mirrors; corrective lenses, 50 mile radius from home, no driving

outside of town

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

In person; renewal by mail for military

and military dependents only.

Yes

No (unless expired more than 30 days)

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes, physicians may report unsafe drivers if they so choose. The form to be used is a request

re-evaluation form. It can be found on our Web site or by calling our ofﬁce.

Immunity No

DMV follow-up An appointment is scheduled and the driver is notiﬁed to appear for an interview, written and road test

may be included.

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity No

Medical Advisory Board

Role of the MAB Medical information is reviewed by Department of Public Safety personnel. Upon having good cause

to believe that a licensed operator is not qualiﬁed to be licensed, may upon written notice of at least 5

days to the licensee, require him or her to submit to an examination or interview. The department shall

take action as may be appropriate and may withdraw/cancel the license of such person or permit him or

her to retain such license, or may issue a license subject to restrictions.

Medical Review contact information Information on making referrals can be obtained through the contacts above.

South Dakota

127

Name of State & DMV

contact information

Tennessee Department of Safety

Driver License Division

1150 Foster Avenue

Nashville, TN 37249-1000

http://state.tn.us/safety/driverservices.shtml

615-741-3954

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 better eye with/without

correction, minimum 20/60

each/both eye with restrictions

Yes, for 20/200 better eye, 20/60

through scope; visual ﬁeld 150° or

larger, telescope no greater than 4X

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

For professional drivers only

Stereo Optic

Color vision requirement Yes, commercial only

Type of road test Standardized, certain requirements in course.

Restricted licenses Yes: with area limitations

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Mail in every other cycle, by mail,

in person and by Internet

No (except in case of

hazardous material )

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity Yes

Legal protection No

DMV follow-up Driver is notiﬁed in writing of referral.

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity No

Medical Advisory Board

Role of the MAB Paid physicians make recommendations upon review of medical report. Action is based upon recom-

mendation of the majority.

Medical Review contact information Driver Improvement Ofﬁce can be reached at 615-251-5193

http://state.tn.us/safety/forms/medical.pdf

Tennessee

128

Name of State & DMV

contact information

Texas Department of Public Safety

Driver License Division

PO Box 4087

Austin, TX 78773-0001

www.txdps.state.tx.us/

512-424-2600

Licensing Requirements

Visual acuity Each/both eyes without correction ...............................................

Each/both eyes with correction ...................................................

If one eye blind—other without correction ...................................

If one eye blind—other with correction ........................................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/50

20/50 with eye specialist statement

20/40 in better eye for unrestricted

license; 20/70 in better eye with

restrictions.

Yes, provided that the client has

acuity of 20/40 through the telescope

and passes road test.

Visual ﬁelds Minimum ﬁeld requirement .........................................................None

Color vision requirement There is a requirement for all new drivers (not speciﬁed)

Type of road test Standardized Course

Restricted licenses Yes, restrictions applied per medical advisory direction (daytime only, speed limit <45 mph;

no expressway driving) Restrictions are based on medical advice and may include daytime driving

only where the speed limit <45 mph and no expressway driving.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

6 years

In person; every second renewal

period may be eligible for alternate

renewal by Internet, telephone, or mail.

At in-person renewal

May be required based upon

evaluation of medical, physical,

or mental impairments.

May be required based upon

evaluation of medical, physical,

or mental impairments.

Age-based renewal procedures No. Effective 9/1/2007, drivers 79 or older must renew in person; renewal is required every 2 years for

drivers 85 or older.

Reporting Procedures

Physician/medical reporting Any physician licensed to practice medicine in Texas may inform the Department of Public Safety.

This release of information is an exception to the patient-physician privilege. There is no special

reporting form; a letter from the physician will sufﬁce.

Immunity Yes

DMV follow-up The driver is notiﬁed in writing of the referral and required to provide medical information from his/her

personal physician.

Legal Protection Yes

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity Not anonymous or conﬁdential. However, an attempt is made to protect the identity of the reporter. If

the client requests an administrative hearing to contest enforcement action, the identity of the reporter

may be revealed at that time.

Texas

129

Texas (continued)

Medical Advisory Board

Role of the MAB The MAB advises the Department of Public Safety on medical issues regarding individual drivers.

The Department bases its actions on the recommendation of the physician who reviews the case.

Medical Review contact information Texas Department of Public Safety

Medical Advisory Board

PO Box 4087

Austin, TX 78773

512-424-7120

130

Name of State & DMV

contact information

Utah Department of Public Safet

Driver License Division

PO Box 144501

Salt Lake City, UT 84114-4501

www.driverlicense.utah.gov

801-965-4437

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/100 in better eye with restrictions.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

120° horizontal, 20° vertical, 90°

with restrictions

Stereo Optical (DMV2000)

Color vision requirement No

Type of road test In applicant’s own car, with examiner. Certain driving tasks required to complete.

Restricted licenses Yes: daytime only, speed limit <45 mph, radius limit.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Mail in every other cycle if no sus-

pensions, revocations, convictions,

and not more that 4 violations.

Yes, for age 65+. All drivers are

required to take the vision test when

renewing in person. The age-based

vision-testing requirement pertaining

to those 65 and over applies only to

the renewal by mail program.

No, unless examiner feels the appli-

cant’s ability to drive is in question

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Yes

Immunity Yes, any physician or other person who becomes aware of a physical, mental or emotional impair-

ment which appears to present an imminent threat to driving safety and reports this information to the

Department of Public Safety, through its agents, in good faith shall have immunity from any damages

claimed as a result of so doing.

Legal protection No

DMV follow-up Driver is notiﬁed in writing of referral. License is suspended upon referral

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity Not conﬁdential

Utah

131

Utah (continued)

Medical Advisory Board

Role of the MAB A Driver License Medical Advisory Board was created to advise the Director of the Driver License

Division and to recommend written guidelines and standards for determining the physical, mental,

and emotional capabilities appropriate to various types of driving in an effort to minimize the conﬂict

between the individual’s desire to drive and the community’s desire for safety.

Medical Review contact information Program Coordinator, Utah Driver License Division

PO Box 144501

Salt Lake City, Utah 84114-4501

Phone: 801/965-3819

Fax: 801/965-4084

http://publicsafety.utah.gov/dld/med_standards.html

132

Name of State & DMV

contact information

Vermont Department of Motor Vehicles

120 State Street

Montpelier, VT 05603

www.dmv.state.vt.us/dmvhp.htm

802-828-2000

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 in better eye.

Yes, and must pass road test, daytime

only under 10,000 lbs.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

Each eye 60° External binocular, 60°

external and 60° nasal monocular

Yes

Color vision requirement No

Type of road test Standard

Restricted licenses Yes, for glasses or contact lenses

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

2 to 4 years

Mail and in person

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Doctors may only provide information to the DMV with the permission of the patient

Immunity No

Legal protection No

DMV follow-up Driver is notiﬁed of referral by mail.

Other reporting Will accept information from court, other DMVs, police, concerned citizens, or family members, provided

the complaint is signed.

Anonymity Only up until a hearing is requested.

Medical Advisory Board

Role of the MAB Vermont no longer has a Medical Advisory Board.

Vermont

133

Name of State & DMV

contact information

Virginia Department of Motor Vehicles

Attn: Medical Review Center

PO Box 27412

Richmond, VA 23269-0001

www.dmv.state.va.us/

804-367-0531 or 804-367-6203

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 better eye, 20/70 daylight only,

20/200 better eye with restrictions.

Yes, with 20/200 through carrier,

20/70 through telescope—test

required.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

100° monocular and binocular;

70° monocular and binocular—

daylight only. 40 ° or better temporal

and 30° or better nasal—vision in

one eye only.

Stereo Optical/Titmus 10mm W

@333 mm.

Color vision requirement No

Type of road test Behind-the-wheel test is administered with the DMV examiner instructing and evaluating the person on

speciﬁc driving maneuvers.

Restricted licenses Yes. A person can obtain a restricted license with a variety of restrictions if authorized by Virginia

law and granted by DMV (based on performance on road test, for medical reasons, or for violation

of probation) or by the court (based on conviction). The restrictions range from corrective lenses,

hand controls, and 5-mile radius of residence, to daylight driving only, ignition interlock device,

and to and from work/school.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

Customers may use alternative

method of renewing driver’s license

applications every other cycle unless

suspended or revoked, 2+ violations,

DMV medical review indicator on

license, failed vision test. Alternative

methods include mail-in, Internet,

touch-tone telephone, fax, and

ExtraTeller.

Yes

Only if 2+ violations in 5 years

Age-based renewal procedures No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are not required to report unsafe drivers. However, for physicians who do report unsafe

drivers, laws have been enacted to prohibit release of the physician’s name as the source of the report.

Immunity No

Legal protection

DMV follow-up

Virginia

134

Virginia (continued)

Other reporting DMV relies upon information from courts, other DMVs, law enforcement ofﬁcers, physicians and other

medical professionals, relatives and concerned citizens to help identify drivers who may be impaired.

Anonymity Virginia law provides conﬁdentiality, only for relatives and physicians.

Medical Advisory Board

Role of the MAB The board enables the Department of Motor Vehicles (DMV) to comply with its responsibilities of

monitoring drivers throughout the State who may have physical or mental problems. The board assists

the commissioner through the development of medical and health standards for use in the issuance of

driver’s licenses. The board helps the department avoid the issuance of licenses to persons suffering

from any physical or mental disability or disease that will prevent their exercising reasonable and ordi-

nary control over a motor vehicle while driving it on the highways. They review the more complex cases

and cases referred for administrative hearings and provide recommendations for medical review action.

Medical Review contact information Questions about medical review can be directed to 804-497-7188

www.dmv.state.va.us/webdoc/citizen/medical/index.asp

135

Name of State & DMV

contact information

Washington Department of Licensing

Driver Services

PO Box 9030

Olympia, WA 98507-9030

www.dol.wa.gov/

360-902-3900

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/40 in better eye; 20/70 in better

eye with restriction. Person must

have vision better than 20/200.

20/50 or worse with both eyes person

must take standard drive test.

Yes: training and test required. Training

is not required but encouraged.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

110° in horizontal meridian for

binocular and monocular.

OPTEC 1000; Keystone Telebinocular;

Keystone DVSII

Color vision requirement Yes, for new and professional drivers.

Type of road test Standardized scoring using approved test routes at each licensing ofﬁce.

Restricted licenses Yes, depending on circumstances. Corrective lenses to meet minimum acuity; daytime driving only

based on eye care practitioner’s report, or after failed night time driving test; also if needed to compen-

sate for visual or physical impairment-equipment restrictions, route, distance, or geographic area limits

depending on outcome of testing driver’s ability. We no longer give night drives or have route, distance,

or geographic area limits. We do still have equipment restrictions.

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

In-State renewal—in person only. Out

of State, can renew by mail once.

Yes, both eyes together only. Full eye

test anytime we issue a new license.

Waived unless warranted by vision,

health or medical screening.

Waived unless warranted by vision,

health or medical screening.

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity No

Legal protection No

DMV follow-up Letter to the driver with information detailing due process and action following any failure to respond.

Other reporting Will accept information from court, other DMVs, police, family members, and other competent

sources. If in doubt, the reporting party may be required to establish ﬁrsthand knowledge and

standing for making a report.

Washington

136

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB Washington does not have an MAB.

Medical Review contact information Information on referrals can be found at www.dol.wa.gov/driverslicense/reportunsafe.html

or by writing to

Driver Records

Department of Licensing

PO Box 9030

Olympia, WA 98507-9030

Washington (continued)

137

West Virginia

Name of State & DMV

contact information

West Virginia Department of Transportation

Division of Motor Vehicles

Building 3, Room 1240

1800 Kanawha Boulevard East

Charleston, WV 25317

www.wvdmv.gov

800-642-9066 or 304-558-3900

Licensing Requirements

Visual acuity Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40

20/60 better eye; if less then optom-

etrist or ophthalmologist must declare

ability to be safe.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

None

Color vision requirement No

Type of road test Standard Road Skills Exam

Restricted licenses None

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

5 years

5 years, no examinations required

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting Physicians are encouraged to report and may do so.

Immunity No

Legal protection No

DMV follow-up A medical report is sent to the driver, to be completed by his/her physician. Failure to comply—the driv-

ers license is revoked.

Anonymity Not conﬁdential

Medical Advisory Board

Role of the MAB To review medical cases and advise the Division on the condition of the driver and how their condition

might affect their ability to drive. If the MAB comes to the conclusion that the driver is unsafe they make

a recommendation to the Commissioner of Motor Vehicles and it is the Commissioner that has the ﬁnal

say as to revoke the driver.

Medical Review contact information Questions about medical review can go to 304-558-0238

138

Name of State & DMV

contact information

Wisconsin Driver Services, Medical Division

Medical Review Section

PO Box 7918

Madison, WI 53707

www.dot.wisconsin.gov/drivers/index.htm

608-266-2327

Licensing Requirements

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

20/40 to 20/100 in better eye

Not acceptable

20/40 to 20/100 in better eye

20/100 in better eye with or without

correction

Not to meet vision standards but can

use to drive

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

20° better eye for regular license

Stereo optical machines

Color vision requirement Yes

Type of road test Knowledge and sign test, prior to road test. Limited area test is non-ﬁxed, otherwise standardized.

Restricted licenses Yes, restrictions can be recommended by physician, vision specialist or determined by road test (day-

time driving only, mileage radius, road posted and/or freeway restriction).

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

8 years

In person

By mail if person is out of State

Yes

Determined by DOT, vision specialist,

or physician.

Determined by DOT, vision specialist,

or physician

Age-based renewal procedures None

Reporting Procedures

Mandatory medical reporting None

Physician/medical reporting Physicians are not required but encouraged to report. They can report by submitting form MV3141

Driver Condition or Behavior Report or by letter on stationary letterhead.

Immunity Yes

Legal protection Yes

DMV follow-up Driver is notiﬁed in writing requirements and depending on requirements given 15, 30, or 60 days to

comply. If do not comply within the time period given, driver’s license is cancelled. They are notiﬁed in

writing of cancellation

Other reporting Will accept information from court, other DMVs, police, family members, and other resources.

Anonymity WI has open records law; however, individuals can submit acceptable pledge of conﬁdentiality form

MV3454

Wisconsin

139

Wisconsin (continued)

Medical Advisory Board

Role of the MAB Action is taken based on recommendation of the majority, the individuals driver record, medical informa-

tion provided from physician and, if appropriate, driving examination results. Wisconsin has 2 types of

Medical Review Boards:

1. By-mailboard: paper ﬁle is mailed to 3 physicians (specialists, i.e., neurologists, endocrinologists) for

recommendation, based on medical condition.

2. In-person board: interview with 3 physicians (psychiatrist, neurologist, and internal medicine).

The ﬁnal step in the review process is judicial review which goes through a court process.

Medical Review contact information Information about the medical review program can be obtained through the following:

E-mail: [email protected]

Phone: 608-266-2327

FAX: 608-267-0518

www.dot.wisconsin.gov/drivers/drivers/aging/impaired.htm

140

Name of State & DMV

contact information

Wyoming Dept. of Transportation

Driver Services Program

5300 Bishop Blvd

Cheyenne, WY 82009-3340

http://dot.state.wy.us

307-777-4871

Licensing Requirements: Must meet minimum of 20/100 with both eyes, with or without correction.

Visual acuity Each eye with/without correction .................................................

Both eyes with/without correction ...............................................

If one eye blind—other with/without correction ............................

Absolute visual acuity minimum ..................................................

Are bioptic telescopes allowed? ..................................................

None

Minimum of 20/100

Minimum of 20/100 with both eyes

20/100

Yes, but the person must meet the

minimum visual acuity & visual ﬁeld

levels with the lenses–generally

restricted to “no interstate driving”, as

well as restrictions to speed and area.

Visual ﬁelds Minimum ﬁeld requirement .........................................................

Visual ﬁeld testing device ...........................................................

120°

Keystone Machine

Color vision requirement N/A

Type of road test Driving skills test with an examiner.

Restricted licenses B = glasses required, F = left & right outside rearview mirrors required

G = Daylight driving only, I = limited other (such as distance, speed, etc.)

License Renewal Procedures

Standard Length of license validation.........................................................

Renewal options and conditions ..................................................

Vision testing required at time of renewal? ..................................

Written test required? .................................................................

Road test required? ....................................................................

4 years

Vision screening required for each

renewal.

Yes

No—dependent upon vision special-

ist recommendation and/or decrease

in visual acuity level (i.e., 20/50 or

worse visual acuity)

Age-based renewal procedures Are there any age-based license renewal procedures? No

Reporting Procedures

Mandatory medical reporting No

Physician/medical reporting No

Immunity No

Legal protection No

DMV follow-up Re-examinations are performed upon request from family, medical specialists, law enforcement agen-

cies, and examiner observation.

Other reporting Law enforcement, family member, medical specialist, vision specialist, etc.

Anonymity N/A

Medical Advisory Board

Role of the MAB Wyoming does not have a Medical Advisory Board.

Medical Review contact information Requests for review must be made in writing to:

Driver Services - Medical Review

5300 Bishop Blvd.

Cheyenne, WY 82009

Wyoming

141Chapter 8—State Licensing and Reporting Laws

Coley, M. J., Coughlin, J. F. (2001,

Summer). State Driving Regulations.

Adapted from National Academy on an

Aging Society. The Public Policy and

Aging Report, Volume 11, Number 4.

Washington, DC: The Gerontological

Society of America.

Epilepsy Foundation. Driver information

by State. www.epilepsyfoundation.org/living

/wellness/transportation/drivinglaws.cfm.

Accessed November 21, 2007.

Insurance Institute for Highway Safety.

(2007). U.S. driver licensing procedures

for older drivers. www.iihs.org/laws/

olderdrivers.aspx. Accessed November

31, 2007.

Insurance Information Institute. (2007).

Older Drivers. New York. www.iii.org/

media/hottopics/insurance/olderdrivers/?p

rinterfriendly=yes. Accessed November

21, 2007.

NHTSA. (2003). Older Drivers: State

Reporting Practices. DOT HS 809 301,

2003. Washington, DC: National

Highway Trafc and Safety Administra-

tion www.nhtsa.dot.gov/people/injury/

olddrive/FamilynFriends/state.htm.

Accessed November 21, 2007.

Staplin, L. (2003). Model Driver

Screening and Evaluation Program:

Guidelines for Motor Vehicle Ad-

ministrators. Washington, DC: Na-

tional Highway Trafc and Safety

Administration www.nhtsa.com/people/

injury/olddrive/modeldriver/guidelines.

htm#Table%20of%20Contents.

Accessed November 22, 2007.

Resources

CHAPTER 9

Medical Conditions and

Medications That May

Affect Driving

145

cognition, or motor function) that may

affect his/her driving safety, the physi-

cian may base interventions for driving

safety on this chapter’s guidelines. We

make the following recommendations:

• Treat the underlying medical condi-

tion to correct functional decits and

prevent further functional decline.

• If the functional decit is due to an

offending agent (e.g., medication

with impairing side effects), remove

the offending agent or reduce the

dose, if possible.

• Advise the patient about the risks to

his/her driving safety, and recommend

driving restrictions or driving cessa-

tion as needed.

• For acute or episodic illnesses (e.g.,

seizure disorder and/or diabetics with

hypoglycemia), clinical judgment and

subspecialist input is recommended,

in addition to following specic State

statutes.

If further evaluation is required or the

functional decits are not medically

correctable, refer the patient to a driver

rehabilitation specialist for a driv-

ing evaluation (including an on-road

assessment) for a chronic condition

whenever possible. The driver rehabili-

tation specialist may prescribe adaptive

techniques and devices to compensate

for these decits, and train the patient

in their use. (See Chapter 5 for a further

discussion of driver rehabilitation

services.)

Physicians should advise patients

against driving if they report symptoms

Australia,

190

the United Kingdom,

191

and New Zealand.

192

Although the corresponding recom-

mendations are based on scientic

evidence whenever possible, please note

that use of these recommendations has

not yet been proven to reduce crash

risk,

193

except for a few medical condi-

tions (e.g., treating obstructive sleep

apnea, performing cataract surgery,

and discontinuing a benzodiazepine).

As such, these recommendations are

provided to physicians as a tool to guide

the decision-making process. They are

not intended to substitute for the physi-

cian’s clinical judgment.

How to use this chapter

Physicians may consult this chapter if

they have questions on specic medical

conditions and their effect on driving.

If a patient presents with a particular

medical condition and/or related func-

tional decits (e.g., decits in vision,

190. Austroads. Assessing Fitness to Drive for

Commercial and Private Vehicle Drivers.

Medical Standards for Licensing and Clinical

Management Guidelines. A Resource for Health

Professionals in Australia; 2003.

191. Driver Medical Group DVLA Swansea for

Medical Practitioners. At a Glance Guide to the

Current Medical Standards of Fitness to Drive.

(2003). Swansea, UK.

192. Land Transport Safety Authority. (2002).

Medical Aspect of Fitness to Drive. Wellington,

New Zealand.

193. Although scientic evidence links certain

medical conditions and levels of functional im-

pairment with crash risk, more research is needed

to establish that driving restrictions based on

these medical conditions and levels of functional

impairment signicantly reduce crash risk.

This chapter contains a reference table

of medical conditions and medications

that may affect driving skills, with

consensus recommendations for each.

Whenever scientic evidence supports

the recommendations, it is included.

These recommendations apply only

to drivers of private motor vehicles, and

should not be applied to commercial

drivers. Although many of the listed

medical conditions are more prevalent

in the older population, these recom-

mendations apply to all drivers with

medical impairments, regardless of age.

The medical conditions were chosen

for their relevance to clinical practice

and/or because there is some evidenced-

based literature indicating a correlation

with driving impairment. The inter-

ested clinician is referred to two recent

reviews that comprehensively covered

many of these conditions.

187

188

In addi-

tion, several other countries have pub-

lished guidelines, including Canada,

189

187. Charlton, J., Koppel, S., O’Hare, M., et al.

(2004). Inuence of Chronic Illness on Crash

Involvement of Motor Vehicle Drivers. Monash

University. Accident Research Centre. Report

#213. Supported by Swedish National Road

Administration. Melbourna, Australia: Monash

University.

188. Dobbs, B. M. (2002). Medical Conditions and

Driving: Current Knowledge, Final Report As-

sociation for the Advancement of Automotive

Medicine. NHTSA Publication DOT HS 809

690. Washington, DC: National Highway Traf-

c Safety Administration. www.nhtsa.dot.gov/

people/injury/research/Medical_Condition_Driving/

pages/TRD.html.

189. Canadian Medical Association. Determining

Medical Fitness to Drive: A Guide for Physicians,

6th ed. Ottawa; 2000.

CHAPTER 9

Medical Conditions and

Medications That May

Affect Driving

146 Chapter 9—Medical Conditions and Medications That May Affect Driving

Section 1:

Vision and hearing loss

Vision is the primary sense employed

in driving when compared to hearing

and proprioception, and is responsible

for 95 percent of driving-related sensory

inputs.

194

Age- and disease-related

changes of the eye and brain may affect

visual acuity, visual elds, night vision,

contrast sensitivity, and other aspects

of vision. External obstruction of view

(e.g., blepharoptosis) should not be

overlooked, as it may signicantly limit

visual elds. The literature that is avail-

able on eye disease suggests that driving

impairment is likely mediated by im-

pairment in contrast sensitivity,

195

visual

elds,

196

or visual processing speed.

Whenever possible, vision decits

should be managed and corrected.

Recent data suggest that intervention

with current treatments for common

eye diseases such as age-related macular

degeneration,

197

glaucoma,

198

and cata-

racts

199

have the potential to improve

or stabilize the condition, and in some

cases these interventions have been

noted to reduce crash risk.

200

Patients

with persistent vision decits may

reduce their impact on driving safety by

restricting travel to low-risk areas and

conditions, such as familiar surround-

194. Shinar, D., & Schieber, F. (1991). Visual

requirements for safety and mobility of older

drivers. Hum Factors. 33(5):507–519.

195. Mabtyjari, M., & Tuppurainen, K. (1999). Cata-

ract in trafc. Graefes Arch Clin Exp Ophthalmal.

237:278–282.

196. Szlyk, J. P., Mahler, C. L., Seiple, W., et al.

(2005). Driving performance of glaucoma

patients correlates with peripheral visual eld

loss. J Glaucoma. 14:145–150.

197. Smith, B.T., Joseph, D.P., & Grand,

M.G.(2007). Treatment of neovascular age-

related macular degeneration: past, present,

and future directions. Curr Opin Ophthalmol.

18:240–244.

198. Leske, M.C., Hejl, A., Hussein, M., et al.

(2003). Factors for glaucoma progression and

the effect of treatment: the Early Manifest

Glaucoma Trial. Arch Ophthamol. 121:48–56.

199. Van Den Berg, T., Van Rijn, L.J., Rene, M.,

Michael, R., Heine, C., et al. (2007). Straylight

effects with aging and lens extraction. Am J

Ophthalmol. 144(3):358–363.

200. Owsley, C., McGwin, G. Jr., Sloane, M., et al.

(2002). Impact of cataract surgery on motor

vehicle crash involvement by older adults.

JAMA. 288:841–849.

Medical conditions and medi-

cations that may affect driving

Table of contents

Contents .......................................Page

Section 1 .......................................126

Vision and Hearing Loss

Section 2 .......................................130

Cardiovascular Diseases

Section 3 .......................................134

Cerebrovascular Diseases

Section 4 .......................................136

Neurologic Diseases

Section 5 .......................................142

Psychiatric Disorders

Section 6 .......................................144

Metabolic Disorders

Section 7 .......................................146

Musculoskeletal Disabilities

Section 8 .......................................150

Peripheral Vascular Diseases

Section 9 .......................................151

Renal Disease

Section 10 .....................................152

Respiratory Diseases

Section 11 .....................................154

Effects of Anesthesia and Surgery

Section 12 .....................................156

Miscellaneous Conditions

Section 13 .....................................157

Medications

that are irreversible and incompatible

with safe driving (e.g., visual changes,

syncope or pre-syncope, vertigo, severe

pain, etc.). If despite extensive medi-

cal work-up these symptoms continue,

such patients should be strongly urged

to seek alternate forms of transporta-

tion, including taxis, rides from family

and friends, and medical transportation

services.

In the inpatient and emergency depart-

ment, driving should be routinely ad-

dressed prior to the patient’s discharge

whenever appropriate, especially when

prescribing new sedating medications.

Even for the patient whose symptom

or treatment clearly precludes driv-

ing, it should not be assumed that the

patient is aware that he/she should not

drive. The physician should counsel the

patient regarding driving, and discuss a

future plan (e.g., resumption of driving

upon resolution of symptoms, driver

rehabilitation upon stabilization of

symptoms, and so forth.).

Keep in mind that an individual’s driv-

ing purposes (e.g., responsible for taking

grandchildren to day care) and/or need

to drive for a vocation (e.g., salesperson

who has increased exposure or miles

driven per year) may inuence the

extent of the interventions or advice in

regard to an evaluation. For example,

more restriction or a performance-based

road test may be more aggressively pur-

sued for a patient who frequently drives

long distances over unfamiliar roads

in comparison to a patient who drives

short, familiar routes.

147Chapter 9—Medical Conditions and Medications That May Affect Driving

Section 1: Sensory deprivation

ings, low speed areas, non-rush hour

trafc, daytime, and good weather con-

ditions. This has been noted for certain

eye diseases, especially glaucoma.

201

201. Adler, G., Bauer, M. J., Rottunda, S., et al.

(2005). Driving habits and patterns in older

men with glaucoma. Social Work Health Care.

40(3):75–87.

Sensory Deprivation

1. Visual acuity

a. Cataracts

b. Retinopathy

(diabetic or hypertensive)

c. Keratoconus

d. Macular degeneration

e. Nystagmus

f. Telescopic lens

2. Visual eld

a. Glaucoma

b. Hemianopia/quadrantanopia

c. Monocular vision

d. Ptosis or upper lid redundancy

e. Retinitis pigmentosa

3. Contrast sensitivity

4. Defective color vision

5. Poor night vision and glare recovery

6. Diplopia

7. Hearing loss

Please note that the recommendations stated below are subject to your particular

State’s licensing requirements. (See Chapter 8 for a State-by-State reference list of

licensing requirements.) Many States require far visual acuity of 20/40 for licensure;

however, recent studies indicate that there may be no basis for this requirement.3

State driver licensing agencies are urged to base their visual acuity requirements

on the most current data, as appropriate. However, referral to an ophthalmologist

is recommended since common causes for visual impairment (cataracts, macular

degeneration, glaucoma) can improve and/or stabilize with treatment.

Visual acuity may be measured with both eyes open or with the best eye open, as

the patient prefers. The patient should wear any corrective lenses usually worn for

driving.

Patients with decreased far visual acuity may lessen its impact on driving safety

by restricting driving to low-risk areas and conditions (e.g., familiar surroundings,

non-rush hour trafc, low speed areas, daytime, and good weather conditions).

For best-corrected far visual acuity less than 20/70, the physician should recom-

mend an on-road assessment performed by a driver rehabilitation specialist (where

it is permitted and available) to evaluate the patient’s performance in the actual

driving task.

For best-corrected far visual acuity less than 20/100, the physician should recom-

mend that the patient not drive unless safe driving ability can be demonstrated in

an on-road assessment, where permitted and available. (See also Telescopic lens in

this section.)

No restrictions if standards for visual acuity and visual elds are met, either with or

without cataract removal.

Patients who require increased illumination or who experience difculty with glare

recovery should avoid driving at night and under low-light conditions, such as

adverse weather conditions.

No restrictions if standards for visual acuity and visual elds are met.

It is recommended that diabetic patients have annual eye examinations.

Visual acuity

Cataracts

Diabetic or hypertensive retinopathy

148

Patients with severe keratoconus correctable with hard contact lenses should drive

only when the lenses are in place. If lenses cannot be tolerated, patients with severe

keratoconus should not drive even if they meet standards for visual acuity, as their

acuity dramatically declines outside their foveal vision, rendering their peripheral

vision useless.

No restrictions if standards for visual acuity and visual elds are met.

Patients who experience difculty with glare recovery should avoid driving at

night. Patients with the neovascular “wet” form of the disease may require frequent

assessment due to the rapid progression of the disease.

No restrictions if standards for visual acuity and visual elds are met.

A bioptic telescope is an optical telescope mounted on the lens of eyeglasses. Dur-

ing normal use, the wearer can view the environment through the regular lens.

When extra magnication is needed, a slight downward tilt of the head brings the

object of interest into the view of the telescope.

202

The specialist who prescribes a

telescopic lens should ensure that the patient is properly trained in its use.

It has not been established whether telescopes enhance the safety of low-vision

drivers. As stated in the American Academy of Ophthalmology’s Policy Statement,

Vision Requirements for Driving (approved by Board of Trustees, October 2001):

“More than half the States allow drivers to use bioptic telescopes mounted on

glasses, through which they spot trafc lights and highway signs. It has not yet

been demonstrated whether the estimated 2,500 bioptic drivers in the United

States drive more safely with their telescopes than they would without them. The

ability to drive safely using bioptic telescopes should be demonstrated in a road

test in all cases.”

Please note that the statement above is subject to your particular State’s licensing

requirements. A road test should be administered only in those States that permit

the use of bioptic telescopes in driving.

While it is acknowledged that an adequate visual eld is important for safe driving,

there is no conclusive evidence to dene what is meant by “adequate” nor any con-

sistent standard as to how visual elds are tested. Visual eld requirements vary be-

tween States, with many States requiring a visual eld of 100 degrees or more along

the horizontal plane, and other States having a lesser requirement or none at all.

203

(See Chapter 8 for a State-by-State reference list of visual eld requirements.)

If the primary care physician has any reason to suspect a visual eld defect (e.g.,

through patient report, medical history, or confrontation testing), he/she should

refer the patient to an ophthalmologist or optometrist for further evaluation. The

primary care physician and specialist should be aware of their particular State’s

visual eld requirements, if any, and adhere to them.

202. Peli, E., & Peli, D. (2002). Driving With Condence: A Practical Guide to Driving with Low Vision.

Singapore: World Scientic Publishing Co. Pte. Ltd.; p.100–101.

203. Peli, E., & Peli, D. (2002). Driving With Condence: A Practical Guide to Driving with Low Vision. Singa-

pore: World Scientic Publishing Co. Pte. Ltd.; p.20–22.

Keratoconus

Macular degeneration

Nystagmus

Telescopic lens

Visual eld

Chapter 9—Medical Conditions and Medications That May Affect Driving

149

For binocular visual eld at or near the State minimum requirement or of question-

able adequacy (as deemed by clinical judgment), a driver evaluation (including

on-road assessment) performed by a driver rehabilitation specialist is strongly rec-

ommended. Through driving rehabilitation, the patient may learn how to compen-

sate for decreased visual elds, although not hemi-neglect. In addition, the driver

rehabilitation specialist may prescribe enlarged side and rear view mirrors as needed

and train the patient in their use.

No restrictions if standards for visual acuity and visual elds are met. Continued

follow-up with an ophthalmologist and monitoring of visual elds and intraocular

pressure are recommended.

The physician may choose to refer the patient to a driver rehabilitation special-

ist for assessment and rehabilitation. With or without rehabilitation, the patient

should drive only if he/she demonstrates safe driving ability in an on-road assess-

ment performed by a driver rehabilitation specialist.

Please note that the recommendations stated above are subject to your particular

State’s licensing restrictions, if any, for hemianopia and quadrantanopia.

Patients with acquired monocularity may need time to adjust to the lack of depth

perception and reduction in total visual eld. This period of adjustment varies

among individuals, but it is reasonable to recommend temporary driving cessation

for several weeks.

Following this period, there are no restrictions if standards for visual acuity and

visual elds are met. Upon resumption of driving, patients should be advised to

assess their comfort level by driving in familiar, trafc-free areas before advancing

to heavy trafc. Again, use of larger mirrors and evaluation and training by a driver

rehabilitation specialist is encouraged.

Individuals with xed ptosis or lid redundancy may drive without restrictions

if their eyelids do not obscure the visual axis of either eye, and they are able to

meet standards for visual acuity and visual elds without holding their head in an

extreme position. Blepharospasms should be controlled so there is no interference

with vision.

No restrictions if standards for visual acuity and visual elds are met.

Patients who require increased illumination or who experience difculty adapting

to changes in light should not drive at night or under low-light conditions, such as

during storms.

Glaucoma

Hemianopia/Quadrantanopia

Monocular vision

Ptosis or lid redundancy, blepharospasm

Retinitis pigmentosa

Visual eld (continued)

Chapter 9—Medical Conditions and Medications That May Affect Driving

150

Contrast sensitivity is a measure of an individual’s ability to perceive visual stimuli

that differ in contrast and spatial frequency. Contrast sensitivity tends to decline

with age; accordingly, decits in contrast sensitivity are much greater in older indi-

viduals compared to their younger counterparts.

204

Among older drivers, binocular measures of contrast sensitivity have been found

to be a valid predictor of crash risk in patients with cataracts.

205

However, there are

presently no standardized cut-off points for contrast sensitivity and safe driving,

and it is not routinely measured in eye examinations.

No restrictions if standards for visual acuity and visual elds are met.

Decits in color vision are common (especially in the male population) and

usually mild.

There appears to be no correlation between defective color vision and crash

rates.

206

Only 19 States require prospective drivers to undergo color vision screen-

ing, and most of these States require screening for commercial drivers only.

207

Despite reported difculties with color vision discrimination while driving (dif-

culty distinguishing the color of trafc signals, confusing trafc lights with street

lights, and difculty detecting brake lights), it is unlikely that color vision impair-

ments represent a signicant driving hazard.

208

With the standardization of trafc

signal positions, color blind individuals are able to interpret trafc signals correctly

because they can identify the trafc signal by its position. Physicians may wish to

advise patients that the order of signals in the less commonly used horizontal place-

ment is (from left to right) red, yellow, green.

If the patient reports poor visibility at night, the physician should recommend

optometric and/or ophthalmologic evaluation. If the evaluation does not reveal a

treatable cause for poor night vision, the physician should recommend that the pa-

tient not drive at night or under other low-light conditions, such as during storms

or at dusk.

Patients with double vision in the central aspect of vision (20 degrees above and

below, left and right of xation) should not drive. Patients with uncorrected diplo-

pia should be referred to an ophthalmologist or optometrist for further assessment

to determine if the defect can be corrected with prisms or a patch and meet stan-

dards for driving. There should be a three-month adjustment period, after which

specialists can determine if adequate adjustment has occurred.

209

204. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge, p. 15. DTNH22-

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under

contract with the Washington, DC: National Highway Trafc Safety Administration.

205. Owsley, C., Stalvey, B. T., Wells, J., et al. (2001). Visual risk factors for crash involvement in older drivers

with cataract. Arch Opthalmol. 119: 881–887.

206. Policy Statement. American Association of Ophthalmology, 2006. www.aao.org/about/policy/upload/

AAODrivingPolicyWebcopy.pdf. Accessed December 12, 2007.

207. Peli, E., & Peli, D. (2002). Driving With Condence: A Practical Guide to Driving with Low Vision.

Singapore: World Scientic Publishing Co. Pte. Ltd.; p.25.

208. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge. DTNH22-

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under

contract with NHTSA, p. 15. Washington, DC: National Highway Trafc Safety Administration.

209. Canadian Ophthalmological Society. Vision Standards for Driving in Canada, 2000. http://eyesite.ca/

english/program-and-services/policy-Statements-guidelines/drivingstd.html. Accessed December 12, 2007.

Contrast sensitivity

Defective color vision

Poor night vision

Diplopia

Chapter 9—Medical Conditions and Medications That May Affect Driving

151

No restrictions.

Relatively few studies have examined the relationship between hearing

impairment and risk of motor vehicle crash. Of these, none have shown a

signicant relationship between hearing impairment and risk of crash.

210

210. Dobbs, B. M. (2002, February). Medical Conditions and Driving: Current Knowledge. DTNH22-

94-G-05297. Submitted to the Association for the Advancement of Automotive Medicine under

contract with NHTSA, p. 37-38. Washington, DC: National Highway Trafc Safety Administration.

Hearing loss

Section 2:

Cardiovascular diseases

1. Unstable coronary syndrome

(unstable angina or myocardial

infarction)

2. Cardiac conditions that may cause a

sudden, unpredictable loss of

consciousness

a. Atrial utter/brillation with

bradycardia or rapid ventricular

response

b. Paroxysmal supraventricular

tachycardia (PSVT), including

Wolf-Parkinson-White (WPW)

syndrome

c. Prolonged, nonsustained

ventricular tachycardia (VT)

d. Sustained ventricular

tachycardia

e. Cardiac arrest

f. High grade atrio-ventricular

(AV) block

g. Sick sinus syndrome/sinus

bradycardia/sinus exit block/

sinus arrest

3. Cardiac disease resulting from struc-

tural or functional abnormalities

a. Congestive heart failure (CHF)

with low output syndrome

b. Hypertrophic obstructive

cardiomyopathy

c. Valvular disease

(especially aortic stenosis)

4. Time-limited restrictions: cardiac

procedures

a. Percutaneous transluminal coro-

nary angioplasty (PTCA)

b. Pacemaker insertion or revision

c. Cardiac surgery involving

median sternotomy

d. Coronary artery bypass graft

(CABG)

e. Valve repair or replacement

f. Heart transplant

5. Internal cardioverter debrillator

(ICD)

Although the data are still unclear

in regard to a denitive relationship

between crash risk and cardiovascu-

lar diseases, a recent study did note a

modest increase in total crash risk and

at-fault risk for older adults with cardiac

disease.

211

For the patient with known

cardiac disease, the physician should

strongly and repeatedly caution him/

her to seek help immediately upon

experiencing any symptoms—including

prolonged chest discomfort, acute short-

ness of breath, syncope, pre-syncope,

palpitations, lightheadedness—that may

indicate an unstable cardiac situation.

Under no circumstances should the

patient drive to seek help.

While hypertension is not included

in this section, physicians should

always be alert to any potential impair-

ment in driving skills resulting from

hypertensive end-organ damage or

antihypertensive medications.

211. McGwin, G., Sims, R. V., Pulley, L., &

Roseman, J. M. (2000). Relations among

chronic medical conditions, medications,

and automobile crashes in the elderly: a

population-based case-control study.

Am J Epidemiol. 152,424–431.

Chapter 9—Medical Conditions and Medications That May Affect Driving

152

Patients should not drive if they experience symptoms at rest or at the wheel.

Patients may resume driving when they have been stable and asymptomatic for

one to four weeks, as determined by the cardiologist, following treatment of the

underlying coronary disease. Driving may usually resume within one week after

successful revascularization by percutaneous transluminal coronary angioplasty

(PTCA) and by four weeks after coronary artery bypass grafting (CABG).

212

(See also recommendations for CABG below [4.c in this section].)

A main consideration in determining medical tness to drive for patients with

cardiac conditions is the risk of pre-syncope or syncope due to a brady- or ta-

chyarrhythmia.

213

For the patient with a known arrhythmia, the physician should

identify and treat the underlying cause of arrhythmia, if possible, and recommend

temporary driving cessation until control of symptoms has been achieved.

No further restrictions once control of heart rate and symptoms have been

achieved.

No restrictions if the patient is asymptomatic during documented episodes.

Patients with a history of symptomatic tachycardia may resume driving after they

have been asymptomatic for six months on antiarrhythmic therapy.

Patients who undergo radio frequency ablation may resume driving after six months

if there is no recurrence of symptoms, or sooner if no pre-excitation or arrhythmias

are induced at repeat electrophysiologic testing.

No restrictions if the patient is asymptomatic during documented episodes.

Patients with symptomatic VT may resume driving after three months if they are

on antiarrhythmic therapy (with or without an ICD) guided by invasive electro-

physiologic (EP) testing, and VT is noninducible at repeat EP testing. They may

resume driving after six months without arrhythmia events if they are on empiric

antiarrhythmic therapy (with or without an ICD), or have an ICD alone without

additional antiarrythmic therapy.

214

Patients may resume driving after three months if they are on antiarrhythmic

therapy (with or without an ICD) guided by invasive electrophysiologic (EP)

testing, and VT is noninducible at repeat EP testing.

Patients may resume driving after six months without arrhythmia events if they are

on empiric antiarrythmic therapy (with or without an ICD), or have an ICD alone

without additional antiarrythmic therapy.

215

212. Petch, M. C. (1998). European Society of Cardiology Task Force Report: Driving and Heart Disease.

Eur Heart J. 19(8):1165–1177.

213. Binns, H., & Camm, J. (2002). Driving and arrhythmias. Br Med J. 324:927–928.

214. Epstein, A. I., Miles, W. M., Benditt, D. G., et al. (1996). Personal and public safety issues related to

arrhythmias that may affect consciousness: implications for regulation and physician recommendations.

Circulation. 94:1147–1166.

215. Ibid.

Section 2: Cardiovascular diseases

Unstable coronary syndrome

(unstable angina or myocardial

infarction)

Cardiac conditions that may cause

a sudden, unpredictable loss of

consciousness

Atrial utter/brillation with bradycardia

or rapid ventricular response

Paroxysmal supraventricular tachycardia

(PSVT), including Wolf-Parkinson-White

(WPW) syndrome

Prolonged, nonsustained ventricular

tachycardia (VT)

Sustained ventricular tachycardia (VT)

Chapter 9—Medical Conditions and Medications That May Affect Driving

153

When long-distance or sustained high-speed travel is anticipated, patients should

be encouraged to have an adult companion perform the driving. Patients should

avoid the use of cruise-control.

216

Please refer to the recommendations for sustained ventricular tachycardia.

If the patient experiences a seizure, please refer to the recommendations for seizure

disorder in Section 4, Neurological Diseases.

If clinically signicant cognitive changes persist following the patient’s physical re-

covery, cognitive testing is recommended before the patient is permitted to resume

driving. In addition, on-road testing performed by a driver rehabilitation specialist

may be useful in assessing the patient’s tness to drive.

For symptomatic block managed with pacemaker implantation, please see

pacemaker recommendations in this section.

For symptomatic block corrected without a pacemaker (e.g., by withdrawal of medi-

cations that caused the block), the patient may resume driving after he/she has been

asymptomatic for four weeks and EKG documentation shows resolution of the block.

No restrictions if patient is asymptomatic. Regular medical follow-up is recom-

mended to monitor progression.

For symptomatic disease managed with pacemaker implantation, please see

pacemaker recommendations in this section.

Physicians should be alert to possible cognitive decits due to chronic cerebral

ischemia. Physicians may refer patients with clinically signicant cognitive

changes to a driver rehabilitation specialist for a driver evaluation (including

on-road assessment) to evaluate the patient’s driving safety.

A main consideration in determining medical tness to drive for patients with

abnormalities of cardiac structure or function is the risk of pre-syncope or syncope

due to low cardiac output, and of cognitive decits due to chronic cerebral ischemia.

Patients who experience pre-syncope, syncope, extreme fatigue, or dyspnea at rest

or at the wheel should cease driving.

Cognitive testing is recommended for those patients with a history of cognitive

impairment that may impair the patient’s driving ability. Physicians may refer

patients with clinically signicant cognitive changes to a driver rehabilitation

specialist for a driver evaluation (including on-road assessment) to evaluate the

patient’s driving safety.

216. Ibid.

Sustained ventricular tachycardia (VT)

(Continued)

Cardiac arrest

High grade atrio-ventricular (AV) block

Sick sinus syndrome/sinus bradycardia/

sinus exit block/ sinus arrest

Cardiac disease resulting from

structural or functional abnormalities

Chapter 9—Medical Conditions and Medications That May Affect Driving

154

Patients should not drive if they experience symptoms at rest or while operating a

motor vehicle.

Physicians should reassess patients for driving tness every six months to two years

as needed, depending on clinical course and control of symptoms. Patients with

functional class III CHF (marked limitation of activity but no symptoms at rest,

working capacity 2 to 4 METS) should be reassessed at least every six months.

Patients who experience syncope or pre-syncope should not drive until they have

been successfully treated.

Patients who experience syncope or pre-syncope or unstable angina should not

drive until the underlying disease is corrected.

Driving restrictions for the following cardiac procedures are based on the patient’s

recovery from the procedure itself and from the underlying disease for which the

procedure was performed.

The patient may resume driving 48 hours to one week after successful PTCA and/

or stenting procedures, depending on the patient’s baseline condition and course of

recovery from the procedure and underlying coronary disease.

217, 218

The patient may resume driving one week after pacemaker implantation if:

The patient no longer experiences pre-syncope or syncope

a. EKG shows normal sensing and capture; and

b. Pacemaker performs within manufacturer’s specications.

219

Driving may usually resume four weeks following coronary artery bypass grafting

(CABG) and/or valve replacement surgery, and within eight weeks following heart

transplant, depending on resolution of cardiac symptoms and the patient’s course of

recovery. In the absence of surgical or post-surgical complications, the main limita-

tion to driving is the risk of sternal disruption following median sternotomy.

If cognitive changes persist following the patient’s physical recovery, cognitive

testing is recommended before the patient is permitted to resume driving. In addi-

tion, on-road testing performed by a driver rehabilitation specialist may be useful in

assessing the patient’s tness to drive.

Please see the recommendations for nonsustained and sustained ventricular tachy-

cardia (2.c and 2.d in this section).

217. Petch, M. C. (1998) European Society of Cardiology Task Force Report: Driving and Heart Disease.

Eur Heart J. 19(8):1165–1177.

218. Consensus Conference, Canadian Cardiovascular Society: Assessment of the cardiac patient for tness to

drive. (1992). Can J Cardiol. 8:406–412.

219. Ibid.

Congestive heart failure (CHF)

with low output syndrome

Hypertrophic obstructive cardiomyopathy

Valvular disease (especially aortic stenosis)

Time-limited restrictions:

cardiac procedures

Percutaneous transluminal coronary

angioplasty (PTCA)

Pacemaker insertion or revision

Cardiac surgery involving median

sternotomy

Internal cardioverter debrillator

Chapter 9—Medical Conditions and Medications That May Affect Driving

155

Section 3:

Cerebrovascular disorders

1. Post intracranial surgery

2. Stroke

3. Transient ischemic attacks (TIA)

4. Subarachnoid hemorrhage

5. Vascular malformation

6. Syncope

Strokes and other insults to the cerebral

vascular system may cause a wide variety

of symptoms, including sensory decits

(e.g., numbness or loss of sensation),

motor decits (e.g., weakness), and

cognitive impairment (e.g., memory,

hemispatial inattention). These symp-

toms range from mild to severe and may

resolve almost immediately or persist for

years. Because each patient is affected

uniquely, the physician must take into

account the individual patient’s constel-

lation of symptoms, severity of symptoms,

course of recovery, and baseline function

when making recommendations con-

cerning driving. Studies have indicated

that a signicant number (>40%) of

community dwelling stroke patients

continue to drive a car.

220

However, the

majority of stroke patients (87 %) may

not receive any type of formal driving

220. Legh-Smith, J., Wade, D. T., & Langton

Hewer, R. L. (1986). Driving after stroke.

J R Soc Med. 79: 200–203.

evaluation, but simply resume the

operation of a motor vehicle.

221

The

larger the presence of a homonymous

visual eld defect, the more likely it is

that the patient will lose his/her driver’s

license. Unfortunately, many patients

may not be aware of this decit.

222

Driving should always be discussed

prior to the patient’s discharge from

the hospital or rehabilitation center.

Patients with residual decits who wish

to resume driving should be referred to a

driver rehabilitation specialist whenever

possible. Although the time frame for

this evaluation will depend on the

severity and extent of the decits, many

evaluations for cognitive and motor

defects will occur somewhere between

three to six months. Upon stabilization

of symptoms, the DRS assesses the

patient for tness-to-drive through

clinical and on-road evaluations. After

assessment, the DRS may recommend

adaptive techniques or adaptive devices

(e.g., wide rear view mirror, spinner

knob for the steering wheel, left foot

accelerator) and provide training for

221. Fisk, G.D., Owsley, C., & Vonne Pulley, L.

(1997). Driving after stroke: driving exposure,

advice, and evaluations. Arch Phys Med Rehabil.

78:1338–1345.

222. Poole, D., Chaudry, F., & Jay, W. M. (2008).

Stroke and driving. Topics Stroke Rehab.

15:37–41.

their proper use. Even patients with

mild decits should undergo driver

evaluation prior to resuming driving, if

possible. Research indicates that a post-

stroke determination of driving safety

made on a medical basis alone may be

inadequate.

223

More recent studies note

associations with impairment on road

tests with measures of perception, visual

selective attention, mental speed, work-

ing memory, executive function and

complex visual-perception/attention

information.

224, 225, 226

For the patient whose symptoms

clearly preclude driving, it should

not be assumed that the patient is

aware that he/she should not drive.

In such cases, the physician should

counsel the patient on driving

cessation.

223. Wilson, T., Smith, T. (1983). Driving after

stroke. Int Rehab Med. 5(4):170–177.

224. Engrum, E.S., Lambert, E. W., & Scott, K.

(1990). Criterion-related validity of the

cognitive behavioral driver’s inventory:

brain injured patients versus normal controls.

Cogn Rehabil. 1990;8:20–26.

225. Lundberg, C., Caneman G.,, Sven-Marten S.,,

et al. (2003). Scand J Psychol. 44:23–30.

226. Nouri F. M., & Lincoln N. B. (1993). Predicting

driving performance after stroke. Br Med J.

307;482–483.

Section 3: Cerebrovascular diseases

The patient should not drive until stabilization or resolution of disease and surgery

symptoms. See also stroke recommendations below (Section 3.2).

Patients with acute, severe motor, sensory, or cognitive decits should refrain from

driving. Depending on the severity of residual symptoms and the degree of recovery,

this restriction may be permanent or temporary.

Upon the patient’s discharge from the hospital or rehabilitation center, the

physician may recommend temporary driving cessation until further neurological

recovery has occurred. Once neurological symptoms have stabilized, physicians

should refer appropriate patients with residual sensory loss, cognitive impairment,

visual eld defects, and/or motor decits to a driver rehabilitation specialist for

driver assessment and rehabilitation. The specialist may prescribe vehicle adaptive

devices and train the patient in their use.

Post intracranial surgery

Stroke

Chapter 9—Medical Conditions and Medications That May Affect Driving

156

Patients with neglect or inattention should be counseled not to drive until

symptoms have resolved and safe driving ability has been demonstrated through

assessment by a driver rehabilitation specialist.

All patients with moderate to severe residual hemiparesis should undergo driver

assessment before resumption of driving. Even if symptoms improve to the extent

that they are mild or completely resolved, patients should still undergo driver

assessment, if available, as reaction time may continue to be affected and other

comorbid conditions could further increase risk.

Patients with aphasia who demonstrate safe driving ability may fail in their efforts

to renew their license due to difculties with the written examination. In these

cases, the physician should urge the licensing authority to make reasonable accom-

modations for the patient’s language decit. A driving rehabilitation specialist may

be able to determine whether the decit is expressive in nature and thus may allow

for interpretation of written (e.g., trafc signs) stimuli. However, trafc signs may

still be interpreted based on color, shape, and symbol recognition.

Patients with residual cognitive decits should be assessed and treated as described in

section 4 on Dementia. Periodic re-evaluation of these patients is recommended, as

some patients may recover sufciently over time to permit safe driving.

Patients who have experienced a single TIA or recurrent TIAs should refrain from

driving until they have undergone medical assessment and appropriate treatment.

Patients should not drive until symptoms have stabilized or resolved. Driving may

resume following medical assessment and, if deemed necessary by the physician,

driver evaluation performed by a driver rehabilitation specialist (including on-road

assessment).

Following the detection of a brain aneurysm or arterio-venous (AV) malformation,

the patient should not drive until he/she has been assessed by a neurosurgeon. The

patient may resume driving if the risk of a bleed is small; an embolization procedure

has been successfully completed; and/or the patient is free of other medical con-

traindications to driving, such as uncontrolled seizures or signicant perceptual or

cognitive impairments.

Syncope usually results from various cardiovascular causes, and is recurrent in up to

30 percent of cases. Cardiac arrhythmias are the most common cause of syncope.

227

(See Section 2 for causes of cardiac syncope.)

Driving restrictions for neurally mediated syncope should be based on the severity

of the presenting event and the anticipant likelihood of recurrence. No driving

restrictions are necessary for infrequent syncope that occurs with warning and with

clear precipitating causes. Patients with severe syncope may resume driving after

adequate control of the arrhythmia has been documented and/or pacemaker follow-

up criteria have been met (see 4 in Section 2).

228

For patients who continue

to experience unpredictable symptoms after treatment with medications and

pacemaker insertion, driving cessation is recommended.

227. Beers, M. H., & Berkow, R. (eds). (1999). The Merck Manual of Diagnosis and Therapy, 17thed.

Whitehouse Station, NJ: Merck and Co., Inc. Section 6, Chapter 200.

228. North American Society of Pacing and Electrophysiology/American Heart Association: Personal and

Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation

and Physician Recommendations (Part 3 of 4). September 1, 1996.

Stroke (continued)

Transient ischemic attacks (TIA)

Subarachnoid hemorrhage

Vascular malformation

Syncope

Chapter 9—Medical Conditions and Medications That May Affect Driving

157

This is encouraging information that

supports the feasibility and utility of

using this guide.

While it is optimal to initiate discus-

sions of driving safety with the patient

and family members before driving

becomes unsafe, dementia may be unde-

tected and undiagnosed until late in the

course of the disease. Initially, family

members and physicians may assume

that the patient’s decline in cognitive

function is a part of the “normal” aging

process. Physicians may also hesitate

to screen for and diagnose dementia

because they feel that it is futile—in

other words, that nothing can be done

to improve the patient’s situation or

slow disease progression. In addition,

physicians may be concerned about the

amount of time required to effectively

diagnose dementia and educate patients

and their families.

239

However, some pa-

tients are able to achieve cognitive sta-

bility, at least for a period of time, with

cholinesterace inhibitors or N-methyl

d-aspartate (NMDA) receptor block-

ers. In addition, patients are now being

diagnosed on the “cusp” of the disease

in the very early stages. A diagnosis of

dementia by itself should not preclude

driving.

Physician reluctance to screen for

dementia is unfortunate because early

diagnosis is the rst step in promoting

the driving safety of these patients.

The second step is intervention, which

includes medications to slow or stabilize

the course of the disease, counseling to

prepare the patient and family for even-

tual driving cessation, and serial assess-

ment of the patient’s driving abilities.

When assessment shows that driving

may pose a signicant safety risk to the

patient, driving cessation is a neces-

sary third step. With early planning,

patients and their families can make a

more seamless transition from driving to

nondriving status.

239. Valcour, V. G., Masaki, K. H., Curb, J. D., &

Blanchette, P. L. (2000). The detection of

dementia in the primary care setting. Arch

Intern Med. 160:2964–2968.

dementia rating of 1.0).

231

Furthermore,

most patients with Alzhiemer’s disease

will eventually fail subsequent road tests

when followed longitudinally, indicating

that repeat testing at six to twelve months

should be strongly considered.

232

Some

of these studies have led the American

Academy of Neurology to conclude that

patients with a mild level of dementia

severity or greater should no longer

operate an automobile.

233

However,

this recommendation has recently been

challenged by a longitudinal study that

found that some mildly demented drivers

not only passed a performance-based

road test, but also had an acceptable

crash risk prospectively.

234

Furthermore,

recent studies indicate that physician

evaluation in the ofce cannot replace

the on-the-road assessment;

235

however,

tests of working memory and executive

function are improving classication

rates.

236,

237

Finally, a dementia and

driving curriculum modeled after this

AMA guide has been shown to improve

knowledge, attitudes, condence, and

behaviors for health professionals who

deal with older adults with dementia.

238

231. Hunt L., Murphy C., Carr D., Duchek J.,

Buckles V., & Morris, J. (1997). The reliability

of the Washington University Road Test. Arch

Neurol. 54:707–712.

232. Duchek, J. M., Carr DB., Hunt L., et al. (2003).

Longitudinal driving performance in early stage

dementia of the Alzheimer type. J Am Geriatr

Soc. 51:1342–1347.

233. Dubinsky, RM., Stein, AC., Lyons, K. (2000).

Practice parameter: risk of driving and

Alzheimer’s disease (an evidence-based review)

–Report of the Quality Standards Subcommittee

of the American Academy of Neurology.

Neurology. 54, 2205–2211.

234. Ott, BR., Heindel, WC., Papandonatos, GD.,

et al. (2008). Longitudinal study of drivers with

Alzheimer’s disease. Neurology. 70:1171–1178.

235. Ott, B. R., Anthony, D., Papandonatos, G. D.,

D’Abreu, A., Burock, J., Curtin, A., Wu, C. K.,

& Morris, J. C. (2005) Clinician assessment

of the driving competence of patients with

dementia. J Am Geriatr Soc. 53(5):829–833.

236. Grace, J., Amick, M. M., D’Abreu, A., Festa,

E. K., Heindel,W. C., & Ott, B. R. (2005). Neu-

ropsychological decits associated with driving

performance in Parkinson’s and Alzheimer’s

disease. J Int Neuropsychol Soc. 11(6):766–775.

237. Brown, L. B., Stern, R. A., Cahn-Weiner, D.

A., et al. (2005). Driving scenes test of the

Neuropsychological Assessment Battery and on-

road driving performance in aging and very mild

dementia. Arch Clin Neuropsychol. 20:209–215

238. Meuser, T. M., Carr, D. B., Berg-Weger, M.,

Niewoehner, P., & Morris, J. C. (2006). Driving

and dementia in older adults: implementation

and evaluation of a continuing education

project. Gerontologist. 46:680–687.

Section 4:

Neurologic diseases

1. Brain tumor

2. Closed head injury

3. Dementia

4. Migraine and other recurrent

headache syndromes

5. Movement disorders

6. Multiple sclerosis

7. Paraplegia and quadriplegia

8. Parkinson’s disease

9. Peripheral neuropathy

10. Seizure disorder

a. Single unprovoked seizure

b. Withdrawal or change of anti-

epileptic drug therapy

11. Sleep disorders

a. Narcolepsy

b. Sleep apnea

12. Stroke

13. Tourette’s syndrome

14. Vertigo

Dementia deserves special emphasis

in this section because it presents a

signicant challenge to driving safety.

With progressive dementia, patients

ultimately lose the ability to drive safely

and lack insight. Therefore, dementia

patients may be more likely than drivers

with visual or motor decits (who tend

to self-restrict their driving to accom-

modate their declining abilities) to

drive even when it is highly unsafe

for them to be on the road. It becomes

the responsibility of family members

and other caregivers to protect the

safety of these patients by enforcing

driving cessation.

Several recent reviews on this topic

may be of interest to physicians.

229,

230

Fitness-to-drive studies in patients

with dementia indicate that 90 percent

may be able to pass a road test in the

very mild stages of the disease (clinical

dementia rating of 0.5), whereas 40

percent may fail at a mild level of

cognitive impairment (clinical

229. Dobbs, B., Carr, D. B., & Morris, J. C. (2002).

Management and assessment of the demented

driver. Neurologist. 8:61–70.

230. Brown, L. B., & Ott, B. R. (2004). Driving and

dementia: a review of the literature. J Geriatr

Psychiatry Neurol. 17:232–240.

Chapter 9—Medical Conditions and Medications That May Affect Driving

158

Section 4: Neurologic diseases

Driving recommendations should be based on the type of tumor; location; rate of

growth; type of treatment; presence of seizures; and presence of cognitive or percep-

tual impairments. Due to the progressive nature of some tumors, the physician may

need to evaluate the patient’s tness to drive serially.

See also the stroke recommendations in Section 3.2.

If the patient experiences seizure(s), please see the seizure disorder recommendations

below (4.10 in this section).

Patients should not drive until symptoms or signs have stabilized or resolved.

For patients whose symptoms or signs resolve, driving may resume following

medical assessment and, if deemed necessary by the physician, driver evaluation

(including on-road assessment) performed by a driver rehabilitation specialist.

Patients with residual neurological or cognitive decits should be managed as

described in Section 3.

If the patient experiences seizure(s), please see the seizure disorder

recommendations below.

The following recommendations are adapted from the Canadian Consensus

Conference on Dementia and the Alzheimer’s Association Policy Statement on

Driving and Dementia (approved 10/20/01):

• A diagnosis of dementia is not, on its own, a sufcient reason to withdraw

driving privileges. A signicant number of drivers with dementia are found to

be competent to drive in the early states of their illness.

240

Therefore, the

determining factor in withdrawing driving privileges should be the individual’s

driving ability. When the individual poses a heightened risk to self or others,

driving privileges must be withheld.

• Physicians should consider the risks associated with driving for all of their

patients with dementia, and they are encouraged to address the issue of driving

safety with these patients and their families. When appropriate, patients should

be included in decisions about current or future driving restrictions and cessa-

tion; otherwise, physicians and families must decide in the best interests of the

patient whose decision-making capacity is impaired.

• Physicians are recommended to perform a focused medical assessment that includes

a history of any new impaired driving behaviors (e.g., new motor vehicle crashes)

from a family member or caregiver and an evaluation of cognitive abilities, includ-

ing memory, attention, judgment, and visuospatial abilities. Physicians should be

aware that patients with a progressive dementia who are initially believed to be safe

to drive will require serial assessment, and they should familiarize themselves with

their State reporting laws and procedures for dementia (if any). (See Chapter 8 for

a reference list of State reporting laws.)

If concern exists that an individual with dementia has impaired driving ability, and

the individual would like to continue driving, a formal assessment of driving

skills should be administered. One type of assessment is an on-road driving assess-

ment performed by a driver rehabilitation specialist.

240. Carr, D. B., Duchek, J., & Morris, J. C. (2000). Characteristics of motor vehicle crashes with dementia of

the Alzheimer type. J Am Geriatr Soc. 48(1):18–22.

Closed head injury

Brain tumor

Dementia

Chapter 9—Medical Conditions and Medications That May Affect Driving

159

• Physicians should encourage patients with progressive dementia to plan early

for eventual cessation of driving privileges by developing alternative transpor-

tation options. The patient should be encouraged to coordinate these efforts

with his/her family members and caregivers, and to seek assistance (as needed)

from the local Area Agency on Aging.

Patients with recurrent severe headaches should be cautioned against driving

when experiencing neurologic manifestations (e.g., visual disturbances or

dizziness); when distracted by pain; and while on any barbiturate, narcotic,

or narcotic-like analgesic. (See Section 13 for further recommendations

regarding narcotic analgesics.) Patients without a typical aura preceding the

acute attack may be at higher risk.

If the physician elicits complaints of interference with driving tasks or is

concerned that the patient’s symptoms compromise his/her driving safety,

referral to a driver rehabilitation specialist for a driver evaluation (including

on-road assessment) is recommended.

Driving recommendations should be based on the type of symptoms and level

of symptom involvement. Physicians should be alert to decits that may be

subtle (e.g., muscle weakness, sensory loss, fatigue, cognitive or perceptual

decits, symptoms of optic neuritis) but have a strong potential to impair

driving performance.

A driver evaluation (including on-road assessment) performed by a driver

rehabilitation specialist may be useful in determining the patient’s safety to drive.

Serial evaluations may be required as the patient’s symptoms evolve or progress.

Referral to a driver rehabilitation specialist is necessary if the patient wishes to

resume driving and/or requires a vehicle modied to accommodate him/her as a

passenger. The specialist can recommend an appropriate vehicle and prescribe

vehicle adaptive devices (such as low-resistance power steering and hand

controls) and train the patient in their use. In addition, the specialist can assist

the patient with access to the vehicle, including opening and closing car doors,

transfer to the car seat, and independent wheelchair stowage, through vehicle

adaptations and training.

Driving should be restricted until the patient demonstrates safe driving ability in

the adapted vehicle.

Patients with advanced Parkinson’s disease may be at increased risk for motor

vehicle crashes due to both motor and cognitive dysfunction.

241

Physicians

should base their driving recommendations on the level of both motor and

cognitive symptom involvement, patient’s response to treatment, and presence

and extent of any medication side effects. (See Section 13 for specic recom-

mendations on antiparkinsonian medications.) Serial physical and cognitive

evaluations are recommended every six to twelve months due to the progressive

nature of the disease.

241. Zesiewicz, T. A., Cimino, C. R., Malek, A. R., Gardner, N., Leaverton, P. L., Dunne, P. B., & Hauser,

R. A. (2002). Driving safety in Parkinson’s disease. Neurology. 59:1787–1788.

Dementia (continued)

Migraine and other recurrent

headache syndromes

Movement disorders

(e.g., parkinsonism, dyskinesias)

Multiple sclerosis

Paraplegia and quadriplegia

Parkinson’s disease

Chapter 9—Medical Conditions and Medications That May Affect Driving

160

If the physician is concerned that dementia and/or motor impairments may affect

the patient’s driving skills, a driver evaluation (including on-road assessment)

performed by a driver rehabilitation specialist may be useful in determining the

patient’s tness to drive.

Lower extremity decits in sensation and proprioception may be exceedingly

dangerous for driving, as the driver may be unable to control the foot pedals.

If decits in sensation and proprioception are identied, referral to a driver

rehabilitation specialist is recommended. The specialist may prescribe vehicle

adaptive devices (e.g., hand controls in place of the foot pedals) and train the

patient in their use.

The recommendations below (in this section only) are adapted from the Consensus

Statements on Driver Licensing in Epilepsy, crafted and agreed upon by the Ameri-

can Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of

America in March 1992.

242

Please note that these recommendations are subject to

each particular State’s licensing requirements and reporting laws.

A patient with seizure disorder should not drive until he/she has been seizure-

free for three months. This recommendation appears consistent with recent data.

243

This three-month interval may be lengthened or shortened based on the following

favorable and unfavorable modiers:

Favorable modiers:

• Seizures occurred during medically directed medication changes

• Patient experiences only simple partial seizures that do not interfere with

consciousness and/or motor control

• Seizures have consistent and prolonged aura, giving enough warning to

refrain from driving

• There is an established pattern of purely nocturnal seizures

• Seizures are secondary to acute metabolic or toxic states that are not likely

to recur

• Seizures were caused by sleep deprivation, and sleep deprivation is unlikely

to recur

• Seizures are related to reversible acute illness

242. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America.

(1994). Consensus Statements, Sample Statutory Provisions, and Model Regulations Regarding Driver

Licensing and Epilepsy. Epilepsia. 35(3):696-705.

243. Drazkowski, J. F., Fisher, R. S., Sirven, J. I., et al. (2003). Seizure-related motor vehicle crashes in Arizona

before and after reducing the driving restriction from 12 to 3 months. Mayo Clin Proc. 78:819-825.

Parkinson’s disease (continued)

Peripheral neuropathy

Seizure disorder

Chapter 9—Medical Conditions and Medications That May Affect Driving

161

Unfavorable modiers:

• Noncompliance with medication or medical visits and/or lack of credibility

• Alcohol and/or drug abuse in the past three months

• Increased number of seizures in the past year

• Impaired driving record

• Structural brain lesion

• Noncorrectable brain functional or metabolic condition

• Frequent seizures after seizure-free interval

• Prior crashes due to seizures in the past ve years

• Single unprovoked seizure

The patient should not drive until he/she has been seizure-free for three months.

This time period may be shortened with physician approval. Predictors of recurrent

seizures that may preclude shortening of this time period include:

• The seizure was focal in origin

• Focal or neurologic decits predated the seizure

• The seizure was associated with chronic diffuse brain dysfunction

• The patient has a positive family history for epilepsy

• Generalized spike waves or focal spikes are present on EEG recordings

The patient should temporarily cease driving during the time of medication

withdrawal or change due to the risk of recurrent seizure and potential medication

side effects that may impair driving ability.

If there is signicant risk of recurrent seizure during medication withdrawal or

change, the patient should cease driving during this time and for at least three

months thereafter.

If the patient experiences a seizure after medication withdrawal or change, he/she

should not drive for one month after resuming a previously effective medication

regimen. Alternatively, the patient should not drive for six months if he/she refuses

to resume this medication regimen, but is seizure-free during this period.

The patient should cease driving upon diagnosis. The patient may resume driving

upon treatment when he/she no longer suffers excessive daytime drowsiness or cata-

plexy. Physicians may consider using scoring tools such as the Epworth Sleepiness

Scale

to assess the patient’s level of daytime drowsiness.

244

See Section 10.

See Section 3.

244. Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale.

Sleep. 14:540–545.

Seizure disorder (continued)

Single unprovoked seizure

Withdrawal or change of

anti-epileptic drug therapy

Sleep disorders

Narcolepsy

Sleep apnea

Stroke

Chapter 9—Medical Conditions and Medications That May Affect Driving

162

In evaluating the patient’s tness to drive, the physician should consider any

comorbid disorders (including attention decit hyperactivity disorder, learning

disabilities, and anxiety disorder) in addition to the patient’s motor tics. (For

specic recommendations on these disorders, see Section 5, Psychiatric Disorders).

If the physician is concerned that the patient’s symptoms compromise his/her

driving safety, referral to a driver rehabilitation specialist for on-road assessment

is recommended.

Physicians should be aware that certain medications used in the treatment

of Tourette’s syndrome have the potential to impair driving performance.

(See Section 13 for more information on medication side effects.)

Vertigo and the medications commonly used to treat vertigo have a signicant

potential to impair driving skills.

For acute vertigo, the patient should cease driving until symptoms have fully

resolved. Under no circumstances should the patient drive to seek medical

attention.

Patients with a chronic vertiginous disorder are strongly recommended to

undergo on-road assessment performed by a driver rehabilitation specialist

prior to resuming driving.

Tourette’s syndrome

Vertigo

Chapter 9—Medical Conditions and Medications That May Affect Driving

163

Section 5:

Psychiatric disorders

1. Affective disorders

a. Depression

b. Bipolar disorder

2. Anxiety disorders

3. Psychotic illness

a. Acute episodes

b. Chronic illness

4. Personality disorders

5. Substance abuse

6. Attention decit disorder (ADD)/

Attention decit hyperactivity

disorder (ADHD)

7. Tourette’s syndrome

Patients in the acute phase of a psy-

chiatric illness need to be aware that

driving skills could be affected. In

general, driving is safe when the condi-

tion is stable, although side effects from

medications and compliance with the

medication regimen may need to be

taken into consideration. (For recom-

mendations on medications and driving,

see Section 13, Medications.)

Psychiatrists may wish to consult the

American Psychiatric Association’s

Position Statement on the Role of Psy-

chiatrists in Assessing Driving Ability

(American Journal of Psychiatry. 1995.

1S2(5):819; also at www.psych.org/

pract_of_psych/driving_pstate.cfm).

Section 5: Psychiatric disorders

Physicians should advise the patient not to drive during the acute phase of illness.

Physicians should also be aware that certain medications used in the treatment of

affective disorders have the potential to impair driving performance. (See Section

13 for more information on medication side effects.)

No restrictions if condition is mild and stable. The physician should always speci-

cally ask about suicidal ideation and cognitive and motor symptoms.

Patients should not drive if they are actively suicidal or experiencing signi-

cant mental or physical slowness, agitation psychosis, impaired attention, and/

or impaired concentration. Patients who seek care for these conditions should be

counseled not to drive themselves to the clinic or hospital.

No restrictions if condition is stable.

Patients should not drive if they are actively suicidal, depressed as in 1.a (above) or

in an acute phase of mania. Patients who seek care for these conditions should be

counseled not to drive themselves to the clinic or hospital.

Patients should not drive during severe episodes of anxiety. Otherwise, there are no

restrictions if the condition is stable.

Physicians should also be aware that certain medications used in the treatment of

anxiety disorders have the potential to impair driving performance. (See Section

13 for more information on medication side effects.)

Affective disorders

Depression

Bipolar disorder

Anxiety disorders

Chapter 9—Medical Conditions and Medications That May Affect Driving

164

Physicians should advise the patient not to drive during the acute phase(s) of

illness. Physicians should also be aware that medications used in the treatment of

psychotic illness have the potential to impair driving performance. (See Section 13

for more information on medication side effects.)

Patients should not drive during acute episodes of psychosis. Patients who seek care

for acute psychosis should be counseled not to drive themselves to the clinic or

hospital.

No restrictions if the condition is stable and there are no other factors

(e.g., medication side effects) that can affect driving performance.

No restrictions unless the patient has a history of driving violations and his/her psy-

chiatric review is unfavorable. This includes—but is not limited to—uncontrolled

erratic, violent, aggressive or irresponsible behavior.

Due to the high comorbidity of substance abuse with personality disorders,

physicians are urged to be alert to substance abuse in these patients and counsel

them accordingly (see recommendations for substance abuse below).

Driving while intoxicated is not only highly dangerous to the driver, passengers,

and other road users, but it is also illegal. Drunk driving is the most common crime

in the United States, and it is responsible for thousands of trafc deaths each year.

Alcohol is not the only cause of intoxicated driving. Substances including, but not

limited to, marijuana, cocaine, amphetamines (including amphetamine analogs),

opiates, and benzodiazepines may also impair driving skills.

Physicians should follow up all positive screens with appropriate interventions, in-

cluding brief interventions or referral to support groups, counseling, and substance

abuse treatment centers. Physicians should strongly urge substance abusers to tem-

porarily cease driving while they seek treatment, and to refrain from driving while

under the inuence of intoxicating substances. A nonjudgmental and supportive

attitude and frequent follow-up may aid substance abusers in their efforts to achieve

and maintain sobriety.

Physicians should also familiarize themselves with any State laws holding them

responsible for detaining intoxicated patients who have driven to the hospital or

clinic until they are legally unimpaired.

A recent review noted increased risk of driving behaviors and a positive effect

of stimulant medications on driving performance.

245

Physicians should educate

their patients about the increased risk associated with the disease and the potential

benets of treatment.

See Section 4.

245. Barkley, R. A., & Cox, D. (2007). A review of driving risks and impairments associated with

attention-decit/hyperactivity disorder and the effects of stimulant medication on driving

performance. Journal of Safety Research. 38(1):113–28.

Psychotic illness

Acute episodes

Chronic illness

Personality disorders

Substance abuse

Attention Decit Disorder/Attention

Decit Hyperactivity Disorder

Tourette’s syndrome

Chapter 9—Medical Conditions and Medications That May Affect Driving

165

Section 6: Metabolic disorders

1. Diabetes mellitus

a. Insulin dependent diabetes

mellitus (IDDM)

b. Non-insulin dependent diabetes

mellitus (NIDDM)

2. Hypothyroidism

3. Hyperthyroidism

Individuals in the acute phase of a

metabolic disorder (e.g., diabetes,

Cushing’s disease, Addison’s disease,

hyperfunction of the adrenal medulla,

and thyroid disorders) may experience

signs and symptoms that are incompat-

ible with safe driving. Physicians should

advise these individuals to refrain from

driving (including driving to seek

medical attention) until the symptoms

have abated. There are data that suggest

that older diabetic patients may be at

increased risk for impaired driving, but

the literature is not consistent in this

area. Concern has been raised that the

trend in the medical profession has

been toward tighter control, which

could result in hypoglycemia and

possibly increased crash risk.

Section 6: Metabolic disorders

No restrictions if the patient demonstrates satisfactory control of his/her

diabetes, recognizes the warning symptoms of hypoglycemia, and meets

required visual standards.

The major concerns with insulin dependent diabetics are hypoglycemia unawareness.

There are several studies that have noted that patients with type 1 IDDM had

impaired driving performance during episodes of hypoglycemia and were unaware

of their low blood sugars at the time of driving assessment.

246, 247

It is apparent from these studies that many drivers did not take appropriate action

even when they recognized the symptoms of hypoglycemia. Diabetic patients who

use insulin should be evaluated for hypoglycemia and should consider checking

their blood sugar before driving or on prolonged trips. This is especially the case

for individuals who have exhibited hypoglycemia unawareness (e.g., documented

blood sugars below 60 mg/dL without symptoms).

Patients should be counseled not to drive during acute hypoglycemic or hypergly-

cemic episodes. In addition, patients are advised to keep candy or glucose tablets

within reach in their car at all times, in the event of a hypoglycemic attack.

For peripheral neuropathy, see Section 4.

Patients who experience recurrent hypoglycemic or hyperglycemic attacks should

not drive until they have been free of signicant hypoglycemic or hyperglycemic

attacks for three months.

Patients who are managed by lifestyle changes and/or oral medications have no

restrictions unless they develop relevant disabilities (e.g., diabetic retinopathy).

If the physician prescribes an oral medication that has a signicant potential to

cause hypoglycemia, he/she should counsel the patient as above. Oral medications

may also increase the likelihood of hypoglycemia, which should be managed as in

1.a in this section.

246. Weinger, I., Kinsley, B. T., Levy, C. J., et al. (1999). The perception of safe driving ability during

hypoglycemia in patients with type I diabetes. Am J Med. 107:246–253.

247. Cox, D. J., Gonder-Frederick, L. A., Kovatchev, B. P., et al. (2000). Progressive hypoglycemia’s impact on

driving simulation performance: occurrence, awareness, and correction. Diabetes Care. 23:163–170.

Diabetes mellitus

Insulin dependent diabetes mellitus

(IDDM)

Non-insulin dependent diabetes mellitus

(NIDDM)

Chapter 9—Medical Conditions and Medications That May Affect Driving

166

Patients who experience symptoms (e.g., cognitive impairment, drowsiness, and

fatigue) that may compromise safe driving should be counseled not to drive until

their hypothyroidism has been satisfactorily treated. If residual cognitive decits

are apparent despite treatment, a driver evaluation (including on-road assessment)

performed by a driver rehabilitation specialist may be useful in determining the

patient’s ability to drive safely.

Patients who experience symptoms (e.g., anxiety, tachycardia, palpitations, etc.)

should be counseled not to drive until their hyperthyroidism has been satisfactorily

treated and symptoms have resolved.

Hypothyroidism

Hyperthyroidism

Chapter 9—Medical Conditions and Medications That May Affect Driving

167

at-fault crash risk in a recent study.

256

Similarly, an examination of medically

impaired drivers in Utah found an

increased crash risk for drivers with

musculoskeletal disorders, but not for

those with muscle or motor weakness.

257

Conversely, patients with a specic

diagnosis of osteoarthritis

258

were no

more at risk for a crash than controls in

one study. Also reassuring was a recent

study noting no increase in crash risk of

drivers with cars that had been adapted

for their musculoskeletal restrictions.

259

Thus, physicians can play a role in

diagnosing, managing, and referring

their patients with musculoskeletal

disorders and, ideally, play a role in

maintaining driving privileges and

improving trafc safety.

Rehabilitative therapies such as physical

or occupational therapy and/or a con-

sistent regimen of physical activity may

improve the patient’s ability to drive

and overall level of physical tness.

Whenever possible, the use of narcotics,

barbiturates, and muscle relaxants

should be avoided or minimized in

those patients with musculoskeletal

disabilities who wish to continue

driving. See Section 13 for

recommendations on specic

classes of medications.

256. McGwin, G., Sims, R. V., Pulley, L., et al.

(2000). Relations among chronic medical

conditions, medications, and automobile crashes

in the elderly: a population-based case-control

study. Am J Epidemiol. 152: 424-431.

257. Vernon, D. D., Diller, E. M., Cook, L. J., et

al. (2002). Evaluating the crash and citations

rates of Utah drivers licensed with medical

conditions, 1992-1996. Accid Anal Prev. 34:

237-246.s

258. Koepsell, T., Wolf, M. , & McCloskey, L.

(1994). Medical conditions and motor vehicle

collision injuries in older adults. J Am Geriatr

Soc. 42,695-700.

259. Henriskkson, P. (2001). Drivers with Dis-

abilities: A Survey of Adapted Cars, Driving

Habits and Safety. VTI rapport 466. Linkoping,

Sweden: Swedish National Road and Transport

Research Institute.

pedal.

248

Driving impairment has been

correlated with the inability to reach

above the shoulder.

249

Older adults with

physical frailty or disabilities may be at

increased risk for a crash,

250,

251

and are

more likely to be injured.

252

Presence

of foot abnormalities, walking less

than one block a day, and impaired left

knee exion have been associated with

adverse driving events.

253

In one study,

older crash-involved subjects were

more likely to have difculty walking

one-quarter mile than controls; and the

authors also noted an increased crash

risk for drivers with a history of falls.

254

Diminished cervical range of motion

and a slowed rapid pace walk have

also been recently associated with an

increased crash risk.

255

The use of nonsteroidal anti-inamma-

tory agents (NSAIDs) and a diagnosis of

arthritis were associated with increased

248. Jones, J. G., McCann, J., & Lassere, M. N.

(1991). Driving and arthritis. Br J Rheumatol.

1991;30:361-364.

249. Hu, PS., Trumble, DA., Foley, DJ., et al. (1998).

Crash risks of older drivers: a panel data analysis

Accid Anal Prev. 30:569-581.

250. Sims, R. V., McGwin, G., Allman, R. M., et al.

(2000). Exploratory study of incident vehicle

crashes among older drivers. J Gerontol Series A

Bio Sci Med Sci. 55:M22-27.

251. Marottoli, R. A., Wagner, D. R., Cooney, L. M.,

& Tinetti, M. E. (1994). Predictors of crashes

and moving violations among elderly drivers.

Ann Intern Med. 1994;121:842-846.

252. Kent, R., Funk, J., &Crandall, J. (2003). How

future trends in societal aging, air bag avail-

ability, seat belt use, and eet composition will

affect serious injury risk and occurrence in the

United States. Traff Inj Prev. 4:24-32.

253. Marottoli, R. A., Wagner, D. R., Cooney, L. M.,

& Tinetti, M. E. (1994). Predictors of Crashes

and Moving Violations Among Elderly Drivers.

Ann Int Med 121: 842-846.

254. Sims, R. V., McGwin, G., Pulley, L., et al.

(2001). Mobility impairments in crash-involved

drivers. J Aging Health. 12:430.s.

255. Ball, K. K., Roenker, D. L., Wadley, V. G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting? J Am

Geriatr Soc. 54:77-84.

Section 7:

Musculoskeletal disabilities

1. Arthritis

2. Foot abnormalities

3. Limitation of cervical movement

4. Limitation of thoracic and

lumbar spine

5. Loss of extremities or loss of use

of extremities

6. Muscle disorders

7. Orthopedic procedures/surgeries

a. Amputation

b. Anterior cruciate ligament

(ACL) reconstruction

c. Limb fractures and treatment

involving splints and casts

d. Rotator cuff repair—open or

arthroscopic

e. Shoulder reconstruction

f. Total hip replacement

g. Total knee arthroplasty (TKA)

The pain, decrease in motor strength,

and compromised range of motion

associated with musculoskeletal disabili-

ties can affect an individual’s ability to

drive. Physicians should encourage their

patients with musculoskeletal disabilities

to drive a vehicle with power steering

and automatic transmission, if they do

not already do so. Such vehicles require

the least amount of motor ability for

operation among all standard vehicles.

If the physician is concerned that the

patient’s musculoskeletal disabilities im-

pair his/her driving performance, referral

to a driver rehabilitation specialist for

a driver evaluation (including on-road

assessment) is also recommended. In

addition to assessing the patient’s driving

skills, the specialist can prescribe adap-

tive techniques and devices and train the

patient in their use.

Patients with musculoskeletal disorders,

typically have problems with seat belt

and ignition key use, adjusting mirrors

and seats, in steering, in transferring in

and out of the car, in driving in reverse,

and in using the controls like the foot

Chapter 9—Medical Conditions and Medications That May Affect Driving

168

If symptoms of arthritis compromise the patient’s driving safety, referral to a

physical or occupational therapist for rehabilitative therapy and/or to a driver

rehabilitation specialist for driver evaluation (including on-road assessment)

is recommended. The specialist may prescribe vehicle adaptive devices and train

the patient in their use.

See below for specic recommendations on limitation of cervical movement or

limitation of the thoracic or lumbar spine.

Foot abnormalities (e.g., bunions, hammer toes, long toe nails, and calluses) that

affect the patient’s dorsiexion, plantar exion and/or contact with vehicle foot

pedals should be addressed and treated, if possible. Consideration should be given

to referral to a podiatrist. The physician may also refer the patient to a driver

rehabilitation specialist, who can prescribe vehicle adaptive devices and train the

patient in their use.

Some loss of head and neck movement is acceptable if the patient has sufcient

combined rotation and peripheral vision to accomplish driving tasks (e.g., turning,

crossing intersections, parking, backing up) safely. The physician may also refer the

patient to physical or occupational therapist for rehabilitative therapy, and/or to a

driver rehabilitation specialist, who can prescribe wide-angled mirrors and train the

patient in their use.

Patients with marked deformity, who wear braces or body casts, or who have pain-

fully restricted motion in their thoracic or lumbar regions should be referred to a

driver rehabilitation specialist. The specialist can prescribe vehicle adaptive devices

such as raised seats and wide-angled mirrors, and train the patient in their use. The

specialist can also prescribe seat belt adaptations as needed to improve the patient’s

safety and comfort, and ensure that the patient is seated at least 10 inches from the

vehicle air bags.

Patients with acute spinal fractures, including compression fractures, should not

drive until the fracture has been stabilized and painful symptoms cease to interfere

with control of the motor vehicle. These types of fractures can be extremely painful

and require large doses of narcotics for control of pain, which also can increase risk.

(For paraplegia or quadriplegia, see Section 4.)

For patients who have lost (or lost the use) of one or more extremities, referral

to a driver rehabilitation specialist is highly recommended. These specialists can

prescribe vehicle adaptive devices and/or adaptations to limb prostheses, and train

the patient in their use.

Note that the use of articial limbs on vehicle foot pedals is unsafe because there

is no sensory feedback (i.e., pressure and proprioception). For these patients,

specialized hand controls in place of pedals are required.

Driving should be restricted until the patient demonstrates safe driving ability

(with the use of adaptive devices, as needed).

Section 7: Musculoskeletal disabilities

Arthritis

Foot abnormalities

Limitation of cervical movement

Limitation of thoracic or lumbar spine

Loss of extremities or loss of

use of extremities

Chapter 9—Medical Conditions and Medications That May Affect Driving

169

If the physician is concerned that the patient’s symptoms compromise his/her driv-

ing safety, referral to a driver rehabilitation specialist for driver evaluation (includ-

ing on-road assessment) is recommended. If needed, the specialist may prescribe

vehicle adaptive devices and train the patient in their use.

See Loss of extremities (previous page).

Should not drive for four weeks following right ACL reconstruction. If the patient

drives a vehicle with manual transmission, he/she should not drive for four weeks

following right or left ACL reconstruction.

260

No restrictions if the fracture or splint/cast does not interfere with driving tasks.

If the fracture or splint/cast interferes with driving tasks, the patient may resume

driving after the fracture heals or the splint/cast is removed, upon demonstration

f the necessary strength and range of motion.

Should not drive for four to six weeks following rotator cuff repair. If the patient’s

vehicle does not have power steering, the waiting period may be much longer.

Physicians should counsel patients to wear their seat belts properly (over the

shoulder, rather than under the arm) whenever they are in a vehicle as a driver or

passenger.

Should not drive for four to six weeks following shoulder reconstruction. If the

patient’s vehicle does not have power steering, the waiting period may be much

longer.

Physicians should counsel patients to wear their seat belts properly (over the

shoulder, rather than under the arm) whenever they are in a vehicle as a driver or

passenger.

Should not drive for at least four weeks following right total hip replacement.

If the patient drives a vehicle with manual transmission, he/she should not drive

for at least four weeks following right or left total hip replacement.

Physicians should counsel patients to take special care when transferring into

vehicles and positioning themselves in bucket seats and/or low vehicles, either

of which may result in hip exion greater than 90 degrees. Physicians should also

counsel patients that reaction time may not return to baseline until eight weeks

after the surgery, and that they should exercise extra caution while driving during

this period.

261

260. Gotlin, R. S., et al. (2000). Measurement of brake response time after right anterior cruciate ligament

reconstruction. Arch Physical Med Rehabil. 81(2):201-204.

261. MacDonald, W., & Owen, J. W. (1988). The effect of total hip replacement on driving reactions. J Bone

Joint Surg. 70B(2):202-205

Muscle disorders

Orthopedic procedures/surgeries

Amputation

Anterior cruciate ligament (ACL)

reconstruction

Limb fractures and treatment involving

splints and casts

Rotator cuff repair—open or arthroscopic

Shoulder reconstruction

Total hip replacement

Chapter 9—Medical Conditions and Medications That May Affect Driving

170

Should not drive for three to four weeks following right TKA. If the patient drives

a vehicle with manual transmission, he/she should not drive for three to four weeks

following right or left TKA.

262

The physician should also counsel patients that reaction time may not return to

baseline until eight weeks after the surgery, and that they should exercise extra

caution while driving during this period.

263

262. Pierson, J. L., Ramsey, J., Clayton, R. T., & Stippich, K. T. (February 7, 1999). TKA improves drivers’

brake reaction time. The American Academy of Orthopaedic Surgeons: Academy News.

263. Spalding, T. J., Kiss, J., Kyberd, P., Turner-Smith, A., & Simpson, A. H. (1994). Driver reaction times

after total knee replacement. J Bone Joint Surg Br. 76(5):754–756.

Total knee arthroplasty (TKA)

Chapter 9—Medical Conditions and Medications That May Affect Driving

171

Section 8:

Peripheral vascular diseases

1. Aortic aneurysm

2. Deep vein thrombosis (DVT)

3. Peripheral arterial aneurysm

Section 8: Peripheral vascular diseases

No restrictions to driving unless other disqualifying conditions are present. Indi-

viduals whose aneurysm appears to be at the stage of imminent rupture based on

size, location, and/or recent change should not drive until the aneurysm has been

repaired, if possible.

Patients with acute DVT may resume driving when their international normal-

ized ratio (INR) is therapeutic (or the risk of embolism is otherwise appropriately

treated), and they can demonstrate adequate ankle dorsiexion.

The physician should advise individuals with a history of DVT to take frequent

“mobilization breaks” when driving long distances.

No restrictions unless other disqualifying conditions are present. Patients whose an-

eurysm appears to be at the stage of imminent rupture based on size, location, and/

or recent change should not drive until the aneurysm has been repaired, if possible.

Aortic aneurysm

Deep vein thrombosis (DVT)

Peripheral arterial aneurysm

Chapter 9—Medical Conditions and Medications That May Affect Driving

172

Section 9: Renal disease

1. Chronic renal failure

2. Renal transplant

Section 9: Renal disease

No restrictions unless the patient experiences symptoms that are incompatible with

safe driving (e.g., cognitive impairment, impaired psychomotor function, seizures,

or extreme fatigue from anemia). If the physician is concerned that the patient’s

symptoms compromise his/her driving safety, referral to a driver rehabilitation

specialist for a driver evaluation (including on-road assessment) is recommended.

Many patients with renal failure requiring hemodialysis can drive without restric-

tion. However, management of renal failure requires that the patient be compliant

with substantial nutrition and uid restrictions, frequent medical evaluations, and

regular hemodialysis treatments. Patients with a history of noncompliance should

be advised against driving. Furthermore, certain medications used to treat side

effects of hemodialysis may be substantially impairing (e.g., diphenhydramine for

dialysis-associated pruritis), and dialysis itself may result in hypotension, confusion,

or agitation in many patients. These effects may require that patients avoid driving

in the immediate post-dialysis period.

Patients may resume driving four weeks following successful transplant on the

recommendation of the physician.

Chronic renal failure

Renal transplant

Chapter 9—Medical Conditions and Medications That May Affect Driving

173

sleep.

264

Sleep disorder crash risk may be

elevated further by medication use, such

as narcotics or antihistamine.

265

Sleep

apnea patients have been noted to have

as high as a seven-fold increased crash

risk compared to controls depending

on the study.

266

Patients may also be at

increased risk for serious injury.

267

This

264. Garharino, S., Nohili, L., Beelke, M., De Carli,

F., & Ferrillo, F. (2001). The contributing role of

sleepiness in highway vehicle accidents. Sleep.

24:203-206.

265. Howard, M.E., et al. ( 2004). Sleepiness, sleep-

disordered breathing and accident risk factors

in commercial vehicle drivers. Am J Respir Crit

Care Med. 170:1014-1021.

266. Teran-Santos, J., Jimenez-Gomez, A., &

Cordero-Guevara, J. (1999). The association

between sleep apnea and the risk of trafc ac-

cidents. Cooperative Group Burgos-Santander.

N Engl J Med. 340(11):847-851.

267. Medical News Today. (n.a.) Risk of severe

car crashes greatly increased in sleep apnea

patients. http://www.medicalnewstoday.com/

articles/71543.php.

Section 10:

Respiratory diseases

1. Asthma

2. Chronic obstructive pulmonary

disease (COPD)

3. Sleep apnea

“Drowsy driving” or driving with fatigue

or sleepiness is a common cause for a

motor vehicle crash, and some estimate

that more than 100,000 crashes a year

may be attributed to this problem.

Crash risk increases with diminishing

Section 10: Respiratory diseases

topic has been extensively reviewed

elsewhere.

268

Obstructive sleep apnea

is one of the few medical conditions

where treatment has been shown to

reduce crash risk back to baseline lev-

els.

269

In addition, recent studies indi-

cate a high prevalence of sleep disorders

or daytime sleepiness in older adults

270

and in diabetic patients.

271

268. Charlton, J., et al. (2004). Inuence of chronic

illness on crash involvement of motor vehicle

drivers, Monash University Accident Research

Centre, Report No. 213.

269. George, C. F. (2001). Reduction in motor

vehicle collisions following treatment of sleep

apnea with nasal CPAP. Thorax. 56(7):508-512.

270. Vaz Fragoso, Arauio, K. L., Van Ness, P. H., &

Marottoli, R. A. (2008). Prevalence of sleep

disturbances in a cohort of older drivers. J

Gerontol Series A Bio Sci Med Sci. 63:715-723.

271. Hayashino, Y., Yamazaki, S., Nakayama, T.,

et al. (2008). Relationship between diabetes

mellitus and excessive sleepiness during driving.

Exp Clin Endocrinol Diabetes. 116:1-5.

No restrictions.

Patients should be counseled not to drive during acute asthma attacks, or while

suffering transient side effects (if any) from their asthma medications.

No restrictions if symptoms are well controlled, and the patient does not

experience any signicant side effects from the condition or the medication.

The patient should not drive if he/she suffers dyspnea at rest or at the wheel (even

with the use of supplemental oxygen), excessive fatigue, or signicant cognitive

impairment. If the patient requires supplemental oxygen to maintain a hemoglobin

saturation of 90 percent or greater, he/she should be counseled to use the oxygen

at all times while driving. Due to the often tenuous oxygenation status of these

patients, they should also be counseled to avoid driving when they have other re-

spiratory symptoms that may indicate concomitant illness or exacerbation of COPD

(e.g., new cough, increased sputum production, change in sputum color, fever).

Because COPD is often progressive, periodic reevaluation for symptoms and

oxygenation status is recommended.

If the physician is concerned that the patient’s symptoms compromise his/her

driving safety, referral to a driver rehabilitation specialist for a driver evaluation

(including on-road assessment) is recommended. The patient’s oxygen saturation

may be measured during the course of the on-road assessment to provide additional

information for patient management.

Asthma

Chronic obstructive pulmonary

disease (COPD)

Chapter 9—Medical Conditions and Medications That May Affect Driving

174

Patients with excessive daytime sleepiness, loud snoring (particularly if accompa-

nied by witnessed apneic events), large neck circumference (≥ 16 inches in women,

≥ 17 inches in men), elevated body mass index (above 35 kg/m2), and/or hyperten-

sion that requires two or more medications should be considered at risk for obstruc-

tive sleep apnea, and formal sleep study evaluation should be considered, especially

in any patient who reports having fallen asleep while driving a vehicle. A patient

diagnosed with sleep apnea (apnea/hypopnea index of 5 or greater) who has fallen

asleep while driving, or a patient with severe obstructive sleep apnea (apnea/hypo-

pnea index of 30 or greater) should be counseled to refrain from driving until he/

she is receiving effective treatment (via a positive airway pressure device) following

a formal sleep study to conrm the diagnosis. If these patients undergo other treat-

ments (surgery, oral appliances), they should be advised to have a post-treatment

sleep study to conrm effectiveness. Physicians should counsel patients using posi-

tive airway pressure devices that they should not drive if they do not use the device

unless a formal sleep study conrms resolution of their obstructive sleep apnea

(e.g., following substantial weight loss).

Sleep apnea

Chapter 9—Medical Conditions and Medications That May Affect Driving

175

cognitive impairment, and/or analge-

sics. (For specic recommendations

on musculoskeletal restrictions and

narcotic analgesics, please see Sections

7 and 13, respectively.)

In counseling patients about their

return to driving after a surgical

procedure, it is useful to ask whether

the patient’s car has power steering

and automatic transmission. Physicians

can tailor their advice accordingly.

As patients resume driving, they should

be counseled to assess their comfort

level in familiar, trafc-free areas before

driving in heavy trafc. If the patient

feels uncomfortable driving in certain

situations, he/she should avoid these

situations until his/her condence level

has returned. A patient should never

resume driving before he/she feels ready

to do so and has received approval from

the physician.

• Pre-existing cognitive impairment

• Duration of surgery

• Age (over 60)

• Altered mental status post-surgery

• Presence of multiple comorbidities

• Emergency surgery

If the physician is concerned that

residual visual, cognitive or motor

decits following surgery may impair the

patient’s driving performance, referral

to a driver rehabilitation specialist for

a driver evaluation (including on-road

assessment) is highly recommended.

Physicians should counsel patients who

undergo surgery—both inpatient and

outpatient—not to drive themselves

home following the procedure. Although

they may feel capable of driving, their

driving skills may be affected by pain,

physical restrictions, anesthesia,

Section 11:

Effects of anesthesia

and surgery

1. Abdominal, back, and chest surgery

2. Anesthesia

a. General

b. Local

c. Epidural

d. Spinal

3. Neurosurgery

4. Orthopedic surgery

Physicians should be alert to peri- and

post-operative risk factors that may

affect the patient’s cognitive function

post-surgery, or restrictions on limb

movement or joint range of motion that

place the patient at risk for impairments

in driving performance. Risk factors

include:

Section 11: Effects of anesthesia and surgery

The patient may resume driving after demonstrating the necessary strength and

range-of-motion for driving.

See Section 2 for recommendations for surgeries involving median sternotomy.

Because anesthetic agents and adjunctive compounds (such as benzodiazepines)

may be administered in combination, the patient should not resume driving until

the motor and cognitive effects from all anesthetic agents have subsided.

Both the surgeon and anesthesiologist should advise patients against driving for at

least 24 hours after a general anesthetic has been administered. Longer periods of

driving cessation may be recommended depending on the procedure performed and

the presence of complications.

If the anesthetized region is necessary for driving tasks, the patient should not

drive until he/she has recovered full strength and sensation (barring pain).

The patient may resume driving after recovering full strength and sensation

(barring pain) in the affected areas.

The patient may resume driving after recovering full strength and sensation

(barring pain) in the affected areas.

Abdominal, back and chest surgery

Anesthesia

General

Epidural

Spinal

Local

Chapter 9—Medical Conditions and Medications That May Affect Driving

176

See recommendations for post intracranial surgery in Section 3.

See the recommendations for orthopedic procedures/surgeries in Section 7.

Neurosurgery

Orthopedic surgery

Chapter 9—Medical Conditions and Medications That May Affect Driving

177

Section 12:

Miscellaneous conditions

1. Cancer

Section 12: Miscellaneous conditions

Patients who experience signicant motor weakness or cognitive impairments

from the cancer itself, metastases, cachexia, anemia, radiation therapy, and/or

chemotherapy, which can cause cognitive impairment and/or neuropathy,

should cease driving until their condition improves and stabilizes.

Many medications prescribed to relieve the side effects of treatment

(e.g., antiemetics for nausea) may impair driving performance. Physicians

should counsel their patients accordingly. (See Section 13 for

recommendations for specic medications.)

Cancer

Chapter 9—Medical Conditions and Medications That May Affect Driving

178

available on-line.

278

Medication side effects that can affect

driving performance include drowsiness,

dizziness, blurred vision, unsteadiness,

fainting, slowed reaction time, and ex-

trapyramidal side effects. In many cases,

these side effects are dose-dependent

and may attenuate with time.

Whenever possible, the physician

should prescribe non-impairing medica-

tions. If the physician must prescribe

or change the dosage of a medication

that can potentially impair driving

performance, he/she should counsel

the patient about the side effects. The

physician should also recommend that

the patient take the rst few doses in a

safe environment to determine the pres-

ence and extent of any side effects, and

that he/she temporarily cease driving as

needed until the body has adjusted to

the medication.

In addition to being alert to potential

side effects, the patient, caregivers,

and physicians should also understand

that with certain medications, subjec-

tive effects do not always correlate

with impairment.

279

Medications that

cause drowsiness, euphoria, and/or

anterograde amnesia may also diminish

insight, and the patient may experience

impairment without being aware of it.

278. Walgreens Health Services. Continuing

Pharmacy Education Web Site. Medication-

Related Impaired Driving: For Pharmacist.

https://webapp.walgreens.com/cePharmacy/

programsHTML/transportation-tech.pdf. Accessed

November 16, 2007.

279. Mattila, M. (1988). Acute and subacute effects

of diazepam on human performance: comparison

of plain tablet and controlled release capsule.

Pharmacol Toxicol. 63(5):369–374.

Roache, JD., & Grifths, R. R. (1985).

Comparison of triazolam and pentobarbital:

performance

impairment, subjective effects and abuse liability.

J Pharmacol Exp Therapeut. 234(1):120–133.

Aranko, K., Mattila, M. J., & Bordignon, D.

(1985). Psychomotor effects of alprazolam and

diazepam during acute and subacute treatment,

and during the follow-up phase. Acta Pharmaco-

logica Toxicologica. 56(5):364–372.

Weiler, JM., et al. (2000). Effects of fexofena-

dine, diphenhydramine, and alcohol on driving

performance. a randomized placebo-controlled

trial in the Iowa Driving Simulator. Ann Intern

Med. 132(5):354–363.

older adults may be driving while under

the inuence of other medications.

273,

274

Potential driving impairing (PDI) medi-

cations is a relatively new term that

identies medications that have been

associated with increased crash risk.

Crash risk does increase when multiple

PDI drugs are prescribed.

275

Mechanisms

whereby drugs may impair driving are

myriad and include: sleepiness, fatigue,

or sedation; lightheadness, dizziness,

or low blood pressure; blackouts or

syncope; or impaired judgment coordi-

nation. Medications can affect eyesight

in numerous ways, including blurred

vision, impaired visual elds, and

nighttime vision.

276

However, it should

be noted that many medication and

driving studies are usually correlational

in nature, and may suggest increased

crash risk but not necessarily causation.

Whether it is the medication itself, the

condition for which it is prescribed,

the presence of other comorbidities, or

a combination of these issues is often

difcult to sort out.

277

Clinicians should

be aware of the risk and attempt to use

the safest class of medications based on

the most recent evidence. An excellent

review of this subject for pharmacists

may be of interest to physicians and is

273. Higgins, J. P., Wright, S. W., & Wrenn, K. D.

(1996). Alcohol, the elderly, and motor vehicle

crashes. Am J Emerg Med. 14:265–267.

274. Johansson, K., Bryding, G., Dahl, M. L., et

al.(1997). Trafc dangerous drugs are often

found in fatally injured older male drivers. J Am

Geriatr Soc. 45:1029–1031.

275. Leroy, A., & Morse, M. M. (N.A.). Exploratory

Study of the Relationship Between Multiple

Medications and Vehicle Crashes: Analysis

of Databases. NHTSA Contract DTNH22-

02-C-05075. Publication under review.

[Published as Multiple Medications and Vehicle

Crashes: Analysis of Databases. (2008, May).

NHTSA Report No. DOT HS 810 858. Wash-

ington, DC: National Highway Trafc Safety

Administration. Available at www.nhtsa.dot.gov/

staticles/DOT/NHTSA/Trafc%20Injury%20

Control/Articles/Associated%20Files/810858.pdf.]

276. Wang, K.(2007). Adverse Ocular Side-Effects

of Commonly Prescribed Systemic Medications.

Online CE provided by Pacic University

College of Optometry. www.Opt.pacifcu.edu/ce/

catalog/11466-PHWandgDrugs.html. Accessed

October 21, 2007.

277. Bramness, JG., Skurtvelt, S., Neutel, CI., et

al. (2008). Minor increase in trafc accidents

after prescriptions of antidepressants: a study

of population registry data in Norway. J Clin

Psychiatry. 69:1099–1103.

Section 13: Medications

1. Alcohol

2. Anticholinergics

3. Anticonvulsants

4. Antidepressants

a. Bupropion

b. Mirtazapine

c. Monoamine oxidase

(MAO) inhibitors

d. Selective serotonin reuptake

inhibitors (SSRIs)

e. Tricyclic antidepressants (TCAs)

5. Antiemetics

6. Antihistamines

7. Antihypertensives

8. Antiparkinsonians

9. Antipsychotics

10. Benzodiazepines and other

sedatives/anxiolytics

11. Muscle relaxants

12. Nonsteroidal anti-inammatory

drugs (NSAIDs)

13. Narcotic analgesics

14. Stimulants

Many commonly used prescription

and over-the-counter medications can

impair driving performance. In general,

any drug with a prominent central

nervous system (CNS) effect has the

potential to impair an individual’s

ability to operate a motor vehicle. The

level of impairment varies from patient

to patient, between different medica-

tions within the same therapeutic class,

and in combination with other medica-

tions or alcohol.

Many classes of medication have been

associated with increased crash risk or

impaired driving skills when assessed by

simulators or road tests. These include,

but are not limited to hypnotics, alcohol,

antiepileptic agents, anti-emetic agents,

narcotics, barbiturates, benzodiazepines,

antihistamines, antidepressants, antipsy-

chotics, and muscle relaxants. Some of

the highest crash rates have been noted

with long-acting benzodiazepines when

prescribed to older adults.

272

Other stud-

ies suggest that a signicant number of

272. Hemmelgarn, B., Suissa, S., Huang, A., et

al. (1997). Benzodiazepine use and the risk

of motor vehicle crash in the elderly. JAMA.

278:27–31.

Chapter 9—Medical Conditions and Medications That May Affect Driving

179

When prescribing new medications, the

physician should always consider the

patient’s existing regimen of prescription

and nonprescription medications.

Combinations of drugs may affect drug

metabolism and excretion, and produce

additive or synergistic interactions.

In fact, use of multiple psychoactive

medications is a common cause of

hospitalization for delirium among

older adults.

280

Because individuals

react differently to drug combinations,

280. Ray, W. A., Purushottam, B. T., Shorr, R. I.

(1939). Medications and the older driver.

Clin Geriatr Med. 9(2):413–438.

the degree of impairment caused by

polypharmacy may vary from patient

to patient. With polypharmacy’s strong

but unpredictable potential to produce

impairment, physicians should add

new medications at the lowest dosage

possible, counsel the patient to be alert

to any impairing side effects, and adjust

the dosages of individual medications

as needed to achieve therapeutic effects

with a minimum of impairment.

Section 13: Medications

As little as one serving of alcohol (1.25 oz. 80-proof liquor, 12 oz. beer, 5 oz. wine)

has the potential to impair driving performance in many individuals. Due to age-

related changes in body metabolism (e.g., increased body fat and decreases in lean

muscle mass), the same weight-adjusted amount of alcohol (hydrophilic) is likely

to result in higher blood levels of alcohol and functional impairment in advanced

age. In many cases, individuals may be impaired without being aware of it. Further-

more, alcohol can potentiate the CNS effects of medications to produce profound

and dangerous levels of impairment. Physicians should always warn their patients

against drinking and driving, and against combining alcohol and their CNS-

active medications.

For recommendations on substance abuse, see Section 5.

When a patient takes single or multiple medications with anticholinergic activity,

including some antidepressants, antihistamines, antiemetics, antipsychotics,

and antiparkinsonian drugs, the physician should be alert to the possibility of

anticholinergic toxicity and adjust medication dosages accordingly.

Anticholinergic effects that can impair driving performance include blurred vision,

sedation, confusion, ataxia, tremulousness, and myoclonic jerking. Patients should

be counselled about these symptoms and should alert their physicians immediately

if they occur. Patients should also be advised that psychomotor and cognitive

impairment might be present even in the absence of subjective symptoms

(this has been well documented for antihistamines).

Subtle decits in attention, memory, and reasoning may occur with therapeutic

dosages of anticholinergic drugs without signs of frank toxicity. These decits have

often been mistaken for symptoms of early dementia in elderly patients. Physicians

are advised to be aware of this possibility.

Alcohol

Anticholinergics

Chapter 9—Medical Conditions and Medications That May Affect Driving

180

The patient should temporarily cease driving during the time of medication

initiation, withdrawal, or dosage change due to the risk of recurrent seizure and/or

potential medication side effects that may impair driving performance.

If there is signicant risk of recurrent seizure during medication withdrawal or

change, the patient should cease driving during this time and for at least three

months thereafter.

Note that many anticonvulsants (e.g., valproic acid, carbamazepine, gabapentine,

lamotrigine and topiramate) are also being used as mood stabilizers for treatment of

bipolar disorder, for agitation in dementia, and as sedating agents for anxiety. These

agents are typically an adjunct to antidepressants, antipsychotics and/or anxiolytics.

By themselves, anticonvulsants may be mildly impairing, but the combined medi-

cation effects on psychomotor performance tend to enhance their effects. When

prescribing anticonvulsants and other psychoactive drugs, it is wise to start with low

doses of each and gradually increase the dosage of each one separately to minimize

signicant side effects. In addition, this would allow for a clear identication of

which drug may be producing a benet or problem.

Impairing side effects vary among the different classes of antidepressants, and even

within certain classes of antidepressants. (In general, antidepressants that possess

antagonistic activity at cholinergic, alpha-1-adrenergic, and histaminergic receptors

are the most impairing.) Recent data have also implicated venlaxine as being asso-

ciated with motor vehicle crashes.

281

Whenever possible, physicians should initiate

antidepressant therapy with the least impairing medication possible. However, the

data indicating increased crash risk with the specic use of certain medications may

reveal associations but not necessarily causation. It is difcult to know whether

increased risk is associated with the drug, a drug-drug interaction, or the disease

itself (e.g., depression, which may independently impair attention, judgment, etc).

Patients should be advised not to drive during the initial phase of antidepressant

dosage adjustment(s) if they experience drowsiness, lightheadedness, or other side

effects that may impair driving performance. Patients should also be advised that

they might experience impairment in the absence of any subjective symptoms.

Side effects of bupropion (also known as Wellbutrin

and Zyban

) include anxiety,

restlessness, weight loss, and insomnia (leading to daytime drowsiness). Patients

should be counseled about these side effects and their potential to impair driving

performance. Because bupropion may cause seizures at high doses, it should not be

prescribed to patients with epilepsy, brain injuries, eating disorders, or other factors

predisposing to seizure activity.

Mirtazapine (also known as Remeron

) is typically taken only at night due to its

sedating effects. It has been shown to cause substantial impairment for many hours

after dosing. If daytime sedation is noted as an adverse side effect, another antide-

pressant should be considered or driving discontinued.

281. Walgreens Health Services. Continuing Pharmacy Education Web Site. Medication-Related Impaired

Driving: For Pharmacist. https://webapp.walgreens.com/cePharmacy/programsHTML/transportation-tech.pdf.

Accessed November 16, 2007.

Anticonvulsants

Antidepressants

Bupropion

Mirtazapine

Chapter 9—Medical Conditions and Medications That May Affect Driving

181

Side effects of MAO inhibitors that may impair driving performance include

blurred vision, overstimulation, insomnia (leading to daytime drowsiness),

orthostatic hypotension (with transient cognitive decits), and hypertensive

crisis (presenting with severe headaches and/or mental status changes). The latter

can be caused by failure to adhere to dietary and medication restrictions. Patients

should be counseled about these side effects and their potential to impair driving

performance.

Common side effects of SSRIs that may impair driving performance include sleep

changes (insomnia or sedation), headache, anxiety, and restlessness. While these

side effects tend to be mild and well tolerated, physicians should counsel patients

to be alert to their potential to affect driving performance. Special mention is made

of serotonin syndrome, wherein mental status changes, autonomic hyperactivity,

and neuromuscular side effects are observed due to excessive amounts of the drug or

a drug-drug interaction. Treatment includes discontinuing the offending agent or

hospitalization in severe cases.

Common side effects of TCAs that may impair driving performance include

sedation, blurred vision, orthostatic hypotension, tremor, excitement, and heart

palpitations. In studies involving healthy volunteers, the more sedating TCAs have

been shown to impair psychomotor function, motor coordination, and open-road

driving. Other studies appear to indicate an increased crash risk for drivers who

take TCAs.

282

Whenever possible, other agents like SSRIs or TCA’s with a low propensity for

anticholinergic effects (nortryptiline or desipramine) should be considered for

those who wish to continue driving. If nonimpairing alternatives are not available,

then the physician should advise patients of the potential side effects, and recom-

mend temporary driving cessation during the initial phase of medication initiation/

dosage adjustment. Patients should also be advised that they might experience

impairment even in the absence of subjective symptoms.

Numerous classes of drugs—including anticholinergics, antihistamines, antipsychotics,

cannabinoids, benzodiazepines, 5HT antagonists, and glucocorticoids—are used

for their antiemetic effect. Side effects of antiemetics that may impair driving

performance include sedation, blurred vision, headache, confusion, and dystonias.

Signicant impairment may be present even in the absence of subjective symptoms;

this has been well documented for many benzodiazepines and over-the-counter

antihistamines. Patients should be counseled about side effects and their potential

to impair driving performance, and should be advised that they may experience

impairment even in the absence of subjective symptoms.

For more detailed information, see also Anticholinergics, Antihistamines,

Antipsychotics, and Benzodiazepines in this section.

282. Ray, W. A., Purushottam, B. T., Shorr, R. I. (1993). Medications and the older driver.

Clin Geriatr Med. 9(2):413–438.

Monoamine oxidase (MAO) inhibitors

Selective serotonin reuptake inhibitors

(SSRIs)

Tricyclic antidepressants (TCAs)

Antiemetics

Chapter 9—Medical Conditions and Medications That May Affect Driving

182

In many patients, the rst generation antihistamines (such as diphenhydramine

and chlorpheniramine) have pronounced CNS effects. In studies involving healthy

volunteers, sedating antihistamines have been shown to impair psychomotor

performance, simulated driving, and open-road driving.

283

Furthermore, subjects

may experience impairment even in the absence of subjective symptoms of im-

pairment.

284

In contrast, most nonsedating antihistamines do not produce these

types of impairment after being taken in recommended doses.

285

Even nonsedating

antihistamines may cause impairments if taken in higher-than-recommended doses,

however, and one of them (i.e., cetirizine) may be slightly impairing to certain

patients in normal doses.

Patients who take sedating antihistamines should be advised not to drive while

on the medications. If these patients wish to continue driving, they should be

prescribed a nonsedating antihistamine.

With their hypotensive properties, common side effects of antihypertensives that

may impair driving performance include lightheadedness, dizziness, and fatigue. In

addition, antihypertensives with a prominent CNS effect, including beta-blockers

and the sympatholytic drugs clonidine, guanfacine and methyldopa, may cause

sedation, confusion, insomnia, and nervousness.

Patients should be counseled about these side effects and their potential to

impair driving performance. In addition, patients taking antihypertensives that

may potentially cause electrolyte imbalance (i.e., diuretics) should be counseled

about the symptoms of electrolyte imbalance and their potential to impair driving

performance.

Several medications and classes of medications, including levodopa, antimuscarinics

(anticholinergics), amantadine, and dopamine agonists, may be used in the treatment

of Parkinson’s disease symptoms. Common side effects of antiparkinsonian drugs that

may impair driving performance include excessive daytime sleepiness, lightheaded-

ness, dizziness, blurred vision, dyskinesias, on-off phenomenon, hallucinations, and

confusion. (See also Anticholinergics in this section for more information.)

Patients should be counseled about these side effects and advised not to drive if

they experience side effects. The physician may also consider referring patients for

formal psychomotor testing or for on-road assessment performed by a driver rehabi-

litation specialist.

Most—if not all—antipsychotic medications have a strong potential to impair

driving performance through various CNS effects. Some of the original or

“classic” antipsychotics are heavily sedating, and all produce extrapyramidal

side effects (EPS). Alhough the modern or “atypical” drugs have a lower

tendency to cause EPS, they, too, are sedating.

283. Ibid.

284. Weiler, JM., et al. (2000). Effects of fexofenadine, diphenhydramine, and alcohol on driving performance.

a randomized placebo-controlled trial in the Iowa Driving Simulator. Ann Intern Med. 132(5):354–363.

285. Ray, W. A., Purushottam, B. T., Shorr, R. I. (1993). Medications and the older friver. Clin Geriatr Med.

9(2):413–438.

Antihistamines

Antihypertensives

Antipsychotics

Antiparkinsonians

Chapter 9—Medical Conditions and Medications That May Affect Driving

183

Patients should be counseled about these side effects and advised not to drive if

they experience side effects severe enough to impair driving performance. The

physician should consider referring the patient for formal psychomotor testing or

for on-road assessment performed by a driver rehabilitation specialist. If medication

therapy is initiated while the patient is hospitalized, the impact of side effects on

driving performance should be discussed prior to discharge.

Studies have demonstrated impairments in vision, attention, motor coordination,

and driving performance with benzodiazepine use. Evening doses of long-acting

benzodiazepines have been shown to markedly impair psychomotor function the

following day, while comparable doses of short-acting compounds produce a lesser

impairment.

286

In contrast, benzodiazepine-like hypnotics (such as zolpidem and

zaleplon) have a more rapid rate of elimination. Studies of driving performance

and psychomotor function have shown that ve hours after taking zaleplon and

nine hours after taking zolpidem at recommended doses, it is generally safe to drive

again.41 Recently, reports in the news media and some studies indicate that zolpi-

dem has not uncommonly been found during serum toxicology testing of drivers

involved in fatal accidents or arrested for driving under the inuence of drugs.

287

Patients should be prescribed evening doses of the shortest-acting hypnotics when-

ever possible. Patients who take longer-acting compounds or daytime doses of any

hypnotic should be advised of the potential for impairment, even in the absence

of subjective symptoms. These patients should also be advised to avoid driving,

particularly during the initial phase of dosage adjustment(s).

Most skeletal muscle relaxants (e.g., carisoprodol and cyclobenzaprine) have

signicant CNS effects. Patients should be counseled about these side effects, and

should be advised not to drive during the initial phase of dosage adjustment(s) if

they experience side effects severe enough to affect safe driving performance.

Isolated case reports of confusion following the use of the NSAIDs phenylbutazone

and indomethacin suggest that they may rarely impair driving performance.

288

Recent data reveal an association with motor vehicle crashes, although this could

represent the effects of the disease and not specically treatment.

289

If the patient

reports this side effect, the physician should consider adjusting the dosage or

changing the medication.

286. Ibid.

287. Vermeeren, A., Danlou, P. E., O’Hanlon, J. F. (1999). Residual effects of aaleplon 10 and 20 mg on

memory and actual driving performance following administration 5 and 2 hours before awakening.

Br J Clin Pharmacol. 48:367–374.

Vermeeren, A., Muntjewerff, N. D., van Boxtel, M., et al. (2000). Residual effects of zaleplon and

zopiclone versus the effects of alcohol on actual car driving performance. Eur Neuropsychopharmacol.

10(suppl 3):S394.

Volkerts, E. R., Verster, J. C., Heuckelem, J. H. G., et al. (2000). The impact on car-driving performance

of zaleplon and zolpiden administration during the night. Eur Neuropsychopharmacol. 10(suppl 3):S395.

288. Jones, A. W., Holmgren, A., & Kugelberg, F. C. (2007). Concentrations of scheduled prescription drugs

in blood of impaired drivers: considerations for interpreting the results. Ther Drug Monitor. 29:248–260.

289. Ray, W. A., Gurwitz, J., Decker, M. D., & Kennedy D. L. (1992). Medications and the safety of the older

driver: is there a basis for concern? Hum Factors. 34(1):33–47.

Antipsychotics (continued)

Benzodiazepines and other sedatives /

anxiolytics

Muscle relaxants

Nonsteroidal anti-inammatory drugs

(NSAIDs)

Chapter 9—Medical Conditions and Medications That May Affect Driving

184

Patients should be counseled about the impairing effects of narcotic analgesics

(i.e., opioids) and the potential for impairment even in the absence of subjective

symptoms. They should also be advised not to drive while on these medications.

In addition, many narcotic analgesics have a high potential for abuse. However,

the literature also indicates that physicians often undertreat pain in the general

population and with older adults. Accordingly, physicians should always be alert

to signs of abuse. (For more information, see the recommendations for substance

abuse in Section 5.)

Common side effects of traditional stimulants (such as amphetamines and

methylphenidate) that may impair driving performance include euphoria,

overcondence, nervousness, irritability, anxiety, insomnia, headache, and rebound

effects as the stimulant wears off. Patients should be counseled about these side

effects and advised not to drive during the initial phase of dosage adjustment(s)

if they experience side effects severe enough to impair driving performance.

(The novel stimulant, modanil, is not euphorogenic, nor does it appear to

cause rebound effects. However, its safety for use when driving has not yet

been demonstrated.)

In addition, many stimulants have a high potential for abuse. Accordingly,

physicians should always be alert to signs of abuse. (For more information,

see the recommendations for substance abuse in Section 5.5.)

Narcotic analgesics

Stimulants

Chapter 9—Medical Conditions and Medications That May Affect Driving

CHAPTER 10

Moving Beyond This

Guide: Future Plans to

Meet the Transportation

Needs of Older Adults

187

safety by assessing the functions related

to driving (see the Assessment of Driv-

ing Related Skills [ADReS] in Chapter

3) and reviewing the presence and/or

severity of important medical illnesses

(Chapter 9). The AMA will continue

to promote awareness of the most

recent assessment and rehabilitation

tools, and we encourage physicians to

stay informed on these developments.

2. Increased availability and

affordability of driver rehabilitation

When the results of physician assess-

ment are unclear, or when further

correction of functional decits through

medical management is not possible,

driver rehabilitation specialists (DRSs)

are an excellent resource. DRSs can

perform a focused clinical assessment,

observe the patient in the actual driv-

ing task, and train him/her in the use

of adaptive techniques or devices to

compensate for functional decits. (See

Chapter 5 for more information.)

Unfortunately, access and cost remain

major barriers to the utilization of DRSs

by older drivers and their referring

physicians. DRSs are not available in

all communities, and there are presently

too few to provide services to all older

drivers who are in need of their services

Furthermore, driver assessment and

rehabilitation are expensive, and Medi-

care and private insurance companies

rarely pay for these services.

The previous chapters provide physi-

cians with recommendations and tools

for enhancing the driving safety of their

patients. As in other aspects of patient

care, however, further research can lead

to more effective care. We eagerly await

further evaluation of in-ofce tools

that can predict crash risk or determine

tness-to-drive, as well as improved ac-

cess to driver assessment and rehabilita-

tion. We also look forward to advanced

technology in vehicles to assist drivers

with navigation and safety issues. At

the same time, we wish for safer roads,

better transportation alternatives, in-

creased crashworthiness of vehicles, and

other vehicular improvements that can

help keep our patients safe on the road

as long as possible.

In this chapter, the AMA advocates for

coordinated efforts among the medi-

cal and transportation communities,

policymakers, community planners, the

automobile industry, and government

agencies to achieve the common goal of

safe transportation for the older popula-

tion. As this population continues to

expand and live longer, we all have

the challenge of keeping pace with its

transportation needs.

Listed below is the AMA’s checklist

of research, initiatives, applications,

and system changes that we believe are

crucial for improving and increasing the

safe mobility of the older population.

We encourage readers of this guide to

use this list as a launching pad to boost

your future plans and efforts.

CHAPTER 10

Moving Beyond This Guide:

Future Plans to Meet the

Transportation Needs of

Older Adults

1. Improved physician tools for the

assessment of driving safety

Physicians need an assessment tool that

reliably identies patients who are at

increased risk for a car crash. This test

battery must assess the primary functions

that are related to driving, and must

form a basis for medical interventions to

correct any functional decits that are

identied. In addition, this tool must be

brief, inexpensive, easy to administer,

and validated to predict crash risk and/or

the ability to pass a performance-based,

standardized, reliable and valid road test.

At present, no comprehensive tool is

available. Individual functional tests

(such as the Trail Making Test, Part B;

see Chapters 3 and 4) have been repeat-

edly shown to correlate with crash risk,

yet there is still not a universal cut-off

or score on these tests that can deter-

mine tness-to-drive. Researchers are

currently studying other tests in relation

to driving. The eld has focused on

heterogeneous groups of older adults

with modest correlations in functional

batteries.

290

Further steps will likely

require a focus on different batteries or

tests in a given specic older population

with a specic disease (e.g., glaucoma,

dementia).

While researchers work toward achieving

a comprehensive test battery, physicians

can best evaluate their patients’ driving

290. Ball, K. K., Roenker, D. L., Wadley, V. G., et al.

(2006). Can high-risk older drivers be identied

through performance-based measures in a

Department of Motor Vehicles setting?

J Am Geriatr Soc. 54:77–84.

188 Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

tor vehicle.

297,

298

We encourage State

licensing authorities and driver rehabili-

tation programs to investigate the use of

technologies to increase the availability

of reliable driver assessment services

to the public. Such technologies, if

integrated into or aligned with current

practices, could help form an intermedi-

ate step between physician assessment

and driver rehabilitation or increase the

licensing authority’s capacity to offer

specialized driver assessment to medi-

cally at-risk drivers.

4. The enhanced role of the driver

licensing agency in promoting the

safety of older drivers

As the agency that ultimately awards,

renews, restricts and revokes the driver’s

license, each State’s driver licensing

agency has the task of distinguishing

unsafe drivers from safe drivers. While

each State has its own procedures,

which are highly variable, potentially

unsafe drivers are usually identied by

one of four means: (1) failure of the

individual to meet licensing or license

renewal criteria; (2) report from the

individual or family; (3) report from

physicians, DRSs, law enforcement of-

cers, and others; and (4) judicial report.

To meet the standards for licensing,

the driver licensing agency initially

requires individuals to pass assessments

of knowledge, vision, and driving

skills. License renewal tends to be less

stringent, with many States permitting

renewal by mail. In recent years, certain

States have increased their efforts to

identify older drivers who are at risk

for unsafe driving by stipulating special

renewal procedures for this population.

These procedures include shortened re-

newal intervals, in-person renewal, and

mandatory reassessment of knowledge,

vision, and driving skills.

297. Walter, H., Vetter, SC., Grothe, J., et al. (2001).

The neural correlates of driving. Neuroreport.

12(8):1763–1767.

298. Ott, B. R., Heindel, W. C., Whelihan, W.

M., et al. (2000). A single-photon emission

computed tomography imaging study of driving

impairment in patients with Alzheimer’s disease.

Dement Geriatr Cogn Disord. 11(3):153–160.

and on-road performance in cognitively

impaired and healthy older drivers.

291

Certainly, limitations exist with the use

of simulators, such as lack of standard-

ization in the eld, use of different crash

scenarios, expense, need for techno-

logical support, and simulator-induced

sickness. However, unlike on-road

assessment, simulators can evaluate

performance in driving situations that

would otherwise be infeasible or danger-

ous.

292

293

In addition, there have been

recent attempts to study their validity

294

and reliability.

295

Yet, a recent study was

not able to correlate simulator ndings

with crash data in a cohort of sleep

apnea patients, who have one of the

highest crash rates associated with any

medical conditions.

296

Further research

and experience may conrm that driv-

ing simulators are safe, effective, and

readily acceptable to the public. It will

also be useful to discover if familiarity

with computers and games by successive

aging cohorts affects the outcome of

simulator performance and/or reduces

crashes.

We applaud recent efforts to further

understand the complex role the central

nervous system plays in operating a mo-

291. Freund, B., Gravenstein, S., Ferris, R. (2002).

Evaluating driving performance of cognitively

impaired and healthy older adults: a pilot study

comparing on-road testing and driving simula-

tion (letter to the editor). J Am Geriatr Soc.

50:1309.

292. Reimer, B., D’Ambrosio, L., Coughlin, J., et al.

(2006). Using self-reported data to assess the

validity of driving simulation data. Behav Res

Method. 38(2):314–324.

293. Uc, E. Y., Rizzo, M. , Anderson, S. W., et al.

(2006). Unsafe rear-end collision avoidance

in Alzheimer’s disease. J Neurol Sci. 251

(1–2):35–43.

294. Reimer, B., D’Ambrosio, L., Coughlin, J., et al.

(2006). Using self-reported data to assess the

validity of driving simulation data. Behav Res

Method. 38(2):314–24.

295. Contardi, S., Pizza, F., Sancisi, E., et al. (2004).

Reliability of a driving simulation task for

evaluation of sleepiness. Brain Res Bull.

63(5):427-431.

296. Turkington, P. M., Sircar, M. , Allgar, V., &

Elliott, M. W. (2001). Relationship between

obstructive sleep apnoea, driving simulator

performance, and risk of road trafc accidents.

Thorax. 56(10):800–805.

The American Occupational Therapy

Association (AOTA) is addressing

these issues through two initiatives.

First, AOTA is devising a framework to

increase the number of DRSs within the

occupational therapy (OT) profession.

This framework will include strategies

to promote older driver practice among

current OT practitioners, curriculum

content for continuing education

programs, and training modules for

entry-level OT educational programs.

Secondly, AOTA is actively lobbying

for consistent Medicare coverage of

OT-performed driver assessment and

rehabilitation, under the assertions that

these services fall under the scope of

OT practice and that driving is an in-

strumental activity of daily living. Indi-

vidual DRS programs have also pursued

insurance coverage from Medicare and

other providers, with varying degrees of

success.

In the effort to keep older drivers on

the road safely as long as is reasonable,

increased access to and affordability of

driver assessment and rehabilitation

are essential. We support the AOTA’s

initiatives, and suggest that physicians

use DRSs as a resource for their patients

whenever possible. We also encourage

research in this eld to create standard-

ized off-road and on-road tests that have

respectable levels of reliability, validity,

and test stability. Correlating results

on road tests with prospective at-fault

crash data remains an important area

of future study. Finally, the added value

of physicians referring their patients to

an OT driving program, in comparison

to “usual care,” would be an important

step in the process of obtaining Medi-

care and insurance company support for

funding these types of evaluations.

3. Increased investigation into the

use of simulators and comprehen-

sive assessment methods techniques

Validated driver assessment technolo-

gies may help make driver assessment

more widely available to older driv-

ers. Preliminary research with a com-

mercially available driving simulator

has demonstrated a strong correlation

between simulated driving performance

189

laws that provide immunity from breach

of condentiality lawsuits for physicians

and others who report impaired drivers

to their State licensing authority.

5. Enhanced role of the Medical

Advisory Board

A Medical Advisory Board (MAB) is

generally composed of State-licensed

physicians who work in conjunction

with the driver licensing agency to

determine whether mental or physical

conditions may impair an individual’s

ability to drive safely. MABs vary

among States in size, role, and level of

involvement. For example, the MAB of

the Maryland Motor Vehicle Adminis-

tration reviews the tness of individu-

als to drive safely, while California’s

MAB provides recommendations to

DMV staff for use in developing policies

that affect medically and functionally

impaired drivers.

304

Many States lack

an MAB altogether or have one that is

ineffective.

We encourage each State driver licens-

ing agency to enhance the role of its

MAB in order to provide a greater

capacity for assessment, rehabilita-

tion and support to older drivers. We

also encourage States that lack MABs

to create a multi-disciplinary team of

medical experts to develop and imple-

ment recommendations on the medical

tness of their State’s licensed drivers.

Such recommendations should be based

on the most current scientic data, and

should be implemented in an efcient

review process.

Recently, the National Highway and

Trafc Safety Administration and

the American Association of Motor

Vehicle Administrators (AAMVA)

completed a study of each State’s

304. Raleigh, R., & Janke, M. (2001). The role of

the medical advisory board in DMVs: protecting

the safety of older adult drivers. Maximizing

Human Potential: Newsletter of the Network

on Environments, Services and Technologies for

Maximizing Independence. American Society on

Aging 9(2):4–5.

tem for older drivers. For example, the

agency can work more closely with the

at-risk drivers’ physicians or the Medi-

cal Advisory Board to correct functional

decits through medical treatment, if

possible. Drivers with a high poten-

tial for rehabilitation can be referred

by the licensing agency to a DRS to

learn adaptive techniques and devices.

Licensing agencies can also consider

the patient’s driving needs by issuing

restricted licenses whenever possible to

help the driver maintain mobility while

protecting his/her safety. For those driv-

ers who must relinquish their license,

the agency can provide guidance in

seeking alternative transportation.

At-risk drivers can also be brought to

the attention of the driver licensing

agency by physician referral. How-

ever, many physicians are not aware of

their State’s referral procedures,

303

and

others fear legal liability for breach of

condentiality. With the advent of the

Health Insurance Portability and Ac-

countability Act (HIPAA), physicians

may have questions about the extent

and detail of patient information they

should provide in a referral. Driver

licensing agencies can encourage physi-

cian referral by establishing clear guide-

lines and simple procedures for referral

(e.g., comprehensive referral forms

that can be accessed over the Internet)

and promoting physician awareness of

these guidelines and referral procedures.

In many States, physicians who refer

patients to their State’s driver licensing

agency are not granted legal protec-

tion against liability for breaching the

patient’s condentiality. Indeed, several

States encourage or require physicians

to report impaired drivers without spe-

cically offering this legal protection.

Physicians should join advocacy groups

in their States to pass fair laws that pro-

tect physicians who report in good faith

and ensure anonymity for reporting.

State legislatures are encouraged to es-

tablish or maintain good-faith reporting

303. Cable, G., Reisner, M. , Gerges, S., & Thiru-

mavalavan, V. (2000). Knowledge, attitudes,

and practices of geriatricians regarding patients

with dementia who are potentially dangerous

automobile drivers: a national survey. J Am

Geriatr Soc. 48(1):14–17.

We encourage all States to maintain

or adopt renewal procedures for the

most effective identication of at-risk

older drivers. (See also Enhanced role

of the Medical Advisory Board below.)

We also encourage States to base their

standards for licensing on current sci-

entic data. For example, visual acuity

standards that are based on outdated

research may be unnecessarily restric-

tive to all drivers and to older drivers in

particular. As noted in Chapter 7, the

only recent licensing renewal procedure

that has been associated with decreased

crash risk is the requirement for in-

person renewal.

In addition to the vision screens that

are currently in use, driver licensing

agencies may also wish to utilize newer

tools (such as contrast sensitivity and

the useful eld-of-view test) that have

been shown to correlate with crash

risk.

299, 300

Some of these tools, along

with other tests of function and driving

skills, are currently being eld-tested

by the California Department of Motor

Vehicles as part of its three-tier assess-

ment system.

301

Future ndings from

this system may be useful to some driver

licensing agencies that are interested in

establishing similar tier systems.

Many individuals are understandably

reluctant to report themselves to the

driver licensing agency as unsafe driv-

ers. Although there are few data on

this issue, recent research on referrals

for tness-to-drive in Missouri suggests

that few if any drivers take this step.

302

Driver licensing agencies can do their

part by creating a more supportive sys-

299. Owsley C., Stalvey BT., Wells J., Sloane M.

E., McGwin G. Visual risk factors for crash

involvement in older drivers with cataract. Arch

Ophthalmol. 119:881–887.

300. Owsley C., Ball K., McGwin G., Sloane M. E.,

Roenker DL., White M. F., Overley ET. Visual

processing impairment and risk of motor vehicle

crash among older adults. JAMA.

279(14):1083–1088.

301. Personal correspondence with Mary Janke,

Ph.D., September 26, 2002; and

Janke M. K., & Eberhard J. W. Assessing

medically impaired older drivers in a licensing

agency setting. Accid Anal Prev. 30(3):347–361.

302. Personal communication, Dr. Tom Meuser,

Director of Aging, University Missouri St.

Louis.

Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

190

fruitful area that warrants additional

investigation.

307

9. Vehicle designs that optimize

the safety of older drivers and

their passengers

Age-related changes in vision, cogni-

tion, and motor ability may affect an

individual’s ability to enter/egress a

motor vehicle with ease, access critical

driver information, and handle a motor

vehicle safely. Older persons are also

less able to endure and recover from in-

juries sustained in an automobile crash.

We encourage vehicle manufacturers to

explore and implement enhancements

in vehicle design that address and com-

pensate for these physiological changes.

In particular, vehicle designs based on

the anthropometric parameters of older

persons—that is, their physical dimen-

sions, strength, and range of motion—

may be optimal for entry/egress; seating

safety and comfort; seat belt/restraint

systems; and placement and congura-

tion of displays, mirrors and controls.

Improvements in headlamp lighting to

enhance nighttime visibility and reduce

glare, as well as the use of high-contrast

legible fonts and symbols for in-vehicle

displays, may help compensate for age-

related changes in vision.

308

In addition,

prominent analog gauges may be easier

to see and interpret than small digital

devices.

309

Computers have revolution-

ized the motor vehicle industry by man-

aging airbag safety systems, anti-lock

brakes, and global positioning systems.

In-vehicle assessment tools to assess for

high-risk conditions may be developed

in the future.

In the event of a crash, increasingly

crashworthy vehicle designs and

307. Bedard, M. , Porter, M. M., Marshall, S., et

al. (2008). The combination of two training

approaches to improve older driver safety Traff

Inj Prev. 9:70–76.

308. Schieber, F. (1994). High-priority research and

development needs for maintaining the safety

and mobility of older drivers. Exp Aging Res.

20:35–43.

309. Koonce, JM., Gold, M. , & Moroze, M. (1986).

Comparison of novice and experienced pilots

using analog and digital ight displays. Aviat

Space Environ Med. 57(12 pt. 1):1181–1184.

As a result of the meeting, the FDA

and NTSB concluded that steps must

be taken to better educate the public

and prescribing physicians on the ef-

fects on driving of potentially sedating

drugs. Only limited steps have been

taken thus far, but we support efforts to

increase patient and physician educa-

tion and clarify labeling for consumers.

One recent educational effort informs

pharmacists about potentially driving-

impairing drugs, and offers an exten-

sive curriculum that reviews causes of

crashes and the mechanisms whereby

drugs may impair driving.

306

Physicians

are encouraged to review this excel-

lent resource, given the trend toward

polypharmacy and the myriad problems

associated with adverse drug events.

Currently, manufacturers of medications

do not routinely test their products for

effects on driving, nor are they required

to do so. We support the identica-

tion and routine use of effective testing

parameters to identify medications that

may interfere with the ability to safely

operate a motor vehicle. Similarly,

such parameters could be utilized in the

identication of medications that do

not impair drivers when typically used

as directed.

8. Promote self-awareness and

appropriate self-regulation.

Our society relies on self-regulation at

every level, including driving. Most

drivers with adequate cognitive func-

tion and some modest assistance with

compensatory behaviors and alterna-

tives will choose to preserve safety.

Some preliminary data from Califor-

nia indicate that drivers with greater

impairment were actually safer drivers,

perhaps because they had perceived the

need to make adjustments and had suc-

cessfully done so. More research must be

done on appropriate self-regulation, and

productive use must be made of results

as a part of a comprehensive solution.

A recent study suggests this may be a

306. Lococo, K., et al. Pharmacist Curriculum Drugs

and Driving . https://webapp.walgreens.com/

cePharmacy/programsHTML/transportation-tech.

pdf. Accessed November 12, 2007.

MAB practices.

305

This project detailed

the function of each State’s MAB,

its regulatory guidelines, and barriers

to the implementation of screening,

counseling, and referral activities. The

executive summary of this study had

many important recommendations for

States that license medically impaired

drivers, such as: each State should have

an active board to set standards and

guidelines and to be involved in tness-

to-drive evaluations; board members

should be adequately compensated;

immunity for physicians for reporting

should be granted; and national stan-

dards and forms, and referrals for mobil-

ity counseling and/or DRSs, should be

considered.

7. Increased public awareness of

medication side effects that may

impair driving performance

Many prescription and over-the-counter

medications have the potential to

impair driving performance. Despite

warnings on the label and counseling

by physicians and pharmacists, many

patients are unaware of these risks.

To address this problem, the National

Transportation Safety Board (NTSB)

has recommended (in its Safety Recom-

mendation I-00-5) that the U.S. Food

and Drug Administration (FDA) estab-

lish a clear, consistent, and easily recog-

nizable warning label for all prescription

and over-the-counter medications that

may interfere with the individual’s abili-

ty to operate a vehicle. This recommen-

dation was the focus of a FDA/NTSB

joint public meeting held in November

2001. This meeting hosted presenta-

tions of epidemiological and controlled

data on the effects of sedating drugs and

crash risk, as well as presentations from

innovators of devices that are designed

to test the degree to which drugs may

impair driving.

305. Lococo, KH., & Staplin, L. (2005). Strategies

for Medical Advisory Boards and Licensing

Review. DOT HS 809 874. Washington, DC:

National Highway Trafc Safety Administra-

tion. www.nhtsa.dot.gov/people/injury/research/

MedicalAdvisory/pages/Executive.html. Accessed

November 14, 2007.

Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

191

Existing forms of transportation clearly

need to be optimized for use by older

persons. In a telephone survey of 2,422

people 50 and older, ride-sharing was

the second most common mode of

transportation (after driving); however,

nearly a quarter of the survey partici-

pants cited feelings of dependency and

concerns about imposing as a barrier to

use. Public transportation was the usual

mode of transportation for fewer than

5 percent of survey participants, with

many citing unavailable destinations,

problems with accessibility, and fear of

crime as barriers to use. Fewer than 5

percent used taxis as their usual mode of

transportation due to their high cost.

317

Until these barriers are addressed, these

forms of transportation will remain

inaccessible to many older persons.

Transportation programs created speci-

cally for the older population, such as

senior shuttles and vans, exist in certain

communities. Certain States have

adopted the independent transportation

network (ITN) model developed by Dr.

Katherine Freund initially in Maine.

318

These programs address the Five A’s of

Senior-Friendly Transportation; namely,

availability, accessibility, acceptabil-

ity, affordability, and adaptability (see

Figure).

319

As the older population

continues to grow, we encourage the

creation of new programs or the expan-

sion of existing ones to keep pace with

passengers’ needs. We also encourage

stronger community outreach to in-

crease awareness of such programs.

317. Ritter, AS., Straight, A., & Evans, E. (2002).

Understanding Senior Transportation: Report

and Analysis of a Survey of Consumers Age

50+. American Association for Retired Persons;

Policy and Strategy Group, Public Policy

Institute.

318. ITN America. (2007). www.itnamerica.org.

Accessed November 12, 2007.

319. Supplemental Transportation Programs for Se-

niors. (2001, June). By the Beverly Foundation,

prepared for AAA Foundation for Trafc Safety.

One of the top requests of the nearly

200 Iowans (older drivers, transporta-

tion professionals, and senior-related

professionals) attending the Iowa

Older Drivers Forum was the enhanced

enforcement of speed and aggressive

driving laws.

313

In terms of road and

trafc engineering, the Federal High-

way Administration (FHWA) has

recognized and addressed the needs of

older road users in its Highway De-

sign Handbook for Older Drivers and

Pedestrians, a supplement to existing

standards and guidelines in the areas

of highway geometry, operations, and

trafc control devices.

314

These design

features may be implemented in new

construction, renovation and mainte-

nance of existing structures, and “spot”

treatment at certain locations where

safety problems exist or are anticipat-

ed.

315

Recent positive news is a trend or

reduction in highway deaths for the rst

time since 1992, which in part has been

attributed to installation of median

guard cable on busy highways, building

better roads, and the addition of rumble

strips to the shoulders of roads.

316

The

FHWA handbook will soon be updated

to incorporate the latest research on the

effectiveness of design and engineering

enhancement to accommodate older

road users.

11. Better alternatives to driving

For the older population, alternatives to

driving are often less than ideal or non-

existent. When faced with the choice

of driving unsafely or losing mobility,

many risk their safety by continuing

to drive.

313. Iowa Safety Management System: Safe Mobility

Decisions for Older Drivers Forum. June 19-20,

2002.

314. Staplin, L., Lococo, K., Byington, S., Harkey, D.

(2001, October). Highway Design Handbook

for Older Drivers and Pedestrians. FHWA-

RD-01-103. Washington, DC: Federal Highway

Administration.

315. Ageing and Transport: Mobility Needs and

Safety Issues. (2001). Organisation for Eco-

nomic Co-Operation and Development; p. 60.

316. Tom Warne Report. (2007). Missouri Highway

Deaths Decline. http://tomwarnereport.com/twr/

twr_v4n28.html. Accessed November 15, 2007.

restraint systems designed for fragile

occupants may enhance the safety of

older drivers and passengers. Further-

more, certain add-on features may make

current vehicle designs safer and more

accessible for older drivers. For example,

handholds and supports on door frames

may facilitate entry/egress for drivers

and their passengers. Padded steering

wheels and seat adjuster handles (rather

than knobs) may benet drivers with

decreased hand grip, while adjustable

steering wheels and foot pedals may aid

drivers with limited range of motion.

310

Other adjustable controls and displays

may allow older drivers to tailor their

vehicle to their changing abilities and

needs. New safety features with the

potential to prevent injury in older

adults include: tire pressure monitor-

ing systems, adaptive cruise control/

collision mitigation systems, blind

spot detection/collision warning, lane

departure warnings, rollover prevention,

occupant-sensitive airbags, emergency

brake assist, rearview cameras, and

on-demand emergency response systems

(e.g., OnStar).

311

10. Optimal environments for older

drivers and pedestrians

Many older road users are at a disad-

vantage on roads and highways that are

most heavily used by and traditionally

designed for a younger population. In

a telephone survey of 2,422 people 50

and older, nearly one of ve participants

considered inconsiderate drivers to be

a signicant problem. Other commonly

identied problems included trafc con-

gestion, crime, and fast trafc.

312

These problems may be ameliorated

through trafc law enforcement and

better road and trafc control designs.

310. Ageing and Transport: Mobility Needs

and Safety Issues. (2001). Organisation for

Economic Co-Operation and Development;

p. 69–71.

311. Edmunds.Com. Top 10 High-Tech Car Safety

Technologies; 2007. www.edmunds.com/reviews/

list/top10/114984/article.html. Accessed Novem-

ber 15, 2007.

312. Ritter, AS., Straight, A., & Evans, E. (2002).

Understanding Senior Transportation: Report

and Analysis of a Survey of Consumers Age

50+. American Association for Retired Persons.

Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

192

and programs for the safe mobility of

the aging population.

Supplemental Transportation Programs

for Seniors. By the Beverly Founda-

tion, prepared for AAA Foundation for

Trafc Safety, June 2001. This report

contains the ndings of the Supplemen-

tal Transportation Program for Seniors

project, which was initiated in 2000 by

the AAA Foundation for Trafc Safety,

a philanthropic foundation in Wash-

ington, DC, and the Beverly Founda-

tion, a private foundation in Pasadena,

California. This project was designed as

a nine-month effort to gather informa-

tion about community-based transporta-

tion programs for seniors in the United

States. In describing and evaluating

these programs in order to provide their

ndings to interested organizations, the

project staff recognized the importance

of ve criteria for senior-friendly trans-

portation, which are listed.

Lococo , K., Tyree, R. Medication-Re-

lated Impaired Driving. By NHTSA and

co-sponsored by Walgreens, 2007.

By NHTSA and co-sponsored by

Walgreens, this excellent review of

potential driving-impairing drugs

provides credits or CEUs for pharmacy

technicians. However, this curriculum

is useful reading for any clinician who

prescribes drugs to older adults. The

manual covers causes of motor vehicle

crashes, reviews functional abilities that

are key for operating a motor vehicle,

and lists reasons why medications may

impair driving. There is a discussion

of the term “potentially impairing

medications” and an updated review of

the literature that identies high risk

drugs. Ethical and legal issues in drug

prescribing are addressed. Although the

curriculum was created for pharmacists,

much of the information is helpful to

physicians.

Lococo, K., Staplin, L. Strategies for

Medical Advisory Boards and Licensing

Review. DOT HS 809 874 , July 2005.

This NHTSA-funded project, written

by Lococo and Staplin, reviews the cur-

rent operations and practices of MABs.

A summary of what each State is cur-

rently doing in this area is provided.

Figure 10.1

The Five A’s of Senior-Friendly

Transportation

(Reproduced from Supplemental

Transportation Programs for Seniors,

The Beverly Foundation)

Availability: Transportation exists and

is available when needed (e.g., eve-

nings, weekdays, weekends)

Accessibility: Transportation can be

reached and used (e.g., bus stairs are

negotiable, seats are high enough,

vehicle comes to the door, transit

stops are reachable)

Acceptability: Deals with standards

including cleanliness and safety

(e.g., the transporting vehicle is

clean, transit stops are in safe areas,

drivers are courteous and helpful)

Affordability: Deals with costs

(e.g., fees are affordable, vouchers

or coupons are available to defray

out-of-pocket expenses)

Adaptability: Transportation can be

modiﬁed or adjusted to meet special

needs (e.g., the vehicle can accom-

modate a wheelchair, trip chaining is

possible, escorts can be provided)

12. Education and training tools

Additional resources

The following resources contain ad-

ditional information on meeting the

mobility needs of the older population:

Ritter, A. S., Straight, A., and Evans,

E. Understanding Senior Transporta-

tion: Report and Analysis of a Survey of

Consumers Age 50+. AARP, Policy and

Strategy Group, Public Policy Institute,

2002. This paper was created to explore

the problems of people 50 and older, in

particular, those 75and older with rela-

tion to transportation. May be used in

the development of policies that expand

and improve transportation options for

older persons.

Staplin, L., Lococo, K., Byington, S.,

and Harkey, D. Highway Design Hand-

book for Older Drivers and Pedestrians.

FHWA-RD-01-103, October 2001. This

applications-oriented handbook pro-

vides detailed design recommendations

for ve types of sites: (1) intersections

(at grade); (2) interchanges (grade sepa-

ration); (3) roadway curvature and pass-

ing zones; (4) construction/work zones;

and (5) highway-rail grade crossings.

This handbook is primarily intended

for highway designers, trafc engineers,

and highway safety specialists involved

in the design and operation of highway

facilities. It may also be of interest to re-

searchers concerned with issues of older

road user safety and mobility.

Ageing and Transport: Mobility Needs

and Safety Issues. Organisation for

Economic Co-Operation and Develop-

ment (OECD), 2001. The OECD, an

international organization dedicated to

addressing the economic, social, and

governance challenges of a globalized

economy, produced this investigation

of the travel patterns, transport and

safety needs, and mobility implications

of tomorrow’s elderly. It is intended to

inform strategists, policy-makers, regula-

tors, and the general public of the aging

population’s safety and mobility needs;

dispel myths and misconceptions about

older road users; and present the latest

research ndings to assist decision-

makers in formulating sound policies

Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

193

An executive summary is especially

useful in outlining the direction States

and MABs should pursue in order to

enhance their usefulness and viability,

and have an impact on public safety.

Maintaining Safe Mobility in an Aging

Society. The overarching objective

of this book is to provide a concise,

comprehensive, and up-to-date resource

on aging and transportation. Speci-

cally, it has the following goals: Enable

readers to understand the issues related

to aging and mobility and to respond

to the often heard comment “Just take

their driver license away”; describe the

skills related to safe driving and how

they can be affected by aging; critically

examine the current evidence on how

medical conditions and medications

affect driving skills; provide a compre-

hensive description of screening and

assessment practices, issues, and tools;

provide information to help older adults

transition from full driving to driving

cessation; and explore various means by

which an aging individual can maintain

safe mobility. (Eby, D.W., Molnar, L.J.,

& Kartje, P.S.. Maintaining Safe Mobil-

ity in an Aging Society. New York, NY:

CRC Press. ISBN: 9781420064537.

In press.)

Chapter 10—Moving Beyond This Guide: Future Plans to Meet the Transportation Needs of Older Adults

194

APPENDIX A

CPT

Codes

197Appendix A—CPT

Codes

The following Current Procedural Terminology (CPT

) codes

can be used for driver assessment and counseling, when

applicable. These codes were taken from Current Procedural

Terminology (CPT

). 4th ed., Professional ed. Chicago, IL:

American Medical Association; 2009.

When selecting the appropriate CPT

codes for driver

assessment and counseling, rst determine the primary reason

for your patient’s ofce visit, as you would normally. The

services described in this Guide will most often fall under

Evaluation and Management (E/M) services. Next, select

the appropriate E/M category/subcategory. If you choose to

apply codes from the Preventive Medicine Services category,

consult Table 1 for the appropriate codes. If any additional

services are provided over and above the E/M services, codes

from Table 2 may be additionally reported.

APPENDIX A

CPT

codes

New Patient, Initial Comprehensive Preventive Medicine

Evaluation and management of an individual including an age and gender

appropriate history, examination, counseling/anticipatory guidance/risk factor

reduction interventions, and the ordering of appropriate immunizations(s),

laboratory/diagnostic procedures.

These codes can be used for a complete Preventive Medicine history and physical exam for

a new patient (or one who has not been seen in three or more years), which may include

assessment and counseling on driver safety. If signicant driver assessment and counseling

take place during the ofce visit, Modier-25 may be added to the codes above.

Established Patient, Periodic Comprehensive Preventive Medicine

Reevaluation and management of an individual including an age and gender

appropriate history, examination, counseling/anticipatory guidance/risk factor

reduction interventions, and the ordering of appropriate immunization(s),

laboratory/diagnostic procedures.

Codes from the Preventative Medicine Services 99386-99387 and 99396-99397 can only be

reported once per year. If driver assessment and counseling take place during the ofce visit,

Modier-25 may be added to the codes above.

99386 40-64 years

99387 65 years and older

99396 40-64 years

99397 65 years and older

99401 Approximately 15 minutes

99402 Approximately 30 minutes

99403 Approximately 45 minutes

99404 Approximately 60 minutes

Modier-25 is appended to the ofce/outpatient service code to indicate that a signicant, separately identiable E/M service

was provided by the same physician on the same day as the preventive medicine service.

Counseling and/or Risk Factor Reduction Intervention

Preventive medicine counseling and risk factor reduction interventions provided

as a separate encounter will vary with age and should address such issues as family

problems, diet and exercise, substance abuse, sexual practices, injury prevention,

dental health, and diagnostic and laboratory test results available at the time of

the encounter. (These codes are not to be used to report counseling and risk factor

reduction interventions provided to patients with symptoms or established illness.)

These are time-based codes, to be reported based upon the amount of time spent counseling

the patient. Driver safety or driving retirement counseling fall under the category of injury

prevention. Please note that for driving retirement counseling, a copy of the follow-up letter

to your patient can be included in the patient’s chart as additional documentation. A sample

letter can be found in Chapter 6.

Table 1: Evaluation and Management—Preventive Medicine Services

If the primary reason for your patient’s visit falls under the E/M category of Preventive Medicine Services,

choose one of the following codes:

198 Appendix A—CPT

Codes

Table 2: Additional codes

The codes below can be used for administration of ADReS (see Chapter 3). If you complete the entire assessment, you can

include codes 99420, 95831 and either 99172 or 99173. The ADReS Score Sheet can serve as the report.

Administration and Interpretation of Health Risk Assessment Instrument

Muscle and Range of Motion Testing

Muscle testing, manual (separate procedure)with report; extremity

(excluding hand)or trunk.

Visual Function Screening

Automated or semi-automated bilateral quantitative determination of visual

acuity, ocular alignment, color vision by pseudoisochromatic plates, and eld of

vision (may include all or some screening of the determination(s) for contrast

sensitivity, vision under glare).

Screening Test of Visual Acuity, quantitative, bilateral

The screening used must employ graduated visual acuity stimuli that allow a

quantitative estimate of visual acuity (e.g., Snellen chart).

99420

95831

99172

99173

99406

99407

99408

99409

New CPT

codes for the Revised Physician’s Guide:

Smoking and tobacco use cessation counseling visit; intermediate, greater than

3 minutes up to 10 minutes

Smoking and tobacco use cessation counseling visit; intensive, greater than

10 minutes

Alcohol and/or substance (other than tobacco) abuse structured screening

(eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

Alcohol and/or substance (other than tobacco) abuse structured screening

(eg, AUDIT, DAST), and brief intervention (SBI) services;greater than30 minutes

APPENDIX B

Patient and Caregiver

Educational Materials

201Appendix B—Patient and Caregiver Educational Materials

APPENDIX B

Patient and Caregiver

Educational Materials

These handouts were designed to be user-friendly and simple to read. All patient education materials were written at or below

a 6th grade reading level, and all family and caregiver material was written at a 7th grade reading level.

We encourage physicians to make copies of these handouts for their patients, have them available in the ofce setting, educate

ofce staff to distribute them when appropriate, and use them as talking points when discussing driving issues with patients.

203Appendix B—Patient and Caregiver Educational Materials

Am I a Safe Driver?

Check the box if the statement applies to you.

 I get lost while driving.

 My friends or family members say they are worried about my driving.

 Other cars seem to appear from nowhere.

 I have trouble nding and reading signs in time to respond to them.

 Other drivers drive too fast.

 Other drivers often honk at me.

 Driving stresses me out.

 After driving, I feel tired.

 I feel sleepy when I drive.

 I have had more “near-misses” lately.

 Busy intersections bother me.

 Left-hand turns make me nervous.

 The glare from oncoming headlights bothers me.

 My medication makes me dizzy or drowsy.

 I have trouble turning the steering wheel.

 I have trouble pushing down the foot pedal.

 I have trouble looking over my shoulder when I back up.

 I have been stopped by the police for my driving.

 People no longer will accept rides from me.

 I have difculty backing up.

 I have had accidents that were my fault in the past year.

 I am too cautious when driving.

 I sometimes forget to use my mirrors or signals.

 I sometimes forget to check for oncoming trafc.

 I have more trouble parking lately.

If you have checked any

of the boxes, your safety

may be at risk when you

drive.

Talk to your doctor about

ways to improve your

safety when you drive.

205Appendix B—Patient and Caregiver Educational Materials

Successful Aging Tips

Tip #1: Take care of your health.

Visit your doctor regularly.

Ask about tests and immunizations that are right

for your age group.

Consider testing for cancer that is right for your

age group.

Treat any risk factors for atherosclerosis or

“hardening of the arteries.”

Eat a healthy diet. Your diet should be low in fat

and high in ber.

• Eat plenty of vegetables, fruits, beans and whole

grains.

• Eat low fat proteins in the form of lean red meat,

poultry and sh.

• Get enough calcium by drinking low fat milk

and eating low fat yogurt and cheese.

• Eat a variety of foods to get enough vitamins

and minerals in your diet.

• Drink lots of water.

Exercise to stay t. Be active every day at your

own level of comfort.

• Walk, dance, or swim to improve your

endurance.

• Work out with weights to increase your strength.

• Stretch to maintain your exibility or consider

joining group classes that will help you stay t

(e.g., yoga, tai chi).

Don’t drink too much alcohol. It is recommended

that people over the age of 65, not have more than

one drink per day. (A drink is one glass of wine,

one bottle of beer, or one shot of hard liquor.)

Never drink alcohol with your medicines!

Don’t use tobacco in any form. This means

cigarettes, cigars, pipes, chew or snuff. If you

need help quitting, talk to your doctor.

Tip #2: Keep yourself safe.

Make your home a safe place.

• Keep your home, walkways and stairways well

lit and uncluttered.

• Keep working smoke detectors and a re

extinguisher in your home.

• Adjust the thermostat on your hot water tank

so that you don’t burn yourself.

• Remove rearms from the house.

Prevent falls.

• Make sure all throw rugs have non-slip backs

so they don’t throw you!

• Slip-proof your bathtub with a rubber mat.

• Consider grab bars and a shower chair for

the bathtub.

• Consider a raised toilet seat.

• Consider an occupational therapy home

safety evaluation.

Stay safe in the car.

• Wear your seat belt—and wear it correctly!

(It should go over your shoulder and across

your lap.)

• Never drink and drive!

• Don’t drive when you are angry, upset,

sleepy or ill.

• If you have concerns about your driving safety,

talk to your doctor.

• Do not use a cell phone while driving.

• Do not do other activities such as eating,

reading, and shaving when driving.

(over)

206 Appendix B—Patient and Caregiver Educational Materials

Tip #3: Take care of your

emotional health.

Keep in touch with family and friends.

It’s important to maintain your social life!

Exercise your mind. Keep your mind active

by reading books, doing crossword puzzles,

and learning about computers.

Stay active by joining groups and keeping your

mind alert.

• Consider doing crosswords, puzzles, computer

games, card games, etc.

• Join a club, organization, or religious group and

participate in volunteer activities.

• Consider volunteering to drive an older adult

who no longer has a license!

Keep a positive attitude!

Remember to smile and laugh.

• Focus on the good things in your life, and don’t

dwell on the bad.

• Stay active with the activities that make you

happy.

• If you’ve been feeling sad lately or no longer

enjoy the things you used to, ask your doctor

for assistance.

Tip #4: Plan for your future.

Keep track of your money. Even if someone else

is helping you manage your bank accounts and

investments, stay informed.

Know your own health. This is important for

receiving good medical care.

• Know what medical conditions you have.

• Know the names of your medicines and how

often you take them.

• If you are having trouble remembering taking

your medication, use a pillbox, calendar, or

family member to help you stay on track.

• Make a list of your medical conditions, medi-

cines, drug allergies (if any), and the names

of your doctors. Keep this list in your wallet.

Make your health care wishes known to your

family and doctors.

• Consider lling out an advance directives form.

This form lets you state your health care choices

or name someone to make these choices for you

in case you are unable to do so.

• Give your family and doctors a copy of the

advanced directives form. This way, they have

a written record of your choices in case you are

unable to tell them at the time.

• If you need help with your advance directives,

talk to your doctor or your lawyer.

Create a transportation plan. If you don’t drive,

know how to get around.

• Ask family and friends if they would be willing

to give you a ride.

• Find out about buses, trains, and shuttles in your

area.

• If you need help nding a ride, contact your

local Area Agency on Aging.

207Appendix B—Patient and Caregiver Educational Materials

Tips for Safe Driving

Tip #1: Drive with care.

Always—

• Plan your trips ahead of time. Decide what time

to leave and which roads to take. Try to avoid

heavy trafc, poor weather and high-speed

areas.

• Wear your seat belt—and wear it correctly.

(It should go over your shoulder and across

your lap.)

• Be sure you “t” well in your car. Take advantage

of a CarFit class (see resources) if one is available

in your community.

• Drive at the speed limit. It’s unsafe to drive too

fast or too slow.

• Be alert—pay attention to trafc at all times.

• Keep enough distance between you and the car

in front of you.

• Be extra careful at intersections. Use your turn

signals and remember to look around you for

people and other cars.

• Check your blind spot when changing lanes or

backing up.

• Be extremely careful with left hand turns,

allowing enough time to pass through the

intersection in case of on-coming trafc.

• Be extra careful at train tracks. Remember to

look both ways for trains.

• When you take a new medicine, ask your

doctor or pharmacist about side effects.

Many medicines may affect your driving even

when you feel ne. If your medicine makes you

dizzy or drowsy, talk to your doctor to nd out

ways to take your medicine so it doesn’t affect

your driving.

Never—

• Never drink and drive.

• Never drive when you feel angry or tired. If you

start to feel tired, stop your car somewhere safe.

Take a break until you feel more alert.

• Never drive if your medication is making you

sleepy.

• Never use a cell phone when driving.

• Never eat, drink or do other activities while

driving.

• Never drive in icy or snowy weather.

If—

• If you don’t see well in the dark, try not to drive

at night or during storms.

• If you have trouble making left turns at an

intersection, make three right turns instead

of one left turn.

• If you can, avoid driving in bad weather such

as rain, sleet or snow.

• If a certain route always causes you stress,

try to nd an alternate route.

• If someone in the car is bothering you

(e.g., noisy grandchildren) tell him or her to stop.

(over)

208 Appendix B—Patient and Caregiver Educational Materials

Tip #2: Take care of your car.

• Make sure you have enough gas in your car.

• Make sure your tires have the right amount of

air and check them each month for any wear

or damage.

• Get your car tuned up regularly.

• Keep your windshields and mirrors clean.

• Keep a cloth in your car for cleaning windows.

• Replace your windshield wiper blades when they

get worn out.

• Consider using Rain-X or a similar product to

keep your windows clear.

• If you are shopping for a new car, look for a car

with power steering and automatic transmission.

• If you own a computer you can check to see

how well a car will do if it is involved in a crash.

This information is on the following Web site

of the National Highway Trafc Safety Admin-

istration: www.safercar.gov. You might want to

consider buying a car that has the highest rating

when struck by another vehicle from the front

or side.

Tip # 3: Know where you can ﬁnd a ride.

How do you get around when your car is in

the shop? If you don’t know the answer to this

question, it’s time for you to put together a

“transportation plan.”

A transportation plan is a list of all the ways that

you can get around. Use this list when your car is

in the shop or when you don’t feel safe driving.

Your transportation plan might include:

• Rides from friends and family

• Taxi

• Bus or train

• Senior shuttle

• Volunteer drivers from your local community

or government center.

If you need help creating a transportation plan,

your doctor can get you started.

Tip #4: Take a driver safety class.

To learn how to drive more safely, try taking a

class. In a driver safety class, the instructor teaches

you skills that you can use when you are driving.

To nd a class near you, call one of the following

programs:

AAA Foundation for Trafc Safety

Safe Driving for Mature Operators (course)

www.seniordrivers.org/driving/driving.cfm?button=

publication&selection=MO

AARP Driving Safety Program

The classic course with information on how to

locate an educational venue in your community.

www.aarp.org/families/driver_safety/

wrapper_driver.py

Driving School Association of the

Americas, Inc.

1-800-270-3722

These classes usually last several hours. These

classes do not cost much money—some are even

free. As an added bonus, you might receive a

discount on your car insurance after taking one

of these classes. Talk to your insurance agent and

company to determine if they offer a discount.

209Appendix B—Patient and Caregiver Educational Materials

How to Assist the

Older Driver

As experienced drivers age, changes in vision,

reaction time, and /or medical conditions may

cause them to drive less safely. Sometimes these

changes happen so slowly that drivers may not

even be aware that their skills have declined.

If you have concerns about someone’s driving

safety, here’s what you can do to keep your older

driver safe AND mobile.

Is your loved one a safe driver?

If you have the chance, go for a ride with this

driver. Look for the following warning signs in

his/her driving:

• Forgets to buckle up (use seat belts)

• Does not obey stop signs or red trafc lights

• Fails to yield right of way

• Drives too slowly or quickly

• Often gets lost, even on familiar routes

• Stops at a green light or at the wrong time

• Doesn’t seem to notice other cars, walkers,

or bike riders on the road

• Doesn’t stay in the lane

• Gets honked at or passed often

• Reacts slowly to driving situations

• Makes poor driving decisions

• Fails to use mirrors, check for blind spots, use

turn signals

• Mixes up gas and brake pedal or no longer can

use them smoothly

• Too cautious or too aggressive when driving

Other signs of unsafe driving:

• Recent near misses or fender benders

• Recent tickets for moving violations

• Repeated comments from those riding with your

driver or watching them in trafc about close

calls, near misses, or the driver not seeing other

vehicles.

• Accidents, especially those that were the driver’s

fault.

• Recent increase in the car insurance premium

Riding with or following your driver, every once in

a while, is one way to keep track of your loved one’s

driving. Another way is by talking to the spouse or

friends of the driver you are concerned about.

If you are concerned about your loved

one’s driving, what can you do?

Talk to your loved one. Say that you are concerned

about his/her driving safety. Ask if he or she shares

your concern.

• Don’t bring up your concerns while driving.

It’s dangerous to distract the driver! Wait until

he or she is calm and you have the driver’s full

attention.

• Explain why you are concerned. Give specic

reasons—for example, a medical condition like

poor vision, recent fender benders, getting lost,

or running stop signs.

• Realize that your loved one may become

negative or defensive. After all, driving is

important for independence and self-esteem.

(over)

210 Appendix B—Patient and Caregiver Educational Materials

• If the person you are concerned about does not

want to talk about driving at that time, bring

it up again later. Your continued concern and

support may help your loved one feel more

comfortable with this topic.

• Be a good listener. Take your loved one’s

concerns seriously.

• Consider using a handout like the Hartford’s

“We Need to Talk” which can be accessed at the

following website; www.thehartford.com/

talkwitholderdrivers/brochure/brochure.htm or

writing the Hartford and requesting brochures at;

The Hartford

We Need to Talk

200 Executive Boulevard

Southington, CT 06489

Help make plans for transportation. When your

loved one is ready to talk about his/her driving

safety, you can work together to create plans for

future safety.

• Make a formal agreement about driving. In this

agreement, your loved one chooses a person to

tell him/her when it is no longer safe to drive.

This individual then agrees to help your loved

one make the transition to driving retirement.

(You can nd a sample agreement in At the

Crossroads: A Guide to Alzheimer’s Disease, De-

mentia & Driving. Order a free copy by writing

to At the Crossroads booklet, The Hartford, 200

Executive Boulevard, Southington, CT, 06489.)

• Help create a transportation plan. Your loved

one may rely less on driving if he/she has other

ways to get around. Starting to use other ways to

travel even before the person stops driving may

make the change easier in the future.

Encourage a visit to the doctor. The doctor can

examine a person’s medical history, medication

regimen, and current health to see if any of these

may be affecting his/her driving safety. If so, the

doctor can provide treatment to help improve

medical conditions and possibly driving safety.

Encourage your loved one to take a driving test.

A driver rehabilitation specialist (DRS) can assess

a person’s driving safety through an ofce exam

and driving test. The DRS can also teach special

techniques or provide special equipment to help

a person drive more safely. (To nd a DRS in your

area, ask your doctor for a referral or contact the

Association for Driver Rehabilitation Specialists

(ADED

The Association for Driver Rehabilitation

Specialists (ADED

)

Information on the Association.

www.aded.net/i4a/pages/index.cfm?pageid=1

Also provides a locating tool for nding a

DRS near you.

www.aded.net/custom/directory/

?pageid=209&showTitle=1

If a DRS is not available in your area, contact a

local driving school or your State’s Department of

Motor Vehicles to see if they can do a driving test.

* The acronym ADED was retained when the association

changed its name from the Association of Driver Educators

for the Disabled to its current name.

211Appendix B—Patient and Caregiver Educational Materials

How to help when your loved one

needs to stop driving.

At some point, your loved one may need to stop

driving for his/her own safety and the safety of oth-

ers. You and your family members may come to this

decision yourselves, or at the recommendation of

the doctor, a driver rehabilitation specialist, driving

instructor, or the Department of Motor Vehicles.

When someone close to you retires from driving,

there are several things you can do to make this

easier for him/her:

• Help create a transportation plan. It may be

easier for someone to give up driving if they are

aware of other ways to get around. Help them

create a list of “tried-and-true” ride options.

This list can include:

• The names and phone numbers of friends and

relatives who are willing to give rides, with the

days and times they are available. You should

even consider writing in specic duties, dates,

and times, with the places your loved one needs

to go and the name of the driver on a calendar

to make this a reality.

• The phone number of a local cab company.

• Which bus or train to take to get to a specic

destination. Try riding with your loved one the

rst time to make him/her feel comfortable.

(This may not be possible for many people with

physical weakness or arthritis and certainly

could not be done for those with memory or

thinking problems.)

• The phone number for a shuttle service.

Call your community center and regional

transit authority to see if they offer a door-to-

door shuttle service for older passengers.

• The names and phone numbers of volunteer

drivers. Call your community center, church, or

synagogue to see if they have a volunteer driver

program.

• If you need help nding other ride options,

contact your local Area Agency on Aging.

Local Agency on Aging

Assists in nding resources for the aging

in your community.

www.eldercare.gov

If your loved one can’t go shopping, help him/

her shop from home. Arrange for medicines and

groceries to be delivered. Explore online ordering

or subscribe to catalogs and “go shopping” at home.

Locate which services make house calls—local

hairdressers or barbers may be able to stop by for

a home visit.

Encourage social activities. Visits with friends,

time spent at the senior center, and volunteer work

are important for health and well-being. When cre-

ating a transportation plan, don’t forget to include

rides to social activities. It’s especially important to

maintain social contacts and keep spirits up during

this time of adjustment.

Be there for your loved one. Let the person you

care for know that he or she has your support.

Offer assistance willingly and be a good listener.

This may be an emotionally difcult time, and it’s

important to show that you care. You may need to

nd additional family members or friends to help

with this discussion.

213Appendix B—Patient and Caregiver Educational Materials

Getting By Without Driving

Who doesn’t drive?

If you live long enough, you will eventually have

to stop driving. The average male will have seven

years without the ability to drive, and the average

female ten years! Many people choose to stop

driving because of the hassle and expense of auto

insurance, car maintenance, and gasoline. Other

people stop driving because they feel unsafe on the

road. And some people have never learned

to drive!

If you don’t drive, you’re in good company.

Although most Americans use their cars to get

around, many people get by just ne without one.

In this sheet, we suggest ways to get by without

driving.

Where can you ﬁnd a ride?

Here are some ways to get a ride. See which ones

work best for you.

• Ask for a friend or relative for a ride. Offer to

pay for the gasoline.

• Take public transportation. Can a train, subway

or bus take you where you need to go? Call your

regional transit authority and ask for directions.

• Take a taxi cab. To cut down costs, try sharing

a cab with friends or nd out if your community

offers discounted fares for seniors.

• Ride a senior transit shuttle. Call your com-

munity center or local Area Agency on Aging to

see if your neighborhood has a shuttle service.

• Ask about volunteer drivers. Call your commu-

nity center, church or synagogue to see if they

have a volunteer driver program.

• Ride a Medi-car. If you need a ride to your

doctor’s ofce, call your local Area Agency on

Aging to see if a Medi-car can get you there.

If you can’t go out to get something,

have it come to you.

Many stores can deliver their products straight to

your door.

• Have your groceries delivered. Many stores

deliver for free or for a low fee. You can even call

your family and friends, or volunteers from your

local community center, church or synagogue to

see if someone can pick up your groceries

• Order your medicines by mail. Not only is this

more convenient—it’s often less expensive, too.

Order only from pharmacies that you know and

trust. Some pharmacists will also deliver medica-

tions to the home.

• Have your meals delivered to you. Many

restaurants will deliver meals for free or for a

low fee. Also, you may be eligible for Meals-on-

Wheels, a program that delivers hot meals at low

cost. Call your local Area Agency on Aging for

more information about Meals-on-Wheels.

• Shop from catalogs. You can buy almost any-

thing you need from catalogs: clothing, pet food,

toiletries, gifts, and more! Many catalogs are

now on-line, with the most recent selections

available from Internet Web sites.

(over)

214 Appendix B—Patient and Caregiver Educational Materials

Who can tell me more about services

in my area?

The following agencies can provide you with

information to get you started:

Area Agency on Aging (AAA) Eldercare Locator

www.eldercare.gov

800-677-1116 weekdays

Call this toll-free number and ask for the phone

number of your local Area Agency on Aging

(AAA). Your local AAA can tell you more

about ride options, Meals-on-Wheels, and senior

recreation centers in your area.

Administration on Aging Resource Directory

for Older People

www.aoa.gov/eldfam/How_to_Find/

ResourceDirectory/ ResourceDirectory.pdf

800-222-2225

Call this toll-free number and ask the National

Institute on Aging to send you their Resource

Directory for Older People. This 120-page

directory lists organizations that provide

services for older people.

215Appendix B—Patient and Caregiver Educational Materials

Where Can I Find More

Information?

We’ve listed additional resources on the

following pages to help you assess and

enhance driving safety for the retired

driver. Some resources can help you

create a transportation plan for your

loved one.

National Association of Private

Geriatric Care Managers (NAPGCM)

520-881-8008

www.caremanager.org

A geriatric care manager can help

older people and their families arrange

long-term care, including transportation

services. Call the phone number or visit

the Web site above to nd a geriatric

care manager in your loved one’s area.

National Association of Social

Workers (NASW)

www.socialworkers.org/register/

default.asp

A social worker can provide counsel-

ing to your loved one, assess his/her

social and emotional needs, and assist

in locating and coordinating transporta-

tion and community services. To nd a

qualied clinical social worker in your

loved one’s area, search the NASW

Internet.

Additional clinician, patient,

and caregiver resources

Clinician resources

American Occupational Therapy

Association (AOTA)

Information on occupational therapists

and their role in driving assessment and

rehabilitation.

www1.aota.org/olderdriver/

The Association for Driver

Rehabilitation Specialists (ADED*)

Information on the Association.

www.aded.net/i4a/pages/

index.cfm?pageid=1

Also provides a locating tool for nding

a DRS near you.

www.aded.net/custom/directory/

?pageid=209&showTitle=1

National Highway Trafc Safety

Administration

Many links to resources for

older drivers.

www.nhtsa.dot.gov

and

Adapting Motor Vehicles for People

with Disabilities

www.nhtsa.dot.gov/cars/rules/

adaptive/brochure/brochure.html

American Medical Association (AMA)

Physician’s Guide to Assessing and

Counseling Older Drivers

www.ama-assn.org/ama/pub/

category/10791.html

General older driver information

provided by the AMA.

www.ama-assn.org/ama/pub/

category/8925.html

CanDrive

Dementia and Driving Toolkit:

The Dementia Network of Ottawa

www.candrive.ca/En/

Physician_Resources/toolkit.asp

Canadian Medical Association (CMA)

Determining Medical Fitness to Oper-

ate a Motor Vehicle

CMA Driver’s Guide, 7th edition

www.cma.ca/index.cfm/ci_id/18223/

la_id/1.htm

Administration on Aging (AOA)

Information and resources for older

drivers.

www.aoa.gov

Summary of Internet resources

for the older driver.

www.aoa.gov/prof/notes/Docs/

Older_Drivers.doc

Insurance Institute for

Highway Safety (IIHS)

A frequently-updated site on older

driver laws for driver licensing.

www.iihs.org/laws/olderdrivers.aspx

Older Drivers: Fact Sheets

General information on the older driver

from the Centers for Disease Control

and Prevention, AARP and the Na-

tional Highway Trafc Safety Adminis-

tration.

www.cdc.gov/ncipc/factsheets/older.

htm

www.aarp.org/families/driver_safety/

www-nrd.nhtsa.dot.gov/Pubs/

809475.PDF

AAA Foundation for Trafc Safety

Older driver brochures.

Safe Driving For Mature Operators

(course).

www.seniordrivers.org/driving/

driving.cfm?button=publication&

selection=MO

Caregiver and patient resources

GrandDriver Program

Resources and information on other

older driver sites.

www.granddriver.info/

American Society on Aging

Information on DriveWell, an older

driver educational program that may be

offered in your community.

www.asaging.org/asav2/drivewell/

index.cfm

* The acronym ‘ADED’ was retained when the

association changed its name from the Associa-

tion of Driver Educators for the Disabled to its

current name.

216

The Association for Driver

Rehabilitation Specialists (ADED)

Information on the Association.

www.aded.net

Also provides a locating tool for nding

a DRS in your community.

www.aded.net/custom/directory/?pagei

d=209&showTitle=1

University of Michigan Transportation

Institute

Driving Decisions Workbook

A self-awareness guide to identify areas

of concern for older driver safety.

http://deepblue.lib.umich.edu/

handle/2027.42/1321

Alternative Transportation Options

American Administration on Aging

(AOA)

Eldercare locator

Assists in nding older adult resources

in your community.

www.eldercare.gov

Community Transportation

Association (CTAA)

Information on transportation in the

United States.

www.ctaa.org/ntrc/

American Public Transportation

Association (APTA)

Locate a local transportation provider

in your community.

www.publictransportation.org/systems/

Easter Seals

Transportation solutions for caregivers

www.easterseals.com/site/

PageServer?pagename=ntl_trans_care

National Center for Senior

Transportation

www.seniortransportation.net/

Local Agency on Aging

Assists in nding resources for the aging

in your community.

www.n4a.org/

Seniors on the MOVE

Assists with relocating to another

community.

www.seniorsonthemoveinc.com

New York Department for the Aging

When You Are Concerned—

A Handbook for Families, Friends,

and Caregivers

A handbook for those worried about the

safety of an aging driver.

http://aging.state.ny.us/caring/

concerned

AARP Driving Safety Program

The classic course with information on

how to locate an educational venue in

your community.

www.aarp.org/families/driver_safety/

wrapper_driver.py

Australia

Handbooks on older adults from the

provinces of Victoria and Tasmania in

Australia and the Australian Capital

Territory.

www.transport.tas.gov.au/licence_in-

formation_folder/the_tasmanian_old-

er_drivers_handbook?SQ_DESIGN_

NAME=printer_friendly

www.vicroads.vic.gov.au/NR/

rdonlyres/B15A81F1-2047-45B0-

821C-7AB3317029B6/0/victorianol-

derdrivershandbook5.pdf.

www.act.gov.au/living/roads/older/con-

tents.html

www.cota-act.org.au/Download_Docu-

ments/PDFS/Older_Drivers_Hbook_

web_0703.pdf

Drivers.com

General information on older drivers.

www.drivers.com/

Top_Older_Drivers.html

Mobilise

Disabled Drivers Information Website

(United Kingdom)

www.mobilise.info/Information.asp

American Occupational Therapy

Association (AOTA)

Information on occupational therapists

and their role in driving assessment and

rehabilitation.

www1.aota.org/olderdriver/

Road map to driving wellness.

Information on staying t.

www.asaging.org/CDC/module4/

home.cfm

Caregiver and patient resources

(continued)

AAA Foundation for Trafc Safety

Older driver brochures and the

Safe Driving For Mature

Operators course.

www.seniordrivers.org/driving/

driving.cfm?button=publication&

selection=MO

CarFit and General Information

www.seniordrivers.org/home/

toppage.cfm

RoadWise Review

www.roadwisereview.com/

University of Massachusetts Boston

Center for Gerontology

Keep moving longer: features for safe

driving. A video program that offers

advice on staying mobile.

www.geront.umb.edu/inst/projects/

promoting.jsp

National Highway Trafc Safety

Administration

Older Road Users; other older driver

information and materials.

www.nhtsa.dot.gov/people/injury/

olddrive

Driving Safely while Aging Gracefully

Reviews the skills and problems that

may face older drivers.

www.nhtsa.dot.gov/people/injury/

olddrive/Driving Safely Aging Web/

index.html

The Hartford

We Need to Talk

At the Crossroads: A Guide to

Alzheimer’s Disease, Dementia,

and Driving

State-of-the-art educational materials

for older drivers.

www.thehartford.com/

talkwitholderdrivers

www.thehartford.com/alzheimers/

brochure.html

217

Alternative Transportation Options

(continued)

National Association of Social

Workers (NASW)

Locate a social worker near you.

www.socialworkers.org/register/

default.asp

United We Ride

Coordination of transportation services.

www.unitedweride.gov

Research and Statistics

Federal Highway Administration

Information on older drivers

http://safety.fhwa.dot.gov/older_driver/

older_quiz.htm

Guidelines and recommendations to ac-

commodate older drivers and pedestrians.

Information on environmental design.

www.tfhrc.gov/humanfac/01105/

cover.htm

Older Road Users

General information on older drivers.

www.nhtsa.dot.gov/people/injury/old-

drive/

Research Agenda for Older Drivers

www.nhtsa.dot.gov/people/injury/

olddrive/pub/Chapter3.html

Safe Mobility for Older People: Model

Driver Screening and Evaluation

Program

www.nhtsa.dot.gov/people/injury/

olddrive/safe/

Further Analysis of Drivers Licensed

with Medical Conditions in Utah

www.nhtsa.dot.gov/people/injury/

olddrive/utah/utah_index.htm

The Road Information Program

(TRIP)

A research community on transportation.

www.tripnet.org

www.tripnet.org/

OlderDriversStudyOct2000.PDF

Older Driver Involvements in Police

Reported Crashes and Fatal Crashes:

Trends and Projections

Duke University Science News

http://unisci.com/stories/

20022/0624023.htm

Transportation Safety

Center for Injury Prevention Policy and

Practice

San Diego State University

www.injuryprevention.org/links/

links-trans.htm

AAA Foundation for Trafc Safety

Research on older driver safety

www.seniordrivers.org

Appendix B—Patient and Caregiver Educational Materials

Putting it all together.

Fill out the table below with names and numbers of services in your area. Keep this information at your ngertips by placing it

next to your phone or posting it on your refrigerator.

Service Phone number Cost

APPENDIX C

Continuing Medical

Education Questionnaire

and Evaluation

221

CME Questionnaire:

Instructions: The Physician’s Guide for Assessing and Counseling

Older Drivers contains the correct answers to the following

questions. Circle your answer to each question.

1. Compared to drivers age 25 to 69,

older drivers experience—

a. A higher fatality rate in motor vehicle crashes

b. A higher fatality rate per vehicle mile driven

c. A higher crash rate per vehicle mile driven

d. All of the above

2. The majority of older Americans do not rely on

driving as their primary form of transportation.

a. True

b. False

3. Compared to younger drivers, older drivers are more

likely to wear seatbelts and are less likely to drive at

night, speed, tailgate, and consume alcohol prior to

driving.

a. True

b. False

4. Medications that have the potential to impair driving

ability include—

a. Anticonvulsants

b. Antidepressants

c. Muscle Relaxants

d. a and b only

e. All of the above

5. Aspects of vision that are most important for safe

driving include—

a. Visual acuity

b. Visual elds

c. Contrast sensitivity

d. b and c only

e. All of the above

6. Match the cognitive skill to the appropriate

driving situation:

7. Research has demonstrated that drivers with 20/70 vi-

sual acuity have a signicantly greater crash risk than

drivers with 20/40 visual acuity.

a. True

b. False

8. All of the following are important for viewing the driv-

ing environment EXCEPT—

a. Visual acuity

b. Visual elds

c. Memory

d. Neck rotation

9. A Driver Rehabilitation Specialist (DRS) can—

a. Revoke a client’s drivers license for poor perfor-

mance on a clinical exam

b. Evaluate a client’s driving skills through an on-road

assessment

c. Assess the client’s vehicle and recommend adaptive

equipment to enhance the client’s comfort and driv-

ing safety

d. b and c only

e. All of the above

APPENDIX C

Physicians Guide to

Assessing and Counseling

Older Drivers

1. Applying the brake at a green

light because a child runs into

the path of your vehicle.

2. Listening to the trafc report

on the radio while keeping an

eye on the road.

3. Recalling that a particular

street is a one-way street.

4. Determining the distance

from your car to the stop sign.

___ Memory

___ Visuospatial skills

___ Divided attention

___ Executive skills

Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

222 Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

10. Driving cessation has been associated with an increase

in depressive symptoms in the elderly.

a. True

b. False

11. Which of the following is NOT recommended as

an initial technique to help your patients retire

from driving?

a. With the patient’s permission, involve family

members and caregivers.

b. Explain to the patient why you have recommended

that they retire from driving.

c. Provide your patient with information on

alternatives to driving.

d. Tell the patient’s relatives to hide the car keys.

12. ‘Physicians are required to report patients with

dementia to their state Department of Motor Vehicles’

is an example of—

a. Mandatory Medical Reporting Laws

b. Physician Reporting Laws

c. Physician Liability

d. None of the above

13. Physician-patient privilege can be used to prevent

physicians from abiding by their state’s Physician

Reporting Laws.

a. True

b. False

14. All states protect the identity of the individual who

reports an unsafe driver to the DMV.

a. True

b. False

15. Key functions that are important for safe driving

include—

a. Vision

b. Cognition

c. Motor function

d. a and b only

e. All of the above

16. What conditions are in part responsible for the increase

vulnerability to injury in a motor vehicle crash?

a. osteoporosis

b. atherosclerosis of

c. left-hand turn crashes

d. cars with no air bags

e. All of the above

17. What eye disease when treated has been shown to

lower crash risk in older adults?

a. glaucoma

b cataract

c. macular degeneration

d. diabetic retinopathy

e. All of the above

18. What neurological illness in late life carries the highest

crash risk for those that continue to drive?

a. Alzheimer’s Disease

b. Seizure disorder

c. Stroke

d. Brain Injury

19. Which of the following medications has been shown to

be associated with impaired driving?

a. Valium

b. Anti-depressants

c. Narcotics

d. Benadryl

e. All of the above.

20. Which of the following conditions carries the highest

crash risk?

a. a driver with a spinal cord affecting his arms and legs

that uses a joystick to drive

b. a stroke patient that has to use hand controls on the

steering wheel to drive

c. an amputee that uses hand controls on the steering

wheel to drive

d. an older adult with restricted neck range of motion

21. What are the most common road conditions when

older adults have crashes?

a. wet pavement, morning rush hour, and going

up a hill

b. dry pavement, mid-morning, on a at roadway

c. snowy weather, at night, going around a curve

d. icy conditions, at night, trying to pass another

vehicle

22. What vehicle modications have been shown to reduce

crashes or injuries?

a. infrared brakes

b. side air bags

c. enlarged side view mirrors

d. On-STAR

e. All of the Above

223Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

23. What is true about laws for reporting unsafe drivers?

a. Physicians prefer to have civil immunity for protec-

tion and anonymity when reporting

b. States with mandatory reporting laws appear to have

higher number of reports

c. Physicians have been sued for not reporting unsafe

drivers and they have been sued for reporting.

d. Almost all states require a physician evaluation for

medical tness-to-drive if a driver is reported to the

state authorities as being unsafe

e. All of the above

24. What types of crash scenarios are common for

older adults?

a. high speed crashes

b. low speed and/or left hand turn crashes

c. head-on collisions

d. failure to yield

e. Answer B, D

25. What common medical condition is often undiag-

nosed and likely carries the highest crash rate if

left untreated?

a. Sleep apnea

b. Alzheimer’s Disease

c. Diabetes Mellitus

d. Parkinson’s Disease

Please print and include all information requested.

Name and title _________________________________________________________________________________________

Address _______________________________________________________________________________________________

City _______________________________________________________ State _____ Zip _____________________________

Phone ( ) ________________________________Fax ( ) ________________________________________

E-mail ________________________________________________________________________________________________

Medical specialty _______________________________________________________________________________________

Please mail the completed form to:

Lela Manning, MPH, MBA

Project Coordinator, Older drivers Project

American Medical Association

515 N. State Street

Chicago, IL 60654

(312) 464-4111 (Fax)

224

Please complete this evaluation by circling your response or writing your

comments in the spaces provided.

Overall Impression

1. I feel I can dene the safety risks of older drivers as a public health issue.

Strongly agree Agree Undecided Disagree Strongly disagree

2. This guide is a useful and effective physician education tool.

Strongly agree Agree Undecided Disagree Strongly disagree

3. This guide has raised my awareness of driving as a public safety issue.

Strongly agree Agree Undecided Disagree Strongly disagree

4. I have a better understanding of the medical conditions and medications that may impair my patient’s ability to

drive safely.

Strongly agree Agree Undecided Disagree Strongly disagree

5. I feel comfortable identifying patients who may be at risk for unsafe driving.

Strongly agree Agree Undecided Disagree Strongly disagree

6. I feel comfortable using the various clinical screens to assess patients’ level of function for driving tness.

Strongly agree Agree Undecided Disagree Strongly disagree

7. I feel comfortable using counseling techniques for patients who are no longer t to drive.

Strongly agree Agree Undecided Disagree Strongly disagree

8. I have a better understanding of driver rehabilitation options and alternatives to driving.

Strongly agree Agree Undecided Disagree Strongly disagree

9. I feel comfortable utilizing referral and treatment options for patients who are no longer t to drive.

Strongly agree Agree Undecided Disagree Strongly disagree

10. I have a better understanding of my state’s reporting laws and legal/ethical issues surrounding patients who may not

be safe on the road.

Strongly agree Agree Undecided Disagree Strongly disagree

As a result of participating in this educational activity:

❏ I will change my practice How? ____________________________________________________________________

______________________________________________________________________________________________________

Continuing Medical Education

Evaluation Form

Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

225

❏ I will not change my practice ______________________________________________________________________ Why?

❏ This activity reinforced my current practice __________________________________________ ❏ Other (please explain)

______________________________________________________________________________________________________

I perceived commercial bias in this activity. (“Commercial bias” is dened as a personal judgment in favor of a specic proprietary

business interest of an entity that produces, markets, sells or distributes healthcare goods or services consumed by, or used on, patients.)

❏ Yes ❏ No If yes, please comment: ______________________________________________________

______________________________________________________________________________________________________

Please the usefulness of the following guide materials on a scale of 1 to 5.

1. Physicians’ Plan for Older Drivers’ Safety (PPODS) Very useful 1 2 3 4 5 Not useful at all

2. Red Flags for Further Assessment Very useful 1 2 3 4 5 Not useful at all

3. Assessment of Driving-Related Skills (ADReS) Very useful 1 2 3 4 5 Not useful at all

4. State Licensing and Reporting Laws (Chapter 8) Very useful 1 2 3 4 5 Not useful at all

5. Medical Conditions that May Affect Driving (Chapter 9) Very useful 1 2 3 4 5 Not useful at all

6. Patient Education Materials (Appendix) Very useful 1 2 3 4 5 Not useful at all

Please include any additional comments you feel would be helpful.

______________________________________________________________________________________________________

Only physician participants (MD, DO, or equivalent international medical degree) are eligible to receive AMA PRA Category

1 Credit™. Physicians will receive a certicate of credit, indicating one credit for each hour of participation, rounded to the

nearest quarter credit (or hour). Physicians must complete this form to receive AMA PRA Category 1 Credit.

Non-physician participants may complete this form to obtain a certicate of participation indicating that this activity was

approved for AMA PRA Category 1 Credit.

Check one: ❏ Physician: Certicate of Credit ❏ Non-physician: Certicate of Participation

FOR PHYSICIANS ONLY. Please check one below:

❏ U.S. Licensed Physician Medical Education Number*: __________________________________________

❏ Non-U.S. Licensed Physician Date of Birth (mm/dd/yyyy)**: _________________________________________

Specialty: _____________________________________________________________________________________________

Please Send Completed Questionnaires and Evaluation Forms to: Lela Manning, MPH, MBA

Project Coordinator

Older Drivers Project

American Medical Association

515 N. State Street

Chicago, IL 60654

(312) 464-4111 (Fax)

Appendix C—Physicians Guide to Assessing and Counseling Older Drivers

Index

229Index

AAA Foundation for Trafc Safety,

Safe Driving for Mature Operators course ........................ 208

AARP Driving Safety Program ........................................ 208

Accommodation and adaptation of lens of eye .................. 22

Acute events of older drivers

conditions requiring counseling associated with, ........... 15

counseling following ....................................................... 13

red ags for further assessment after .................... 11, 14–15

Adaptive devices, vehicle ............................... 36, 37, 42, 155

Additional resources for driving safety ..................... 215–217

Administration on Aging Resource Directory for Older

People ................................................................................ 214

Adult protective services (APS) ........................................ 55

Affective disorders ............................................................ 163

Alabama, licensing and reporting procedures in ................ 71

Alaska, licensing and reporting procedures in ................... 72

Alcohol ............................................................. 164, 178, 179

Alzheimer’s Association ...................................................... 43

Policy Statement on Driving and Dementia by ............... 158

Alzheimer’s disease. See also Dementia

evaluation by another health professional

for patient with ................................................................ 45

mandatory reporting of drivers with ............................... 62

repeat driving tests for patients with ............................. 157

AMA Ethical Opinion E-2.24,

“Impaired Drivers and Their Physicians” ........................... 62

Am I a Safe Driver? ..................................................... 20, 203

American Academy of Neurology recommendations ...... 157

American Association of Motor Vehicle Administrators

(AAMVA), study by NHTSA and ........................... 189–190

American Occupational Therapy Association (AOTA) . 188

Amputation ....................................................................... 169

Anesthesia and surgery ............................................. 175–176

Angular movement vision test ........................................... 22

Anterior cruciate ligament (ACL) reconstruction .......... 169

Anterograde amnesia ........................................................ 178

Anticholinergics ............................................................... 179

Anticonvulsants ................................................................ 180

Antidepressants ................................................. 178, 180–181

Antiemetics ............................................................... 178, 181

Anti-epileptic drug therapy ...................................... 161, 178

Antihistamines ......................................................... 178, 182

Antihypertensives ............................................................. 182

Antiparkinsonians ............................................................ 182

Antipsychotics .................................................. 178, 182–183

Anxiety disorders ...................................................... 162, 163

Aortic aneurysm ................................................................ 171

Area Agency on Aging ............................................. 211, 214

Arizona, licensing and reporting procedures in ............ 69, 73

Arkansas, licensing and reporting procedures in ................ 74

Arthritis ............................................................................ 168

Assessment of driving-related skills (ADReS)

case study of scores on ..................................................... 33

cognitive skill ................................................ 23–25, 34–36

CPT codes for ....................................................... 21, 27, 198

discussion of results of ..................................................... 50

import of impairment in functions tested by .................. 21

motor and sensory function ................................. 26, 36–37

repeat administration of .................................................. 38

score sheet for ............................................................ 27–30

sequence of test administration in .................................. 27

use of ................................................................................ 61

vision ....................................................... 21–22, 27, 33–34

Association for Driver Rehabilitation Specialists (ADED)

certication of DRSs by .................................................. 41

online directory of ........................................................... 43

referrals to DRS by ........................................................ 210

Asthma .............................................................................. 173

Atrial utter/brillation .................................................... 152

Atrio-ventricular (AV) block, high grade ........................ 153

Attentional functioning ..................................................... 24

Attention decit disorder/

attention decit hyperactivity disorder .................... 162, 164

Automatic transmission, encouraging

use of vehicle having .................................................. 37, 167

Barbiturates ............................................................... 167, 178

Benzodiazepines and other sedatives/anxiolytics...... 178, 183

Bipolar disorder ................................................................. 163

Blepharospasm .................................................................. 149

Blurred vision. See Visual acuity

Brain tumor ....................................................................... 158

Bupropion ......................................................................... 180

California

licensing and reporting procedures in ....................... 75–76

mandatory reporting requirements

of medical impairments in ............................................... 62

Canadian Consensus Conference on Dementia ............... 158

Cancer ............................................................................... 177

Cardiac arrest .................................................................... 153

Cardiac surgery involving median sternotomy ................. 154

Cardiovascular diseases ............................................. 151–154

Index

230 Index

Cardioverter debrillator, internal ................................... 154

CarFit program .................................................................... 44

Caregiver burnout ............................................................... 51

Case study of dementia patient (Allen)

diagnosis of Alzheimer’s disease for ................................. 59

report of driving issues by daughter of............................. 49

state notication requirements for .................................. 59

Case study of older driver (Clayton Phillips)

assessment of functional capabilities of........................... 19

follow-up counseling in ................................. 41, 49, 50, 52

observation of driving risk and existing conditions of .... 11

performance on ADReS of .............................................. 33

physician letter for driving cessation in .......................... 56

referral to DRS in ...................................................... 41, 44

Cataracts ........................................................................... 147

Central nervous system (CNS) ........................................ 178

Cerebrovascular disorders ......................................... 155–156

Certied driver rehabilitation specialists (CDRSs) ........... 41

Cervical movement limitations ........................................ 168

Chronic conditions, driving safety for patients having

formal assessment of ........................................................ 13

red ags for further assessment in .................................... 11

Chronic obstructive pulmonary disease (COPD) ............ 173

Chronic renal failure ......................................................... 172

Civil damages, protection against ....................................... 62

Clock Drawing Test (CDT) .......................................... 24, 27

correlation with impaired driving performance of .......... 35

score sheet for .................................................................. 29

Cognitive domains .............................................................. 25

Cognitive skills

identifying cause of decline in......................................... 35

tested for driving ............................................... 23–25, 153

tested to diagnose dementia .......................................... 157

Colorado, licensing and reporting procedures in ......... 69, 77

Color detection in vision test ............................................. 22

Color vision, defective ...................................................... 150

Compliance with driving cessation .................................... 63

Condentiality issues. See Patient condentiality

Congestive heart failure (CHF) ........................................ 154

Connecticut, licensing and reporting procedures in .... 78–79

Contrast sensitivity ............................................................. 21

correlation with crash risk of......................................... 189

denition of ................................................................... 150

red ags for further assessment with ................................ 14

Copiloting ........................................................................... 36

Counseling for patient not safe to drive ....................... 49–56

key points addressed in .................................................... 49

by physicians, fullling duty in ................................. 62, 63

to prepare for driving cessation ..................................... 157

situations requiring additional .......................... 53–55, 146

by social worker ............................................................... 54

CPT codes for driver assessment and counseling ..... 197–198

in functional abilities testing of ADReS ........... 21, 27, 198

new ................................................................................ 198

for preventive medicine services ................................... 197

Crash risk

cardiac disease and ........................................................ 151

contrast sensitivity correlated with ............................... 189

detection of impairment correlated with ........................ 24

increases in, physical frailty and...................................... 26

medications associated with .................................. 167, 178

musculoskeletal disorders correlated with ..................... 167

visual testing and ....................................................... 33, 69

Deep vein thrombosis (DVT) ........................................... 171

Delaware

licensing and reporting procedures in ............................. 80

mandatory reporting requirements of

medical impairments in ................................................... 62

Dementia. See also Alzheimer’s disease

cessation of driving by patient having .................... 36, 159

cognition affected by ....................................................... 26

correlation with impaired driving performance

of degenerative ................................................................ 35

detection of...................................................................... 35

incidence of ..................................................................... 36

family involvement in deciding risk level from ............ 158

lack of decision-making capacity in ........................ 54, 157

test results of patients with ...................................... 35, 157

Department of Motor Vehicles (DMV)

driving assessment by ...................................................... 45

form for reporting medical condition(s) to ..................... 63

physician reporting requirements for ................ 52, 59, 189

self-reporting of impairment to ....................................... 52

state laws for driving safety of ......................................... 20

Depression ......................................................................... 163

discussing symptoms of .................................................... 54

questions to assess ............................................................ 54

signs of ............................................................................. 52

Depth perception vision test .............................................. 22

Diabetes mellitus ............................................................... 165

Diplopia ............................................................................. 150

District of Columbia, licensing and

reporting procedures in ................................................. 81–82

Doctor-patient relationship. See Patient-physician

relationship

Driver rehabilitation, increased availability of ......... 187–188

Driver rehabilitation specialist (DRS) ......................... 41–45

barriers to using ............................................................. 187

certication of ................................................................. 41

clients of .......................................................................... 42

clinical assessment by ...................................... 42, 155, 187

consulting ............................................................ 19, 20, 65

costs of services by ........................................................... 43

denition of ..................................................................... 41

on-road assessment by ..................... 34, 35, 37, 38, 42, 167

physician use of ............................................................. 188

prescription of adaptive devices by ......................... 37, 145

referral to ....................................... 33, 36, 38, 44, 155, 167

refusal of assessment by ................................................... 44

report by, physician documentation of ............................ 63

231Index

selecting, questions to ask in ..................................... 43–44

services provided by................................................. 42, 145

sources for nding ...................................................... 43–44

Driver retraining ................................................................. 42

Driving assessment. See also Driver rehabilitation specialist

(DRS)

age-based ......................................................................... 69

discussion of results of ............................................... 50–53

by non-DRS individual ............................................. 44–45

patient refusal to take ...................................................... 20

purpose in driving as inuencing .................................. 146

ways to suggest ................................................................. 19

Driving cessation

counseling to prepare for ....................................... 157, 159

losses from........................................................................ 49

view as step in health promotion of ................................ 54

Driving cessation recommendation .............................. 38, 42

basis of ................................................................. 45, 62–63

documenting .............................................................. 63, 64

economic arguments supporting ..................................... 52

medication use prompting ............................................. 145

for patients having dementia .......................................... 36

reasons physicians avoid making ..................................... 49

reinforcement of ........................................................ 51–52

Driving Decisions Workbook ............................................. 20

Driving educational specialists ........................................... 45

Driving Health Inventory (DHI) ................................. 24–25

Driving safety addressed in diagnosis/treatment plan ........ 15

Driving School Association of the Americas, Inc. ........... 208

Drowsiness, medications causing ...................................... 178

Duty to protect as physician responsibility ................... 59–60

Early Treatment Diabetic Retinopathy Study (ETDRS) ... 22

Educational materials for

patient and caregiver .................... 20, 44, 192–193, 201–217

Eldercare Locator .......................................... 51, 55, 211, 214

Epilepsy ............................................................... 61, 160–161

Ethical and legal responsibilities for reporting ............. 59–66

situations involving ................................................... 63–65

Ethical opinion E-2.24,

“Impaired Drivers and Their Physicians” (AMA) ............. 62

Euphoria, medications causing ......................................... 178

Executive skills, uses in driving of ...................................... 26

Extremities, loss of or loss of use of ................................... 168

Eyesight. See Visual acuity

Family member or caregiver

assistance with physician’s evaluation by ................ 35, 158

counseling, patient permission for .................................. 62

transportation plan developed with involvement of ...... 51

Family member’s concerns about patient’s driving safety

further assessment addressing .......................................... 14

How to Assist the Older Driver addressing ........................ 20

Federal Highway Administration (FHWA) ..................... 191

Five A’s of Senior-Friendly Transportation ............... 191, 192

Florida, licensing and reporting procedures in ....... 61, 83–84

Follow-up appointment following

driving cessation recommendation ............................... 52–53

Food and Drug Administration (FDA),

meeting by NTSB and ...................................................... 190

Foot abnormalities ............................................................ 168

Freund Clock Scoring Criteria ........................................... 35

Functional ability

assessing older driver’s ............................................... 17–30

detailed history and examination of ............................... 35

Geographic orientation ...................................................... 25

Georgia, licensing and reporting procedures in .................. 85

Getting By Without Driving .................................... 213–214

Glaucoma .......................................................................... 149

Glossary of terms for state licensing

and reporting laws ......................................................... 65–66

Hawaii, licensing and reporting procedures in ................... 86

Head injury, closed ............................................................ 158

Health Insurance Portability and Accountability

Act of 1996 (HIPAA)

patient rights and condentiality issues under.......... 60–61

reporting protected health information under ................ 62

Health risk assessment of older driver

conditions requiring ........................................................ 14

denition of ..................................................................... 12

inquiries about driving in .......................................... 12–13

Hearing loss ....................................................................... 151

Hemianopia/quadrantanopia ............................................ 149

Highway Design Handbook for

Older Drivers and Pedestrians .......................................... 191

Hip replacement, total ...................................................... 169

How to Assist the Older Driver .................... 20, 51, 209–211

Hypertension ..................................................................... 151

Hyperthyroidism ............................................................... 166

Hypertrophic obstructive cardiomyopathy ....................... 154

Hypnotics .......................................................................... 178

Hypothyroidism ................................................................ 166

Idaho, licensing and reporting procedures in ..................... 87

Illinois, licensing and reporting procedures in ............. 88–89

Independent transportation network (ITN) model ......... 191

Indiana, licensing and reporting procedures in ............ 90–91

Inpatient setting, counseling driver in ............................... 12

Insulin dependent diabetes mellitus (IDDM) .................. 165

232 Index

Insurance Information Institute ......................................... 70

Insurance Institute for Highway Safety .............................. 70

Iowa, licensing and reporting procedures in ....................... 92

Kansas, licensing and reporting procedures in ................... 93

Kentucky, licensing and reporting procedures in ............... 94

Keratoconus ...................................................................... 148

Knee arthroplasty, total (TKA) ........................................ 170

Language skills for driving .................................................. 25

Lawsuit by patient ................................................... 59, 63–64

Liability protection for physician,

state legislation for ...................................................... 64, 189

License renewal practices

international .................................................................... 70

for older drivers ............................................................... 69

state ........................................................................... 69–70

Licensing agencies, role in driving safety of.

See also Department of Motor Vehicles (DMV).......189-190

Licensing and unsafe driver reporting laws,

state-by-state descriptions of ................................. 45, 69–141

Limb fractures ................................................................... 169

Listening to patient’s concerns ........................................... 53

Local Agency on Aging .................................................... 211

Loss of consciousness, cardiac conditions causing .... 152–153

Louisiana, licensing and reporting procedures in ............... 95

Macular degeneration ....................................................... 148

Maine, licensing and reporting procedures in .................... 96

Mandatory tness-to-drive reporting requirements

for physicians

compliance with ........................................................ 63, 64

states requiring ................................................................ 62

Manual Test of Motor Strength .................................... 25, 27

results of ..................................................................... 36–37

Manual Test of Range of Motion test ........................... 25, 27

scoring of ......................................................................... 37

Maryland, licensing and reporting procedures in ............... 97

Massachusetts, licensing and reporting procedures in .. 98–99

Medical Advisory Board ........................................... 189–190

Alabama .............................................................................. 71

Arizona ................................................................................ 73

California ............................................................................ 76

Connecticut ........................................................................ 79

Delaware ............................................................................. 80

Florida ................................................................................. 84

Georgia ................................................................................ 85

Hawaii ................................................................................. 86

Idaho ................................................................................... 87

Illinois ................................................................................. 89

Indiana ................................................................................ 91

Iowa ..................................................................................... 92

Kansas ................................................................................. 93

Kentucky ............................................................................. 94

Louisiana ............................................................................. 95

Maine .................................................................................. 96

Maryland ............................................................................. 97

Massachusetts ...................................................................... 99

Michigan ........................................................................... 101

Minnesota ......................................................................... 102

Mississippi ......................................................................... 103

Missouri ............................................................................. 105

Nebraska ........................................................................... 108

Nevada .............................................................................. 109

New Jersey ......................................................................... 111

New Mexico ...................................................................... 112

New York........................................................................... 114

North Carolina ................................................................. 115

North Dakota .................................................................... 116

Oklahoma ......................................................................... 119

Oregon .............................................................................. 121

Pennsylvania ..................................................................... 123

Rhode Island ..................................................................... 124

South Carolina .................................................................. 125

South Dakota .................................................................... 126

Tennessee .......................................................................... 127

Texas ................................................................................. 129

Utah .................................................................................. 131

Virginia ............................................................................. 134

West Virginia .................................................................... 137

Wisconsin .......................................................................... 139

Medical conditions that may affect driving .............. 146–177

Medication dose, reducing ................................................ 145

Medications interfering with

driving performance ............................................ 37, 178–184

Medications review for patient ............................... 11–12, 35

Medications, side effects of ......................................... 26, 178

public awareness of, increasing ..................................... 190

review of .......................................................................... 35

Medications with strong potential to affect

driving safety ............................................................. 145–184

types of ............................................................................. 15

Memory tests ................................................................. 23, 24

Metabolic disorders ................................................... 165–166

Michigan, licensing and reporting

procedures in ....................................................... 69, 100–101

Migraine headaches .......................................................... 159

Minnesota, licensing and reporting procedures in ........... 102

Mirtazapine ....................................................................... 180

Mississippi, licensing and reporting procedures in ........... 103

Missouri

license retention following evaluations in ...................... 61

licensing and reporting procedures in ................... 104–105

Mobility needs of patient .................................................... 13

Model Driving Impairment Law ......................................... 62

Monoamine oxidase (MAO) inhibitors ........................... 181

233Index

Monocular vision .............................................................. 149

Montana, licensing and reporting procedures in .............. 106

Motor abilities for operating vehicle .................................. 26

results of tests of .............................................................. 36

Motor Strength, manual test of .................................... 25, 27

score sheet for .................................................................. 28

Movement disorders .......................................................... 159

Multiple sclerosis .............................................................. 159

Muscle disorders ................................................................ 169

Muscle relaxants ............................................... 167, 178, 183

Musculoskeletal disabilities ................................ 26, 167–170

Narcolepsy ......................................................................... 161

Narcotic analgesics ........................................................... 184

Narcotics ........................................................................... 167

National Association of Social Workers Register of Clinical

Social Workers .................................................................... 54

National Family Caregivers Association (NCFA) ............. 51

National Highway Trafc Safety Administration (NHTSA)

data on medically impaired drivers ................................. 61

meeting by FDA and ..................................................... 190

study by AAMVA and .......................................... 189–190

Nebraska, licensing and reporting procedures in ..... 107–108

Neglect or self-neglect

adult protective services to address ................................. 55

signs of ............................................................................. 54

Neurologic diseases ................................................... 157–162

Nevada

licensing and reporting procedures in ........................... 109

mandatory reporting requirements of

medical impairments in ................................................... 62

New Hampshire, licensing and reporting

procedures in ..................................................................... 110

New Jersey

licensing and reporting procedures in ........................... 111

mandatory reporting requirements of

medical impairments in ................................................... 62

New Mexico, licensing and reporting procedures in ........ 112

New York, licensing and reporting procedures in..... 113–114

Night vision

medications affecting .................................................... 178

poor ................................................................................ 150

N-methyl d-aspartate (NMDA) receptor blockers ........... 157

Non-insulin dependent diabetes mellitus (NIDDM) ....... 165

Nonsteroidal anti-inammatory agents (NSAIDs) .......... 167

possible effects on driving of ......................................... 183

North Carolina, licensing and reporting procedures in ... 115

North Dakota, licensing and reporting procedures in ...... 116

Nystagmus ......................................................................... 148

Observations of patient throughout ofce visit .................. 11

Occupational therapists off-road tests

and/or mobility counseling by ............................................ 44

Occupational therapy (OT) profession ............................ 188

Ohio, licensing and reporting procedures in ...... 69, 117–118

Oklahoma, licensing and reporting procedures in ........... 119

Older drivers

educational materials for ................................. 20, 201–217

increasing number of ......................................................... 1

optimal environments for .............................................. 191

plans for alternate transportation of ..................... 187–193

vehicle designs to improve safety of ...................... 190–191

Oregon

licensing and reporting procedures in ................... 120–121

mandatory reporting requirements of

medical impairments in ................................................... 62

reports of medically impaired drivers in .......................... 61

Orthopedic procedures/surgeries ............................... 169–170

Osteoarthritis .................................................................... 167

Pacemaker insertion or revision ....................................... 154

Paraplegia, adapted vehicle for driving with .................... 159

Parkinson’s disease .................................................... 159–160

Paroxysmal supraventricular tachycardia (PSVT) ........... 152

Patient concerns about driving safety ................................. 14

Patient condentiality

exceptions to maintaining............................................... 62

in impaired driver situations ....................... 60–61, 64, 189

reducing impact of breaching .......................................... 62

Patient-physician relationship

condentiality of health information in ................... 60, 61

effects of reporting tness to drive reports on ........... 61–62

reducing impact of breach of condentiality on ............. 63

Pedestrians, optimal environments for ............................. 191

Pennsylvania

licensing and reporting procedures in ................... 122–123

mandatory reporting requirements of

medical impairments in ................................................... 62

provider compliance in ....................................... 59–60, 61

Percutaneous transluminal coronary

angioplasty (PTCA) ......................................................... 154

Peripheral arterial aneurysm ............................................. 171

Peripheral neuropathy ...................................................... 160

Peripheral vascular diseases .............................................. 171

Personality disorders ......................................................... 164

Physical activity regimen ............................................ 37, 167

Physician assessment tools for effects on driving ............. 1–2

future improved ............................................................. 187

Physician documentation of patient’s driving ability ... 20, 63

Physician intervention .................................................. 33–38

cognitive abnormal results prompting ...................... 34–35

course of action for .................................................... 37–38

234 Index

documenting .................................................................... 63

motor ability results prompting ....................................... 36

summary of ...................................................................... 63

visual acuity results prompting .................................. 33–34

visual eld loss prompting ............................................... 34

Physician-patient privilege

denition of ..................................................................... 64

as not preventing report to DMV ................................... 64

Physician responsibilities for reporting unsafe driver

DMV requirements as ............................................. 52, 59, 63

ethical and legal ........................................................ 59–66

when state has no reporting laws .................................... 64

Physician’s Plan for Older Drivers’ Safety (PPODS)

algorithm of ................................................................. 6, 19

documenting steps of ....................................................... 63

formal assessment in ............................................ 19–29, 63

observation in ...................................................... 11–15, 63

Physician, threat by unsafe-driving patient

to nd another .............................................................. 64–65

Polypharmacy .................................................................... 179

Post intracranial surgery ................................................... 155

Potential driving impairing (PDI) medications ............... 178

Power steering, recommending use of

vehicle providing ........................................................ 37, 167

Prescription reinforcement stating “Do Not Drive” ..... 51, 52

Pre-syncope or syncope, risk of ................................. 153–154

Psychiatric disorders .................................................. 163–164

Psychotic illness ................................................................ 164

Ptosis or lid redundancy .................................................... 149

Public safety ........................................................................ 60

Public transportation statistics ......................................... 191

Quadriplegia, adapted vehicle for driving with ................ 159

Range of motion ................................................................. 26

manual test of ............................................................ 25, 27

score sheet for .................................................................. 28

Rapid Pace Walk test .................................................... 24, 27

correlation between future at-fault crash and performance

on ..................................................................................... 36

functions assessed by ....................................................... 36

score sheet for .................................................................. 28

Referral of patient for tness-to-drive evaluation

to DRS ................................................... 33, 36, 38, 44, 167

physicians’ condentiality concerns in ..................... 61–62

physicians’ problems with ............................................... 61

retention of license following ......................................... 61

Referral of patient to DMV for testing ......................... 20, 45

Release of information, patient consent for ....................... 62

Renal disease ..................................................................... 172

Renal transplant ................................................................ 172

Renewal rates for licenses ............................................. 69–70

Resources, driving safety ..................................... 20, 215–217

CarFit .................................................................................. 44

DRS ............................................................................... 43–33

handout ................................................................. 201–217

Resources, mobility needs ......................................... 192–193

Respiratory diseases ................................................... 173–174

Restricted driving .................................................... 34, 38, 42

for cardiac conditions .................................................... 154

medication use prompting ..................................... 145, 178

recommendation basis for ............................................... 45

Retinitis pigmentosa ......................................................... 149

Review of systems (ROS)

comprehensive................................................................. 12

symptoms affecting driving safety revealed by ................ 15

Rhode Island, licensing and reporting procedures in ....... 124

Ride-sharing statistics ....................................................... 191

Roadwise Review CD of AAA ........................................... 20

Rotator cuff repair ............................................................. 169

Safe Driving Tips ................................................................ 45

SAFER Driving survey ........................................................ 20

Safety features, new vehicular .......................................... 191

Safety of older driver having functional

or medical impairments

examples of issues for ............................................. 1, 11, 19

overview of .................................................................... 1–7

Seizure disorder ......................................................... 160–161

Selective serotonin reuptake inhibitors (SSRIs) .............. 181

Self-awareness and self-regulation of driving safety ......... 190

Self-screening tool, Am I a Safe Driver? .................... 20, 203

Sensory deprivation conditions ................................ 147–151

Shopping from home ........................................................ 211

Shoulder reconstruction ................................................... 169

Sick sinus syndrome .......................................................... 153

Simulators, driving ............................................................ 188

Sinus brachycardia/sinus exit block/sinus arrest ............... 153

Sleep apnea ....................................................................... 174

Sleep disorders .......................................................... 161, 174

Snellen E chart test of visual acuity ............................. 22, 27

Social history/health risk assessment, driving on ............... 12

South Carolina, licensing and reporting procedures in 69, 125

South Dakota, licensing and reporting procedures in ...... 126

Spine limitations, thoracic or lumbar ............................... 168

State laws for referrals to DMV .............................. 20, 45, 52

compliance with .............................................................. 63

State licensing and physician reporting laws ........ 45, 69–141

Stimulants ......................................................................... 184

Stroke .................................................................. 61, 155–156

Subarachnoid hemorrhage ................................................ 156

Substance abuse ........................................................ 164, 179

Successful Aging Tips ................................... 20, 45, 205–206

Support systems ................................................................... 53

Surgery, abdominal, back, and chest................................. 175

Suspension of driver’s license, driving subsequent to ......... 64

Syncope ..................................................................... 153–154

effects on driving of ....................................................... 156

235Index

Taxi use statistics ............................................................... 191

Telescopic lens .................................................................. 148

Tennessee, licensing and reporting procedures in ............ 127

Texas, licensing and reporting procedures in ........... 128–129

Tips for Safe Driving ........................................... 20, 207–208

Tourette’s syndrome .......................................................... 162

Trafc Safety Course (AARP) ............................................ 20

Trail-marking test, Part B ............................................. 23, 27

driving performance on ............................................. 34–35

score sheet for ............................................................ 29, 30

Transient ischemic attacks (TIA) .................................... 156

Transportation alternatives

discussed with patient ....................................... 50–51, 146

follow-up of patient’s success using ................................. 63

future plans for....................................................... 187–193

list of ................................................................................ 50

Transportation needs of older adults ......................... 187–193

Tricyclic antidepressants (TCAs) ..................................... 181

Unsafe drivers

identifying ..................................................................... 188

patient’s recognition of .................................................... 53

referral requirements of providers for .............................. 20

reporting. See Physician responsibilities for reporting

unsafe driver

Unstable coronary syndrome ............................................ 152

Useful Field of View (UFOV) ............................................. 24

U.S. Public Health Service guidelines on musculoskeletal

ability and driving ............................................................... 37

Utah, licensing and reporting procedures in ............ 130–131

Valvular disease ................................................................. 154

Vascular malformation ...................................................... 156

Vehicle designs to optimize safety ............................ 190–191

Vehicle modication ....................................... 36, 37, 42, 155

Ventricular tachycardia (VT)

prolonged, nonsustained ............................................... 152

sustained ................................................................ 152–153

Vermont, licensing and reporting procedures in, 132

Vertigo ............................................................................... 162

Vigilance (sustained attention) .......................................... 25

Virginia, licensing and reporting procedures in ....... 133–134

Visual acuity

correlation with crash risk of........................................... 33

frequency of assessing ...................................................... 34

greater than 20/40 ..................................................... 33–34

lessening impact on driving of decreased ...................... 147

less than 20/70 ................................................................. 34

less than 20/100 ............................................................... 34

medical conditions decreasing .............................. 147–148

medications affecting .................................................... 178

state requirements for drivers’ ................................... 33, 69

in vision assessment................................................... 21–23

Vision assessment, visual acuity and visual elds in ..... 21–23

Visual Fields by Confrontation test .............................. 23, 27

Visual elds deterioration ................................................... 34

medical conditions causing ................................... 148–149

Visual perception, visual processing, and

visuospatial skills ........................................................... 23–24

Voluntary reporting laws, liability of

physicians in states having .................................................. 62

Walking ......................................................................... 26, 36

Washington, licensing and reporting

procedures in ............................................................. 135–136

“We Need to Talk” (Harford) ........................................... 210

West Virginia, licensing and reporting procedures in ...... 137

Wisconsin, licensing and reporting procedures in .... 138–139

Wolf-Parkinson-White (WPW) syndrome ...................... 152

Wyoming, licensing and reporting procedures in ............. 140

PD102:10-0193:PDF:4/10:DF